v^uzr 'K&&- v.*» ■**>■ 6 iV* .IV »v* a& TO 'i -A/ •"♦tor /•^ NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland APR *x / FLINT, AUSTIN, M.D., LL.D., Late Professor of the Principle* and Practice of Medicine and of Clinical Medicine in Bellevue Hospital Medical College, New York. A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly revised and rewritten by the Author, assisted by William H. Welch, M.D., Professor of Pathology, Johns Hopkins University, Balti- more, and Austin Flint, Jr., M.D., LL.D., Professor of Physiology, Bellevue Hospital Medical College, X. Y. In one very handsome octavo volume of 1170 pages, with illustrations. Cloth, $5.50; leather, §6.50; very handsome half Russia, raised bands, $7.00. SMITH, J. LEWIS, M.D., Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. T. A Treatise on the Diseases of Infancy and Childhood. New (sixth) edition, thoroughly revised and rewritten. In one handsome octavo volume of 867 pages, with 40 illustrations. Cloth, $4.50; leather, $5.50; half Russia, $6.00. THOMAS, T. GAILLARD, M.D., Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y. A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. STIMSON, LEWIS A., B.A., M.D., Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Curator to Bellevue Hospital, Surgeon to the Presbyterian Hospital, New York, etc. A Practical Treatise on Fractures. In one very handsome octavo volume of 598 pages, with 360 beautiful illustrations. Cloth, $4.75; leather, $5.75. #cc «U tf/Adtea/- O lacistn i^t^ t x+r/c *^<-^/r>^~ r v*~7 DRUITT'S SURGKEOFS YADE-MECUM. A MANUAL OF MODERN SURGERY. EDITED BY STANLEY BOYD, M.B., B.S. Lond., F.R.C.S. Eng., ASSISTANT SURGEON AND PATHOLOGIST TO THE CHARING CROSS HOSPITAL, AND SURGEON TO THE PADDINGTON GREEN HOSPITAL FOR CHILDREN J LATE DEMONSTRATOR OF ANATOMY IN UNIVERSITY COLLEGE, AND SURGICAL REGISTRAR IN UNIVERSITY COLLEGE HOSPITAL. TWELFTH EDITION. WITH THREE HUNDRED AND SEVENTY-THREE WOOD ENGRAVINGS. PHILADELPHIA: LEA BROTHERS & CO. 1887. Q"'$ft PHILADELPHIA : DOR NAN, PRINTER, N. W. cor. Seventh and Arch Streets. TO MY UNCLE, HENRY NEWTON, LATE OF THE BOMBAY CIVIL SERVICE, I DEDICATE THIS, THE TWELFTH, EDITION OF i| unit's burgeon's i|ade-mwmn, IN GRATEFUL ACKNOWLEDGMENT OF THE UNVARYING KINDNESS, SYMPATHY, AND HELP, SUCH AS FEW CAN GIVE, WHICH I HAVE RECEIVED FROM HIM. PREFACE. Few medical works have been more widely known and appreciated than Druitt's " Surgeon's Vade-mecum." In England, I am informed that 50,000 copies have been sold, whilst in America it has been so highly appreciated that a copy was issued by the Government to each surgeon serv- ing in the Federal Army during the great Civil War. These facts would at once suggest that it was desirable to alter the book as little as possible. But owing to Dr. Druitt's ill-health he was unable to edit the last two editions with his old skill and energy; in the last, indeed, he was obliged to share the labor with Professor John Wood, of King's College Hospital, and Mr. R. W. Parker. The latter surgeon illustrated and revised the chapter on Tumors, and gave much help in the portions dealing with gun- shot injuries. His work has been but little altered. Mr. Wood revised the latter two-thirds of the book—a somewhat delicate task during the life of the author—and he seems to have limited himself to making consider- able additions, in which he stated his own views and practice. Naturally, these additions contained very valuable material, and I have retained them, with acknowledgment of their source when they contained anything orig- inating with Professor Wood. It will be seen from the above that the work has not been thoroughly edited for at least ten years; and when I say that in the eleventh edition, which appeared in 1877, antiseptic surgery is regarded as still on its trial, ligatures are left hanging from wounds, the extra-peritoneal method is re- commended in ovariotomy, and we are told to hang a box of Macdougall's powder under the bedclothes to keep down the stench of a stump, it will be obvious to any who understand the far-reaching importance of these points that radical change was necessary. Again and again I tried to patch, but with such a poor result that the attempt invariably resulted in rewriting. The twelfth edition consequently differs much from the eleventh ; scarcely a paragraph of the latter remains unaltered; and in most parts only the sense of the old book has been embodied with other material in the new. The chapter on Discuses of the Eye has been replaced by a short account of the injuries of that organ, for which I am indebted to my Vlll PEEFACE. friend Mr. A. Quarry Silcock, Assistant Surgeon to St. Mary's Hospital and to the Royal Ophthalmic Hospital, Moorfields. Notwithstanding this omission, and in spite of my utmost endeavors to compress, the book has increased considerably in size. This is due to many causes, especially to the greatly increased range of subjects with which I have had to deal, the greater prominence which I felt it necessary to give to pathology, the introduction of short sections on " surgical diagnosis," and of others, here and there, on "general principles,'' to the replacement of many old illustrations by a number of considerably larger ones, and the addition of a copious index. Those familiar with former editions will notice that the division of chapters into numbered sections has been abandoned, and that the ac- counts given are more continuous. The "author" or the "writer" refers to Dr. Druitt; for shortness' sake I have written either in the third or first person. My sources of information have been Holmes's " System of Surgery," Konig's excellent " Lehrbuch der Chirurgie," Hiiter's " Grundrisse der Chirurgie," many parts of the " Deutsche Chirurgie," edited by Billroth and Liicke, and, to a much less extent, Nekton's " Traite de Pathologie Externe." Birch-Hirschfeld's " Lehrbuch der pathologischen Anatomie " and the sixth edition of " Green's Manual of Pathology and Morbid Anatomy " have served me as references in pathology ; whilst in medicine I have consulted Fagge, Bristowe, and Quain's " Dictionary." Erichsen's " Surgery," of which I recently read the proofs and revises, I have rather avoided, lest obvious plagiarism should creep in ; but to it and to its editor my warmest acknowledgments are certainly due. In the section on operative surgery also the effect of Mr. Beck's teaching is very evident. Minor references are made in the text. Seventy-three new woodcuts have been added, and among them an almost complete series illustrating the ligation of arteries. These were drawn from operations on the dead subject, and most of them are of life- size : they are intended to show, not the anatomy of the artery, but the wound as it really is; and it is hoped that they will enable the student easily to perform the operations on post-mortem subjects, if he will place the book alongside the limb to be operated upon. Stanley Boyd. CONTENTS. PART I. CHAPTER I. THE ETIOLOGY OF DISEASE. PAGE Morbid conditions and their causes—Temperature—Methods of preventing the development of, or of destroying bacteria—Distribution in nature—Rela- tion of bacteria to the body—Classification of bacteria . . . 33-41 CHAPTER II. LOCAL DISTURBANCES OF THE CIRCULATION. Anaemia. Local anaemia—Hypersemia. Active hyperemia; causes—Treat- ment of local venous congestions........41-47 CHAPTER III. INFLAMMATION. Etiology—Process of inflammation—Analysis of the clinical signs—Termina- tions of inflammation—Varieties of inflammation—General principles of treatment............47-67 CHAPTER IV. ULCERATION. Pathology of an inflammatory ulcer—Fistula and sinus .... 67-73 CHAPTER V. SUPPURATION AND ABSCESS. Chronic or cold abscess—Hectic fever—Albuminoid degeneration . . 73-84 CHAPTER VI. MORTIFICATION. Signs of gangrene—Arrest of gangrene—Treatment of gangrene from disease 84-91 CHAPTER VII. SCROFULA AND TUBERCULOSIS. Definition—Description—Etiology—Tuberculosis — Structure of the miliary tubercle—Pathology of tuberculosis — Etiology of tubercle—Treat- ment ............. 91-99 X CONTENTS. CHAPTER VIII. LEPROSY (ELEPHANTIASIS GR.ECORUM) ; GLANDERS AND FARCY. PAGE Leprosy—Symptoms—The anaesthetic form—Morbid anatomy and pathology —Etiology—Treatment of leprosy—Glanders and farcy—Pathology and etiology—Treatment..........99-103 CHAPTER IX. VENEREAL DISEASES. Gonorrhoea and urethritis—Gonorrhoea in woman—Soft chancre, chancroid, non-infecting sore, and sloughing and phagedaenic sore — Syphilis — Acquired syphilis—Inherited syphilis—Treatment of syphilis, especially by mercury .*..........103-125 CHAPTER X. TUMORS. A. Mesoblastic tumors, adult types. The fibrous tumor—Fatty tumor, or lipoma—Cartilaginous tumor, chondroma, or enchondroma—Bony tumor, or osteoma—Lymph gland tumor, lymphadenoma; Hodgkin's disease— The muscular tumor, or myoma—Nerve tumor, neuroma—Vascular tumor, angeioma or naevus—B. Mesoblastic tumors, embryonic types. Sarcomata —C. Epi- and Hypo-blastic tumors. Epithelial growths—Gland tumors, adenomata—Cancer, carcinoma—Squamous or pavement epithelioma— Treatment of malignant growths—Cystic tumors and cysts . 126-149 CHAPTER XL SEPTIC DISEASES OF WOUNDS. Erysipelas (cutaneous)—Cellulo-cutaneous or phlegmonous erysipelas—Spread- ing traumatic gangrene (G. foudroyante)—Croup of granulations—Wound diphtheria—Hospital gangrene, sloughing phagedaena—Septicaemia and pyaemia—Septicaemia—Pyaemia.......149-164 PART II. INJURIES. CHAPTER XII. GENERAL EFFECTS OF INJURIES. Injuries—Causes—Symptoms—Treatment—Delirium traumaticum' CHAPTER XIII. SUBCUTANEOUS INJURIES —CONTUSIONS. Injuries—Symptoms—Fate of the effusion—Treatment . 165-166 167-168 CONTENTS. XI CHAPTER XIV. WOUNDS. Different kinds of wounds—Definition—The conduct of an operation (infliction of a wound) under Lister's method—The healing of wounds . . 169-180 CHAPTER XV. GUNSHOT WOUNDS. General description—Lodgement and extraction of balls—Collapse from gun- shot wounds—Gunshot injuries of the limbs—Arrow wounds . . 180-193 CHAPTER XVI. EFFECTS OF HEAT—BURNS AND SCALDS. Burns and scalds—Treatment: general: local—Prevention of contraction, and treatment of the scar—General points about plastic operations . 193-196 CHAPTER XVII. THE EFFECTS OF COLD. General effects of severe cold—Frost-bite—Chilblains .... 196-197 CHAPTER XVIII. EFFECTS OF THE POISONS OF HEALTHY ANIMALS. Snake bite—Poisonous insects.........197-200 CHAPTER XIX. ANIMAL PARASITES—ENTOZOA—VEGETABLE PARASITES. The Guinea-worm—The chigoe or sand-flea—The echinococcus—Vegetable parasites............200-203 CHAPTER XX. DISSECTION OR POST-MORTEM WOUNDS. The dissecting porter's wart—Dissecting-room pustule—Suppuration of the matrix of the nail—Acute lymphangitis and lymphadenitis—Cellulitis of the axilla............203-204 CHAPTER XXI. EFFECTS OF POISON GENERATED BY DISEASED ANIMALS. Hydrophobia—Splenic fever; malignant pustule; internal and external an- thrax ............ 205-210 XII CONTEXTS. PART III. INJURIES AND SURGICAL DISEASES OF VARIOUS TISSUES, ORGANS, AND REGIONS. CHAPTER XXII. SURGICAL DISEASES OF THE SKIN. PAGE Boil (furunculus)—Lupus vulgaris—The scrofulide or tubercular nodule— Molluscum contagiosum—Keloid—Moles . . . . . 211-216 CHAPTER XXIII. INJURIES AND DISEASES OF BURS.E, TENDON SHEATHS, MUSCLES, AND TENDONS. Injuries and diseases of bursae—Diseases of tendon sheaths—Injuries and diseases of muscles and tendons...... 216-222 CHAPTER XXIV. INJURIES AND DISEASES OF LYMPHATIC VESSELS AND GLANDS. Amputation of scrotum—Lymphadenitis—Tubercular glands—Tumors . 222-227 CHAPTER XXV. INJURIES AND DISEASES OF BONE. Fractures—Compound fractures—Particular fractures .... 227—276 CHAPTER XXVI. DISEASES OF BONE. Inflammatory processes in bone. General pathology—Necrosis—Caries— Osteitis deformans—Rickets—Mollities ossium (malacosteon, osteo- malacia)—Tumors of bone........277-291 CHAPTER XXVII. INJURIES AND DISEASES OF JOINTS. Sprains and contusions—Wounds of joints—Dislocation or luxation—Par- ticular dislocations—Dislocations due to flexion, adduction, and rotation in—Dislocations from flexion and abduction—Dislocations caused by over-extension and abduction—Diseases of joints —Synovitis—Arthritis— Gout—Rheumatism—Joint disease of nervous origin—Loose bodies in joints—The diagnosis of joint disease—Limited movement, contractions, and ankylosis...........291-338 CHAPTER XXVIII. DISEASES OF THE HIP-JOINT, OR MORBUS COX.E. Acute arthritis of the hip—Chronic arthritis of the hip—White swelling of the knee ............ 338-350 CONTENTS. Xlll CHAPTER XXIX. INJURIES OF ARTERIES—ARTERIAL HEMORRHAGE AND HEMATOMA. PAGE The artificial arrest of hemorrhage—The effects of loss of blood—Primary, intermediary, and secondary hemorrhage—Secondary hemorrhage: its pathology and treatment—Arterial haematoma, diffused and circumscribed —Traumatic aneurism—Aneurismal varix and varicose aneurism—Dis- eases of the arteries—Inflammation of arteries—Cirsoid aneurism (arterial varix)—True aneurism—Treatment of true aneurism—Naevus, angeioma, or vascular tumor—Haemophilia or hemorrhagic diathesis . . 351-403 CHAPTER XXX. INJURIES AND DISEASES OF THE VEINS. Wounds of veins—Thrombosis—Embolism—Inflammation of veins: phlebitis —Varicose veins..........403^112 CHAPTER XXXI. INJURIES AND DISEASES OF NERVES. Diseases of nerves—Tetanus.........412-425 CHAPTER XXXII. INJURIES OF THE HEAD. Injuries of the scalp—Injuries of the skull-bones—General injuries of the brain—Concussion of the brain—Compression of the brain—Injuries of intracranial vessels—Local injuries of the brain—Contusion and lacera- tion of the brain—Inflammation of the brain and of its membranes— Intracranial abscess—After-effects of injuries to the head—The operations of trephining and elevation of bone—Malformation of the head—Diseases of the head...........425-462 CHAPTER XXXIII. INJURIES AND DISEASES OF THE SPINE AND SPINAL CORD. Injuries—Malformations of the spine—Deformities of the spine—Caries of the spine and angular curvature.......462-479 CHAPTER XXXIV. DISEASES OF THE HANDS AND FEET, CLUB-FOOT, AND OTHER DEFORMITIES OF THE LIMBS. Web-fingers—Whitlow or paronychia—Onychia, or inflammation of the matrix of the nail —Ulcers about the nails—Subungual exostosis—Genu valgum and ,^enu varum, or knock-knee and bow-knee—Club-foot—Talipes equinus—Talipes calcaneus—Talipes varus and equino-varus—Weak ankle, flat-foot, and talipes valgus—Contraction of the toes . . 480^195 XIV CON TEN TS. CHAPTER XXXV. INJURIES OF THE ORBIT AND ITS CONTENTS. PAGE Excision of the eyeball—New growth of the conjunctiva and eyeball—Orbital cellulitis and abscess—Orbital tumors......495-508 CHAPTER XXXVI. DISEASES AND INJURIES OF THE EAR. Examination of the ear—Affections of the external ear—Affections of the tympanum—Affections of the internal ear and auditory nerve . 508-516 CHAPTER XXXVII. INJURIES AND DISEASES OF THE SOFT PARTS OF THE FACE. Affections of the nasal cavities—Affections of the jaws and antrum—Affec- tions of the teeth—Affections of the mouth, gums, and tongue—Diseases of the salivary glands—Diseases of the fauces, tonsils, and soft palate- Injuries and diseases of the lower part of the pharynx and of the oesophagus—Injuries and diseases of the larynx—Operations on the larynx and trachea—Surgical affections of the external parts of the neck and throat—Affections of the thyroid body—Cysts and tumors in the neck.............516-585 CHAPTER XXXVIII. INJURIES AND DISEASES OF THE CHEST. Diseases of the chest-wall—Surgical treatment of diseases of the lungs and heart.............586-596 CHAPTER XXXIX. THE SURGERY OF THE ABDOMEN. Acute peritonitis—Injuries of the abdomen and contained viscera—Wounds of the omentum—Wounds of the liver and gall-bladder—Wounds of the spleen—Wounds of the kidney—Wounds of the pancreas—Wounds of the stomach—Wounds of the intestine—Sutures for wounds of hollow viscera—Resection of the intestine .......596-613 CHAPTER XL. HERNIA. Nature and causes of hernia generally—Reducible hernia—Irreducible hernia—Strangulated hernia—Radical cure of hernia—Inguinal hernia —Femoral or crural hernia—The umbilical, ventral, and other remaining species of hernia..........613-650 CHAPTER XLI. INTESTINAL OBSTRUCTION. Strangulation by "bands"—Volvulus—Intussusception—Traction and com- pression by adhesions other than bands—Compression of the bowel__ Stricture of the bowel—New growths—Foreign bodies—Methods of treatment............651-677 CONTENTS. XV CHAPTER XLII. SURGICAL DISEASES OF THE ABDOMINAL VISCERA. PAGE Gastro-intestinal tract—The kidneys—Liver and gall-bladder—The spleen— The uterine appendages—Ovaries—Fibromyoma of the uterus . 678-721 CHAPTER XLIII. DISEASES AND INJURIES OF THE RECTUM AND ANUS. Examination of rectal cases—Malformations—Malignant growths of the rectum............721-742 CHAPTER XLIV. DISEASES OF THE URINARY ORGANS. Examination of cases and general points in diagnosis—Nephritis secondary to disease of the lower urinary tract—Local complications of stricture— Diseases of the prostate—Retention of urine—Injuries and diseases of the bladder—Tumors of the bladder—Stone in the bladder—Stone in women............742-799 CHAPTER XLV. DISEASES OF THE MALE GENITALS. Diseases of the penis—Diseases of the testis—Diseases of the scrotum—Impo- tence and syphilophobia.........799-818 CHAPTER XLVI. INJURIES AND SURGICAL DISEASES OF THE FEMALE GENITALS. Injuries—Malformations and deformities—Diseases .... 818-824 CHAPTER XLVII. DISEASES OF THE BREAST. Neuralgia of the breast—Abnormalities of secretion—Lacteal tumor or galac- toeele—Acute inflammation of the breast—Adenoma, adeno-fibroma, adeno-sarcoma, and cysto-sarcoma—Cysts.....824-838 PART IV. OF THE OPERATIONS OF SURGERY. CHAPTER XLVIII. OF OPERATIONS IN GENERAL. Preparations for operation—Knives, and how to hold them—Incisions— Bloodless methods—General remarks on operations—After-treatment 839-842 xvi CONTENTS. CHAPTER XLIX. MEANS OF PRODUCING INSENSIBILITY TO PAIN. History down to the discovery of nitrous oxide—The introduction of L'trous oxide gas—Introduction of ether—Introduction of chloroform—Mes- merism—Means of producing local anaesthesia .... 843-855 CHAPTER L. ARTIFICIAL RESPIRATION. Chest pressure—Silvester's method........856-857 CHAPTER LI. SLINGS AND BANDAGES. Slings—Bandages—Uses of bandages—Finger bandage—Capelline bandage —Shawl-cap...........857-864 CHAPTER LII. MINOR SURGERY. Venesection at the bend of the arm—Arteriotomy—Wet cupping—Transfusion of blood—Acupuncture—Vaccination—Counter-irritation—The actual cautery—Setons—Issues—The moxa—Electricity and galvanism . 864-870 CHAPTER LIII. OPERATIONS FOR THE LIGATION OF ARTERIES. General points—Laying bare the vessel—Opening the sheath—Passing the needle—Tying the ligature—Ligation of special arteries . . . 870-901 CHAPTER LIV. AMPUTATIONS AND EXARTICULATIONS. Definition—Indications—The principles of amputation—Preparations for amputation—Performance of an amputation—The circular method—The flap method—Rules for Teale's operation—Amputations and exarticula- tions of the upper limb—Amputations and exarticulations of the lower limb—Affections of stumps . . '......901-930 CHAPTER LV. EXCISION OF BONES AND JOINTS. Excision of bones—Excision of joints. Indications—Excision of special joints.............930-944 THE SURGEON'S VADE-MECUM. PART I. CHAPTER I. THE ETIOLOGY OF DISEASE. The word surgeon, a contraction of chirurgeon (chirurgien, from xelP and epyov), signifies one who cures abnormal conditions by working or operating upon them with the hand. Most cases, therefore, requiring manual treat- ment are placed in that division of the healing art called surgery; but this branch now deals also with many cases in which no such treatment is neces- sary or possible. To be a good surgeon, a thorough general knowledge of medicine, and of the sciences upon which the whole healing art is based, is absolutely essential. -* Morbid Conditions and their Causes. The cases which surgery is called upon to treat may be divided roughly into those of injury, disease, and the results of injury or disease. Although every one knows the difference in meaning implied by the terms injury and disease as commonly used, it is found, when we come to consider the etiology of morbid conditions in general, that no line can be drawn between injuries and diseases. Many cases occur which it is impossible to place under either one head or the other. Disease may be either inherited or acquired. In some cases of inherited disease, as syphilis, it is probable that the actual cause of the disease exists in the ovum or spermatozoa at the time of conception, but in the great majority influences similar to those which produce the general resemblance between children and parents are at work, and the tendency to grow abnor- mally, to perform function imperfectly—the tendency to disease, in short, rather than the disease itself, is inherited. The so-called tubercular diathesis is an example of this. But cases of inherited disease are due to the handing down by parents to their offspring either of the actual causes of disease or of the abnormal tendencies of their tissues, which the parents had acquired from influences external to their organisms. It would seem, therefore, that all primary morbid conditions are ultimately due to the action of causes 3 34 ETIOLOGY OF DISEASE. external to the economy; once acquired, such conditions may or may not be handed down from parents to offspring ; but probably no condition of primary disease is without its secondary results upon the body at large, and in many cases these results are more striking than the primary disease. The causes of primary acquired disease may probably all be ranged under two headings: r r\ x-i. *■ i" Hypersemia. Quantitative. ^ A^mia> Imperfect blood 1. Abnormal Food Supply.— -; formation. Imperfect purifica- tion. Introduction of poisons, foreign bodies, etc., from without. Qualitative. Abnormal Physical Conditions.—Including injuries of all kinds—gross and fine. The great majority of the causes of disease require no explanation of their nature, properties, etc.; but there is one group which has of late years come to occupy a most important position in medicine, and which is so pecu- liar and so little generally known as to demand a short special notice. We mean the vegetable parasites. They may fall into either of the above classes, according as they produce disease by their chemical or mechanical action. The vegetable parasites of practical importance in surgery all belong to the Schizomycetes. The O'idium albicans, or parasite of thrush, may be a yeast; and the Actinomycetes, or ray-fungus, and the Chionyphe Carteri, found in Actinomycosis and Madura foot respectively, may be moulds; but the botan- ical position of all three, and even the existence of the latter, is doubtful, whilst the diseases are comparatively unimportant. The Schizomycetes are very small, unicellular, achlorophyllous organisms, the cells being round, oval, dumb-bell-shaped, rod-shaped, straight or curved, or filamentous. They consist, as a rule, of structureless protoplasm; but their resistance to alkaline and dilute acids makes it probable that they have an outer coat of a substance like cellulose. All multiply by transverse division—the rods almost always, if not always, across their long axis, the spheres sometimes across only one diameter, again across two diameters at right angles to each other. In certain of the rod-forms spore-formation has been shown to alternate with fission—a most important point, as the spores are very much more tenacious of life than the adult organisms. The spores form in the rods in some instances, in others only after the rods have grown into long filaments (leptoihrix). The organisms formed by fission may separate at once from the parents and proceed to divide separately, or multiplication may go on without pre- vious separation, the result being long chains or more or less spherical aggre- gations, according as the division takes place along one or two lines. These spherical collections are often embedded in a viscid substance—zooglcea. Division is very rapidly carried out, and each newly formed cell may at once undergo fission. Cohn has calculated that one bacterium may have 16,000,000 descendants in twenty-four hours. Some of these organisms never move, but most are seen in both active and resting states. The round forms show only Brownian movement when single, but in chains they exhibit a slow locomotion. The straight and twisted rod- forms move backward or forward without turning, and rotate rapidly on their long axes. One or two cilia have been seen in many forms, but it is INFLUENCE OF TEMPERATURE. 35 said that the cell may move rapidly whilst the cilia are motionless, and vice versa. Free supply of oxygen is closely related to active movement, but does not always excite it. Having learned to recognize these organisms, the questions of their life- requirements, of the best methods of destroying them, and of their distribu- tion in nature, must be considered; in order that, by attention to one or all of these points, we may prevent the entry of bacteria into the body and into wounds, this being the most important task of the surgeon. Conditions of Life. Food.—Like all other living things, bacteria must be supplied with the elements of which they consist, to make up for wear and tear. These elements are, carbon, hydrogen, nitrogen, oxygen, phos- phorus, sulphur, calcium, magnesium, and potassium; and some of the hydrogen and oxygen must be supplied in the form of water. It is characteristic of the order that, unlike animals, they can obtain their nitrogen from ammonia and ammoniacal compounds; but, unlike green plants, they are unable to obtain their carbon from carbonic acid. They can take it from tartaric and other organic acids, or from carbohydrates. Tartrate of ammonia (Cohn's fluid) will, therefore, serve to supply nitrogen and carbon to many of these plants; but others, and especially those which invade the tissues of living animals, will not grow unless provided with a highly organized soil. The reaction of the soil has an important influence, alkalinity being far more favorable than acidity to most species. With regard to oxygen, most bacteria require a supply of this element in the free state; the relation of free oxygen to mobility is marked. There are, however, many bacteria which can live for a considerable time without free oxygen, obtaining their supply from the organic compounds which they decompose. It is said by Pasteur that free oxygen is absolutely fatal to one or two species. Water is an absolute necessity for the development of bacteria: nothing that is dry ever decomposes. The concentration of a solution makes a great deal of difference with regard to the organisms that will grow in it, some preferring more or less dilute, others concentrated solutions of the same substances. Most organisms withstand desiccation for long periods. Temperature.—The range of temperature favorable to the growth of each organism varies considerably, both in extent and in position upon the scale. Speaking generally, a temperature about that of the human body is the most favorable. Many hardy species will multiply freely at temperatures far removed from this: but without certain limits, be they narrow or wide, each organism multiplies first more slowly, then not at all, and finally becomes rigid and motionless. The rigor caloris passes at once into death, but the rigor frigoris induced even by —220° F. does not kill many forms, and it is not certain that cold kills any. It simply inhibits their growth and action. Development of all forms ceases, however, below 40° F., and of many forms at a much higher point; it ceases also at 120°-130° F., and many species are killed by this temperature. Boiling for a few minutes kills the majority of organisms. Spores, however, will resist boiling for several hours; a temperature of 240° F. maintained for thirty minutes prob- ably destroys even these, but dry spores of B. anthracis (the most resistant known) are not killed by 284° F. in less than three hours. Rest is necessary for the development of some bacteria, and is favorable for all. The struggle for existence and survival of the fittest is nowhere more obvious than among these organisms. If germs of several kinds exist in a fluid, cceieris paribus, those which are most numerous have the advantage 36 ETIOLOGY OF DISEASE. and will crowd out other forms. But probably the requirements of no two species are exactly alike, so one form may be more suited to the existing conditions than the others, and will more or less rapidly obtain possession of the field. As circumstances alter, perhaps owing to the vital action of this organism itself, they become less favorable to it, more favorable to other forms which then become more and more numerous, the original one dying out. Very slight differences, so slight as to elude detection at present, may prevent or favor the development of an organism; and it is thus, probably, that we are to account for the localization of the inflammations which char- acterize so many general infective diseases—e. g., of the bowel in typhoid, and also for the immunity which many people exhibit with regard to certain of these diseases, though they are, perhaps, much more exposed to infection and, presumably, take in the virus in larger quantity than others who suffer from them. When shall we be able to recognize the difference between a lung, a synovial membrane, or a gland in which the tubercle bacillus grows readily, and similar organs in which it does not grow ? It is, however, probable that many of the above differences between indi- viduals may be due to non-entry of organisms in spite of exposure to them, or to their entry only in numbers which the tissues can overcome. For animals are exposed like men to these parasites, but the mortality is very small among them compared with that which can be brought about by directly inoculating them with pure cultivations of the organisms which cause various diseases. On the other hand, anything which depresses the vital activity of a part ren- ders the growth of organisms in that part more easy, as is seen in the numerous cases of suppuration after subcutaneous injury, of osteomyelitis after injury, of tubercular lesions appearing under unfavorable hygienic conditions in people previously strong. Methods of Preventing the Development of, or of Destroying Bacteria.—It is always more easy to prevent development than to destroy actively growing organisms; but, generally, means which will check develop- ment will also, when applied more strongly, kill the germs. Development of organisms in a suitable soil may be prevented by—ab- straction of water ; by keeping the soil at a temperature above or below that at which organisms can multiply; in most cases by the removal of oxygen; by adding to the soil one of the many substances known as anti- septics from their power of destroying septic and allied organisms—methods founded upon what we know of their life-requirements; or the soil may be sterilized and the further entry of bacteria from without prevented. The actual cautery is sometimes used by surgeons to destroy tissues invaded by some virulent locally infective poison, as that of hospital gangrene; other- wise heat has no place as an antiseptic in surgery. Cold in the shape of ice-bags is frequently employed and probably the temperature of the tissues is reduced sufficiently to impede or prevent the multiplication of many cells; at the same time, free access of blood is permitted, transudation is increased and a chance is afforded that organisms may be carried away by the lymph- stream and distributed in small numbers among healthy tissues to die there. "Dry dressings" are much used, the idea being to dry up all discharge as it escapes from a wound, and thus to prevent putrefaction, so that a large wound may heal beneath such a dressing just as a smaller one frequently heals beneath a scab. Generally, such dressings are impregnated with some antiseptic, to render them safe, even though they may be unable to dry up all discharge. Removal of oxygen is never employed in surgery to prevent development of organisms. ANTISEPTICS—CARBOLIC ACID. 37 4 The use of antiseptic substances for the purpose of preventing decomposition in wounds is now almost universal in surgery. These bodies vary greatly in their power of destroying microorganisms. At first they were tested, and somewhat rudely, as to the percentage of each required to prevent putre- faction or stinking decomposition ; this percentage was spoken of as the efficient strength of the antiseptic. Putrefaction was thus chosen because decomposition of wound-discharges was obviously intimately related to the occurrence of wound-diseases, and the change was easily recognizable by smell and clinically also by discoloration of the dressings; but there are many objections to it as a scientific test. In the first place, putrefaction has no exact meaning ; it is a very complex process, a number of different but varying organisms—many as yet but little known—being found in putrid materials ; the Bacterium tenno, a non-pathogenic fungus, is the most con- stant, and to it are attributed the foul-smelling bodies. Next, septic diseases, though generally connected with wounds in which bacteria are found, are not necessarily connected with putrid or offensive wounds. And, lastly, dis- eases, apparently the same as certain of the so-called wound-diseases, may arise without any discoverable wound. The term septic wound-diseases, there- fore, must be taken as meaning diseases which originate in connection with wounds in which bacterial decomposition is going on—often, but not neces- sarily, putrid decomposition. An antiseptic must be regarded as an agent which is inimical not only to the organisms of putrefaction but to bacterial decomposition of all kinds; and lastly, it must be noted that the object of antiseptic surgery is now, not simply the prevention of putrefaction of wound- discharges, but the shielding of these fluids from every form of bacterial change. This may be done—1, by killing all bacteria which approach the wound ; 2, by rendering the conditions such that organisms, though they may live, cannot develop ; 3, by preventing access of organisms to an aseptic wound. Of these methods the first is certainly the safest in practice. Koch ("Ueber Desinfection," Mitth. a. d. Gesundheitsamte, vol. i., 1881) points out that with regard to an antiseptic substance we must know, 1. Whether it will kill all microorganisms ; and to decide this point he tests them upon the spores of B. anthracis or of the bacilli of malignant oedema found in garden- soil—the most resistant organisms known. 2. Its behavior to the less resis- tant organisms—bacilli, bacteria, and micrococci. 3. The percentage of it required to prevent the development of germs in suitable media. 4. Prac- tical points, such as the concentration required to produce the above effects, the necessary duration of action, the influence of various fluids used as sol- vents in developing the action of the antiseptic, etc. To determine these points Koch dipped threads in fluids or substances containing spores, bacilli, etc., and dried them ; they were then exposed for varying times to the action of the antiseptic in different forms and varying strengths ; and, finally, they were placed upon solid culture-soils and the microscope was employed to tell whether any of the organisms developed, as also was the inoculation of animals. The results thus obtained were the following: Carbolic Acid.—Five per cent. (1 in 20) fails to destroy spores in forty- eight hours; but bacilli {B. anthracis) are killed in one minute. The con- centration necessary to prevent the development of various organisms differs much ; from 1 in 850 for splenic fever spores to 1 in 400 for germs falling from the air. The most potent form is a watery solution. The vapor of pure carbolic acid does not act well; and the compounds of carbolic acid come distinctly after the pure substance, sulphocarbolate of zinc being the most powerful. The high place taken in surgery by carbolic acid is due to its almost 38 ETIOLOGY OF DISEASE. instantly fatal effect upon adult organisms and its power of inhibiting devel- opment of spores; it is practically useless as a destroyer of spores. Chloride of Zinc.—Five per cent, failed to kill spores in a month, and was without effect in preventing their development. One per cent, failed to kill M. prodigiosus in forty-eight hours. The undoubted value of ZnCl2 in surgery is, according to these facts, inexplicable; further observation is necessary. Corrosive Sublimate.—One per thousand destroyed the spores in one minute; this, then, is the only antiseptic capable of employment in surgery which will certainly disinfect a surgeon's hands when they are just washed in the lotion. Care must be taken to remove all soap from a part to be disin- fected with sublimate, as the two are said to form a compound of little anti- septic value. 1 part in 20,000 will prevent the development of spores. Koch points out that for practical purposes no disinfectant is reliable unless it does its work (i. e., destroys spores) in less than twenty-four hours. Of a large number of substances examined, carbolic acid (1 in 20), corrosive sublimate (1 per cent.), osmic acid (1 per cent.), permanganate of potash (5 per cent.), bromine, chlorine, and iodine were the only ones which stood the test; and of these osmic acid and permanganate of potash cannot be used on account of cost and other reasons. The percentage of an antiseptic which must be present to prevent develop- ment of an organism varies with the organism, and largely with the amount of albumen and the salts present in the culture-soil. The following results were obtained by Koch for spores of B. anthracis in a solution of meat peptone: Oil of mustard.........1 in 33,000 Sublimate..........1 in 20,000 Chromic acid.........1 in 8,000 Salicylic acid.........1 in 1,500 Eucalyptol..........1 in 1,000 Carbolic acid...... . . 1 in 850 Boracic acid . . . . . . . . . 1 in 800 Borax...........1 in 700 Koch found that whenever they could be used, watery solutions were more effective than oily or alcoholic, the latter being sometimes quite inefficient; thus Volkmann reports a fatal case of splenic fever from catgut prepared in carbolic oil from the intestine of a sheep dead of the disease, and used as ligatures after the amputation of a breast. When placed in contact with water-containing tissues, some of the antiseptic will diffuse and the watery solution will be active, but oily solutions are useless as germicides when applied to dry objects. Distribution in Nature.—Bacteria exist wherever putrescible and fermentescible material is present—i. e., their distribution is that of higher vegetable or animal life. In the polar regions, above the line of vegetation on mountains, or in mid-ocean, they may be absent or very rare; thus Tyn- dall found that putrescible but sterile fluids in flasks opened high on the Alps often evaporated to dryness without any decomposition. They increase rapidly in number with density of population. They are found in the earth to the depth of one metre ordinarily; they exist in all water, except such as comes from Artesian wells; and the air contains them together with the spores of moulds, yeast cells, and other organic and inorganic dust. The supply to the air is kept up by the wind sweeping over the dry and powdery remains of substances which have putrefied ; aud from the air organisms are deposited upon every surface exposed to it. But even in large towns organ- isms are not always so numerous in air that a wound or a sterile fluid cannot RELATION OF BACTERIA TO THE BODY. 39 be left exposed for a minute without the certainty that decomposition will set in ; in Edinburgh, Lister found that after half an hour's exposure of some urine, only three moulds grew. It may, in some parts, however, be impos- sible to pour fluid from a flask into tubes without imminent danger of putrid decomposition. Ordinarily, the spores of moulds are much commoner in air than organisms of putrefaction ; the latter seem to have their special habitat in water, a drop of which will almost certainly infect a sterile solution. Relation of Bacteria to the Body.—Bacteria in numbers are taken in with every breath, and with almost every mouthful of food and drink. Those entering the air-passages are deposited on the mucous membrane of nose, mouth, pharynx, and larger bronchi; thev exist only in the tidal air, the complemental being free from particles of all kinds. Organisms do not develop in the acid gastric juice, but below the entry of the bile and pan- creatic ducts they become numerous, giving rise to products similar to those of pancreatic digestion. The raucous membranes are as much outside the body as the skin; but inanimate particles pass through them, so it is probable that some of those organisms which are universally present are also constantly passing through them into the tissues. The skin is abso- lutely protective against them, but the smallest breach of continuity enables them to enter. Certain organisms—those of the infective diseases of wounds—almost always enter through wounds, whilst others—those of the acute specific fevers—enter as a rule through mucous membranes; but probably no organism is absolutely bound to one mode of entry. Having actually entered the body, the bacteria fall into two classes of great clinical importance, according as they are able or unable to live and grow in the tissues. Those which grow and give rise to disease are called pathogenic; those which die or are eliminated without giving rise to disease are non-pathogenic. The line between these classes is not sharply defined, organisms which grow only in specially predisposed individuals or parts uniting those which never grow in the body to those which almost always grow when introduced into the tissues. The organisms which are constantly present in the bronchi and alimentary tube, and which enter freely in proportion to the number taken in with the air or food, are non-pathogenic; they either die in the tissues or are elimi- nated by the kidneys. They do ndt die immediately, and when injected in quantity into the blood may appear alive in the urine. Among these organisms must be placed the bacteria of putrefaction. These by their action in the discharges of wounds produce the chemical poison which is apparently the cause of septic intoxication, and its milder varieties—septic traumatic and hectic fever. Only very exceptionally do they exist alive in the tissues; and it may be stated roundly that an antiseptic dressing never becomes putrid from organisms which have escaped from the tissues into the wound. The pathogenic organisms are fortunately not universally present; but now and again certain of them enter the tissues by one or other of the above channels. The person then is in imminent danger of the diseases to which they give rise. The class of infective diseases, or diseases due to the action of pathogenic organisms, is probably a very large one, and is divisible into two groups, local and general; the former being due to organisms which multiply at their point of entry, and spread thence only by continuity of tissue, whilst in the latter the organisms enter and probably multiply in the blood, causing injurious changes in it, sometimes settling and exciting secondary inflam- mations. In the tissues bateria may produce by their life-action compounds which 40 ETIOLOGY OF DISEASE. are pyrogenous or fever-exciting, others which are phlogogenous or inflamma- tion-exciting, whilst others again produce actual necrosis of the surrounding cells. Before they can produce local lesions they must settle—i. e., be arrested at some spot. Some organisms multiply in the blood and are found in the vessels everywhere; others form small masses which become arrested in the finer vessels ; others grow in lymphatics, others again in certain tissues only. Just now germs are in the ascendant; the tendency is to find one as the cause of any obscure disease. It is therefore necessary to insist upon stringent proof before accepting any such discoveries. This proof consists : (1) in demonstrating the constant presence of an organism, recognizable by its form, mode of growth, or physiological action, throughout, or in the early stages of the disease ; (2) in isolating this organism and obtaining pure cultures of it; (3) in inoculating animals with pure cultures and producing the disease in them. As animals frequently are not subject to diseases of man, the latter part of the proof is sometimes difficult to carry out. Classification of Bacteria.—Some botanists (Nageli) believe that all the Schizomycetes are modifications, due to external circumstances, of a very few forms ; they are thought to adapt themselves so rapidly to surrounding conditions that within the limits of an experiment they may be seen to change their form, and distinct evidence of altered physiological activity may be obtained. According to this view, it depends upon external circumstances whether the micrococcus of erysipelas or gonorrhoea or the bacillus of tubercle or glanders develops from one of the primary forms. None of these organisms is specific and cannot be regarded as a species in classification. Others (Cohn, Koch) hold that there are a great number of specific forms characterized by shape, size, mode of growth when cultivated, and physi- ological action; and in prolonged cultivations they have failed to find evidence of variation such as is described above. Many bacteria indistin- guishable by form and size have markedly different modes of growth and physiological actions, and preserve them ; they will therefore be different species. The increase and diminution in the virulence of organisms reported by various experimenters have sometimes been unreal (Davaine) ; and when real (Pasteur's attenuation of the poisons of splenic fever and chicken-cholera) do not prevent specific classification, for the organisms are quite recognizable by their form, size, and modes of growth in solid soils, and they never produce any disease other than splenic fever or chicken-cholera. The question of the mutability of bacteria is, however, still sub judice. At present the balance of evidence is decidedly against it, so we shall assume that there are many distinct species of bacteria and adopt Cohn's classification of them. He divides the Schizomycetes into the following orders: 1. Sph^erobacteria, or Micrococci.—Round or short oval cells, single, in chains or zooglcea-masses. 2. Microbacteria, or Bacteria. (The latter name is unhappily used also for the whole class.)—Cylindrical or oval cells of which the length is not more than twice the breadth, single, in pairs, chains, or zooglcea-masses; not known to form spores. 3. Desmobacteria, or Bacilli.—Cylindrical, length more than twice the breadth, often growing into long unbranched filaments; zooglcea-masses rare, but short chains and swarms common. Spores have been found in many forms. 4. Spirobacteria, or screwlike organisms. Of no importance surgically. Spirochcda Obermeieri of relapsing fever is the chief. Each order contains one or two genera, and these again species. The latter are classed according as they are pigment-forming {chromogenic), fer- LOCAL DISTURBANCES OF THE CIRCULATION. 41 mentative (zymogenic), or pathogenic. We shall encounter many of each kind in the following pages. The student should diligently practise the various methods of staining and recognizing these organisms. Detection of a specific form will often determine the diagnosis of a doubtful case. To those who have perfected themselves in the methods of pure cultivation a great field of research in the etiology of disease is open. CHAPTER II. LOCAL DISTURBANCES OF THE CIRCULATION. These are due to causes acting primarily, not upon the heart nor upon the vascular system as a whole, but upon a portion of the latter only; secondarily, however, local changes must be followed by general, as the vas- cular system contains a fairly constant quantity of blood. A local disturb- ance may complicate a general one, being, in fact, induced by local causes ordinarily too slight to do so. General circulatory disturbances are there- fore of great importance surgically, but works on medicine must be consulted for a description of them. Local departures from the normal state produce either too little or too much blood in a part, conditions known as anosmia or hyperemia. Such variations are common physiologically; they become pathological when they exceed the physiological limits in duration or degree. An.emia. Local An.emia.—The word is used loosely to express either partial or complete bloodlessness of a part (also diminution of red corpuscles in the blood). Causes.—Conditions obstructing the entry of blood—e. g., uniform com- pression of the vessels of a part, as by Esmarch's bandage or free effusion beneath the skin or fascia; constriction of arteries by ligature or compres- sion by tumors, abscesses, etc.; diminution of the lumen of arteries by thickening of their walls from simple or syphilitic endarteritis, or by con- traction induced by ergot, cold, etc.; blocking of the vessel by thrombosis or embolism ; and, lastly, arrest of function. Symptoms and Results.—Anaemic parts are pale, shrunken, dry, and cooler than normal, the symptoms increasing with diminution of blood-flow. In chronic partial ancemia these signs are all present; and, in addition, growth is slow and perhaps imperfect; so also is function—e.g., sensation is dulled ; adult parts atrophy or degenerate fattily, or both atrophy and degenerate; and cramps of muscles often cause much pain, as is seen in the legs of old people with degenerate arteries. Such chronic malnutrition greatly diminishes the resisting power of tissues to injury, and renders them prone to inflammation easily running into ulceration or gangrene. Total ancemia in man continued beyond a few hours inevitably causes death of the part. Some tissues resist anaemia longer than others; the in- testine dies sooner than skin or muscle. If the anaemia be not of sufficient duration itself to cause death, this may still result from inflammation setting in upon restoration of the circulation. Thus Cohnheim found that by ren- 42 LOCAL DISTURBANCES OF THE CIRCULATION. dering a rabbit's ear bloodless and keeping it so for periods of eight to forty-eight hours, he could produce any stage of inflammation—oedema, purulent infiltration, hemorrhagic infiltration, gangrene ; aniemia therefore causes that change in the vessel-walls which is the essential lesion of in- flammation. When an artery is obstructed, the result to the parts it supplies depends upon the anastomoses of the vessel beyond the obstruction. If these are very free, either with branches of the same trunk above the obstruction, or with other unobstructed arteries (branches of the mesenteric, ulnar, or radial), the effect upon the circulation may be practically nil, blood being immediately carried into the trunk beyond the obstruction by collateral channels. When the anastomosis is less free, as in the case of the femoral, a time follows obstruction in which it is doubtful whether collateral circula- tion will be established throughout the limb, and upon the distance to which blood penetrates depends the fate of the limb. Sometimes, even here, there is scarcely any sign of embarrassment; at others, oedema which soon subsides occurs; or a toe is lost, or, again, the limb dies up to the knee. Ordinarily, the limb remains pale for a few hours, and would become cold but for ex- ternal warmth, and the functions of its muscles and nerves are more or less depressed; within twenty-four hours the surface is generally slightly redder and two or three degrees warmer than that of the opposite limb, owing to full dilatation of all collateral channels diminishing the resistance to the entry of blood to a minimum. This dilatation is certainly reflex, inhibition of the vasoconstrictor nerves being excited by some stimulus arising in the anaemic parts; but prolonged anaemia has probably much to do with it, acting as on the removal of Esmarch's bandage. The duration of the dila- tation varies, doubtless with that of the precedent anaemia; it may continue some days, and is often accompanied by burning pain. Ultimately collateral vessels, previously small, become larger, thicker walled, and tortuous from increase in length, and pulsation may return in the trunk beyond the ob- struction ; there is no evidence of the formation of new vessels. If the ob- struction is gradual, the probability of the establishment of collateral circu- lation is always greater than under opposite conditions. But the result is very different when the artery beyond the obstruction has none but capillary anastomoses. The secondary branches of the cere- bral, retinal, pulmonary, splenic, and renal arteries are examples of these so-called terminal arteries; and the renal, splenic, and retinal arteries them- selves almost solely supply their respective organs. If such an artery is suddenly and completely blocked, its branches con- tract, and the area supplied by it becomes anaemic; then, as the contraction gives way, Cohnheim says that blood regurgitates from the veins and dis- tends every vessel, the region now becoming swollen and dark with blood, whilst round it is a bright red ring due to dilatation of the neighboring vessels and their capillaries. From these blood doubtless enters the most external capillaries of the area, but the resistance soon becomes too great, and it stagnates. Ultimately, as the vessels die, corpuscles pass through their walls and infiltrate the tissues largely. Such lesions are called infarcts. But when gravity or valves oppose the return of blood through veins, the area of the obstructed artery remains pale. Litten gives another account of infarction, viz., that it never occurs from veins unless intravenous pressure is much increased, as in the renal by clamp- ing the cava at the diaphragm. Under ordinary circumstances, it is always due to the existence of small arteries, such as the twigs from the phrenic, suprarenal, lumbar, and spermatic arteries to the kidneys. When the renal artery is tied, these enlarge, and a large quantity of blood enters the part by HYPEREMIA. 43 them; the pressure in them is not sufficient, however, to maintain circulation and vitality, though some blood reaches the renal vein, infarction and swelling of the kidney being greater when this is tied than when it is open. This, Littefl says, proves that venous regurgitation is not the cause of infarction; whilst the fact that no infarction occurs, even though the renal vein be open, after th*1 renal artery has been rendered truly terminal by stripping the kidney out of its bed of fat, shows that small arteries entering through the capsule are the cause of this phenomenon. Both Litten and Cohnheim agree that the corpuscles do not pass out through ruptured vessels, but Cohnheim makes them escape after prolonged anaemia has altered the vessel-wall as in the rabbit's ear, whilst Litten states that the escape begins immediately after the obstruction, and is due simply to mechanical stretching of the capillaries and small veins. Whichever view is correct, it is certain that infarction does not follow the obstruction of some terminal arteries—e. g., that of retina and divisions of cerebral arteries; the supplied areas remain anaemic, the cells lose their nuclei, swell, and then undergo fatty change, forming a yellow, usually wedge-shaped mass on section. When infarction has occurred the patch gradually becomes decolorized, whilst the tissues undergo the above changes. The fatty material may be absorbed, leaving a depressed scar; or a firm cheesy mass may remain, surrounded by scar-tissue, and ultimately calcify. Obstruction of a terminal artery therefore leads to death of the part sup- plied by it, but the ordinary signs of gangrene are absent because the parts are prevented from drying and shielded from the causes of putrefaction, and the part falls into a state of necrobiosis. In this condition it affords a soil in which organisms grow much more easily than in living tissues ; and either the plug which blocks the vessel may contain them (see pyaemia), or they may reach the area separately through the blood. Treatment.—Removal of the cause wherever possible. Measures calcu- lated to improve the general health. Proper exercise, methodical friction, and flannel or lambswool about the affected part will be useful in chronic local anaemia. In these cases patients should be cautioned against even such slight injuries as are commonly inflicted in cutting nails, and against exposure to cold. Nothing can be done for the blocking of terminal arteries, except to prevent such a condition of clots in the veins leading from wounds as shall cause them to break down. Hyperemia. This may be of two kinds: (1) Arterial or active, (2) venous,passive, or mechanical. Active Hyperemia. Causes.—Conditions diminishing arterial resist- ance in a part, the general arterial pressure being maintained. They may be arranged in three groups: (1) those producing dilatation by direct action upon the arterial wall; (2) those acting reflexly, inhibiting the vaso-con- strictor action of the sympathetic by exciting the sensory nerves of the part; (3) those inhibiting the action of the sympathetic through vaso-dilator nerves, such as the chorda, the nervi erigentes, or the auricularis magna of the rabbit; but the universal existence of such nerves is not established. 1. Influences Acting Directly on the Vessel-wall.—Stimulants and irritants differ only in degree; a stimulant causes the muscular coat to contract, an irritant injures its contractility, and it yields before a distending force. Dilatation from actual injury of the muscular coat is the cause of the hyperaemia which accompanies inflammation, and is, surgically, the most important form. The cause of the inflammation, be it mechanical, 44 LOCAL DISTURBANCES OF THE CIRCULATION. chemical, or physical, actually damages, and consequently impairs the functions of the muscular and all other tissues in the wall of the vessel. In these cases the stimulus required to cause contraction of a vessel is greater than normal, and perhaps even the drawing of a needle across an exposed arteriole may be ineffectual. Hyperaemia is frequently secondary to anaemia, as shown by the free general bleeding after the removal of Esmarch's bandage, and that dilatation which facilitates the establishment of collateral circulation (page 26), is doubtless in great measure thus accounted for. It is due sometimes to fatigue of the nervous and muscular structures concerned in maintaining the pre- liminary state of contraction, and always to more or less malnutrition of the muscular coat. The sudden removal of external pressure after this has been exercised for a long time produces hyperaemia, in some cases with dangerous consequences. Thus the sudden emptying of a peritoneum tightly distended with fluid, of a greatly distended bladder, especially when the patient is standing, or the removal of a large tumor, may lead to fainting, because the great abdominal veins dilate and contain a large proportion of the blood. Smaller vessels may under these circumstances rupture, giving rise to the blood often mixed with the last urine drawn from chronically distended bladders, and which may tinge the urine for days after the first emptying of the bladder Aspi- rating a pleura often shows a similar result. In these cases the muscle of the vessel walls, accustomed to assistance, appears to be unequal to the strain thus suddenly thrown upon it, and it may be days before it recovers its ordi- nary power. Warmth up to 118° F. produces direct relaxation ; and, as it has this effect in parts of which all nerves have been divided, part at least of its ordinary action must be direct. Above 118° it causes a preliminary con- traction which may pass directly into heat-rigor and death, if the tempera- ture is sufficiently raised. The immediate anaemia is seen in the white spot found if a drop of hot sealing-wax is quickly removed from a hand upon which it has fallen; the subsequent persistent dilatation from injury of muscle is also well known. Moderate cold will maintain for a long time pallor or blueness of the skin, or a mottled condition, white with purple patches—the blood moving slowly through the latter. But after the application of an icebag for a few hours, the skin will usually be found bright red, the vessels being dilated and the blood passing rapidly through them. 2. Influences Either Directly or Reflexly Preventing the Action of the Vaso-constrictor Nerves.—Section of the sympathetic in the neck produces redness of the side of the head and neck, perhaps even of the arm, sometimes accompanied by sweating ; redness of the conjunctiva, secretion of tears, flattening of the cornea from diminished intraocular tension, contracted pupil and ptosis. It many cases these symptoms are not ordinarily present, but are brought on by slight exertion. The abnormal may be two or three degrees higher than the normal side. Such symptoms are met with in rare cases of stabs and gunshot wounds of the neck.1 Hutchinson reports cases of fractured clavicle with injury to the brachial plexus, causing paralysis of the arm, accompanied by all these symptoms; in others, only narrowing of the pupil and of the palpebral fissure have indicated injury of the sympathetic. Similar results are noted in some cases of tumors in the neck pressing on and causing degeneration of the sym- pathetic ; goitres are among the commonest. 1 Weir Mitchell, Morehouse, and Keen, Gunshot Wounds and other Injuries of Nerves. CAUSES OF ACTIVE HYPEREMIA. 45 Strange to say, no hyperaemia of the extremities has been recorded after section of their nerves, but Waller and Weir Mitchell produced hyperaemia and rise of temperature between the fourth and fifth fingers by freezing their ulnar nerves at the elbow. Excitation of the central end of a sensory nerve produces reflex dilatation of the vessels of the part supplied by it, but rise of arterial tonus elsewhere, the result being active hyperaemia. The probability is that irritants act earliest and most easily upon the sensory nerves ; then upon the vessels them- selves. Consequently, the slightest stimuli—such as friction, stimulant liniments, etc.—probably produce redness in this way. It seems that the production of hyperaemia in superficial parts often leads to anaemia of viscera beneath them, which perhaps explains the action of fomentations, etc., in relieving inflammation of deep organs. Collateral hyperemia (page 26) has been attributed to increased pressure upon the collateral vessels. But that these specially dilate must be due to some reflex inhibition of the vaso-constrictor nerve, for the effect of blocking an artery is to raise, for a longer or shorter time, the pressure throughout the arterial system. Local dilatation implies a local cause, and this might be anaruia, were it not that surrounding vessels, which are not rendered anaemic by the obstruction, dilate to supply the anaemic area. So-called compensatory hyperozmioz must be mentioned here, though the nervous mechanism arranging for them is not understood. In these, after removal of an organ, the blood which should go to it passes to the organ or organs which are capable of taking on its functions ; after nephrectomy, the blood goes to the other kidney, and if this is seriously diseased the patient dies; after removal of the spleen in animals increased blood-supply goes to lymphatic glands, marrow of bones, and other lymphatic structures. 3. Some hypersemiae are believed to be due to excitation of vaso-inhibitory or vaso-dilator nerves. But little is known about them. V. Recklinghausen says that these hypersemiae are more acute and run a more rapid (often quite short) course than the above, are generally accompanied by neuralgic pains, and often by increased secretion of the glands in the affected area and exudation into the tissues or desquamation of epithelium from the surface. Blushing from shame, anger, alcohol, indigestion, affords at once a physi- ological and pathological example, but the chorda and the nervi erigentes are the types of vaso-dilator nerves. V. Recklinghausen regards as examples the hyperaemiae accompanying neuralgiae of the branches of the fifth ; herpes zoster and the many wheals, papules, and erythemata which break out upon the skin with burning pain ; the results of neuritis secondary to injury coining on after a week or more, producing hyperaemia, with pains and often swelling, recurring perhaps periodically and ending in that painful, thin, tense, shiny, and hairless condition known as glossy-skin. Finally v. Recklinghausen places joint- lesions occurring in ataxy, myelitis, hemiplegia, etc., as neuroses allied to vaso-dilator neuroses. Symptoms.—Bright redness, elevation of temperature even to six or eight degrees above that of the opposite side, sense of pulsation, hyperaesthesia and sometimes pain ; in glandular organs or parts the secretion is sometimes increased,-some swelling is always present, varying with the vascularity of the part. The blood at first rushes through the widened vessels with excessive rapidity, the distinction between the axial and plasmatic layers being lost, and the blood in the veins being red and often pulsating. But the initial rate of flow sinks if the general arterial pressure falls, as is usual after a time. The transudation from the vessels is increased in every case, but until the lymphatics are unequal to the task of carrying it off no oedema occurs. 46 LOCAL DISTURBANCES OF THE CIRCULATION. As a rule, redness and swelling have completely disappeared post mortem. Hemorrhages not uncommonly occur during active hyperaemia, especially if the vessels of the part are diseased, or of new formation. Treatment.—In all directly excited cases removal of the cause : also in reflex cases where the cause is discoverable; the removal of any source of irritation in the course of a nerve resulting from injury; the application of belladonna or of liq. plumbi fort.; and attention to digestion and the bowels. 4. Passive, Venous, or Mechanical Hyperemia (Congestion).— In this condition a part contains in its capillaries and veins an excess of blood in a more or less venous state, these vessels being wider and the blood-stream in them slower than normal. Causes.—Either diminution of the forces which carry on the circulation, or direct obstruction to the return of blood by the veins ; congestions resulting from the former cause are called hypostatic, from the latter obstructive. The great cause of hypostatic congestion is cardiac weakness, but similar diminution in the driving force may result from obstruction in the arterial path, and incompetence of the valves in veins will tend in a similar direction. Practically, however, hypostatic congestions mean those due to cardiac failure. This results from senile decay, exhausting illness, fatty degeneration, uncom- pensated valve disease, high fever, etc. Under these conditions a sharp lookout must be kept to prevent hypostatic congestions. These are best seen in the lungs. When the heart is acting weakly, the result will be more obvious the longer the circuit through which it has to drive the blood, consequently blood will tend most to lag in the lower and hinder parts of the lungs, which in dorsal decubitus are the lowest parts— i. e., the intravenous pressure due to gravity is highest here. If the patient changes his position little, this high pressure is almost constantly maintained, distending vessels which are imperfectly nourished ; moreover, those parts of the lung always move least and are still further hampered by the position in bed, so little help from movements is derived by the circulation. Conse- quently the lower and hinder parts of the lungs become darkly congested ; they do not collapse when the chest is opened, but feel heavy and more solid and contain less air than the upper anterior parts; on section a quantity of bloody fluid, more or less frothy, can be pressed from the tissues and cavi- ties of the lung and the part is usually softened. This condition not unfre- quently passes into one of catarrhal pneumonia and real consolidation of lung (hypostaticpneumonia). Everywhere the circulation is more or less abnormal, and doubtless this helps in the production of bedsores over the sacrum and heels; but irritation and anaemia from constant pressure, friction, and perhaps contact with urine, etc., plays the chief part. Obstructive congestions result from heightened intrathoracic regurgitant pressure, from uncompensated valve disease, from thrombosis of main veins, or from complete or partial occlusion of them by external pressure which does not proportionately affect the arteries; the fillet in bleeding, and the contracting connective tissue in cirrhosis of the liver act in this way. When a vein is blocked, the effects vary according to the ease with which the blood contained in it can find its way by other channels to the heart. This may occur without the slightest difficulty, or, on the other hand, it may be impossible. The difference between the obstructive and hypostatic cases is this, that in the former the arterial pressure is undiminished ; consequently the intravenous pressure is greatly increased. If no movement of blood occurred from a certain point in an artery up to the obstruction in the vein, the pressure all along the column would be that of the artery at the above- mentioned point; but some lateral escape of blood generally occurs, some movement of the column, some friction is overcome, and the arterial pressure INFLAMMATION. 47 is proportionately diminished in the veins—progressively so as the circulation becomes reestablished. Skins and Results.—The signs of venous congestion are primarily three: blueness or cyanosis, slight swelling from overfull vessels, and diminished temperature, both due obviously to the slowness of the circulation through the part. Certain results follow, varying in intensity with the duration of the congestion and with the intravenous pressure; they are, ozdema from transudation of fluid from the vessels ; escape of red corpuscles either by diapedesis or actual rupture of vessels ; wasting of elements of a part—e.g., liver-cells—from constant pressure of distended vessels; thickening of soft parte by increase of connective tissue. In cases where the circulation is not reestablished, moist gangrene is, of course, the result. Treatment of Local Venous Congestions.—Remove any removable obstruction to the circulation. Elevate the part moderately to favor return of blood by the veins ; systematic friction toward the heart may act simi- larly. Wrap the part in cotton-wool, and place hot bottles in the bed, but not in contact with the limb, to keep up the temperature. To prevent hypostatic congestions, change the position of the patient frequently, that gravity may not act for long together against the circulation in the same set of veins ; and get the patient out of bed into a chair as soon as possible. Should the heart be acting weakly or irregularly, easily digestible fluid food must be given often and regularly, and digitalis may be tried. Should gangrene threaten, means must be taken to prevent decomposition of the part. CHAPTER III. INFLAMMATION'. As the great majority of morbid conditions met with in practice are of an inflammatory nature, the importance of an accurate acquaintance with all that is known concerning inflammation is self-evident. ' Definition.—Inflammation is the succession of changes which take place in a living tissue as the result of some kind of injury, provided that the injury be insufficient directly to destroy its vitality (Sanderson). Certain nutritive disturbances may also excite it. Etiology. It must always be remembered that there are two elements to be considered in the production of every morbid process—the tissue-elements and some injurious influence acting upon them ; also, that the former possess a power of resisting such influences which varies in different individuals, in the same individual in different states of bodily health, and even in different parts of the same individual. Thus, a cause which produces inflammation in one person or in one part will fail to do so in another person or another part. The effect produced by an injurious influence upon the tissues varies directly as its intensity, and, up to a certain point, as the duration of its action. A cause may be of such slight intensity as to produce no deleterious effect, unless it act for some time ; and no matter how long it act, it may never pro- duce the higher stages of inflammation. Increase the strength, or both the 48 INFLAM MATION.- strength and time of action of the cause, and the inflammation becomes pari passu more intense, till perhaps gangrene results. The extent of an inflammation is limited to the area of action of its cause. Spread of an inflammation implies precedent spread of its cause ; chronicity implies continuous action of the original, or equivalent causes. Immediately an injurious influence ceases to act, all cells, not hopelessly damaged, tend to recover by their innate power ; thus Lister has seen inflam- matory stasis resolve in an amputated limb. Recovery is greatly assisted by a suitable supply of blood. The etiology of inflammation has been worked out partly in the wards, but chiefly in the laboratory of the experimental pathologist. The exciting causes may be ranged under the following heads: 1. Simple Anosmia.—By excluding blood from a part for a sufficient length of time, any desired stage of inflammation . may be produced on allowing the circulation to reestablish itself (Cohnheim). This is seen on returning to the abdomen bowel which has been strangulated, when inflam- mation—previously absent—sets in; also, sometimes, on relieving strangula- tions of other parts, as limbs. 2. Mechanical Injuries.—Subcutaneous injuries of this kind, even though severe, rarely present any symptoms of inflammation ; microscopi- cally the tissues show early stages of the process. The passage of a knife through tissues is probably so injurious as to kill a microscopic layer of tissue on each side of it, and free exudation of fluid and cells follows from the vessels in the immediate neighborhood, which dilate freely. But if the wound is protected from further irritation, this is all over within 24 or 30 hours, and healing begins. As a rule, prolonged action of such injuries is prevented ; but a tight stitch may excite even suppuration round it beneath an antiseptic dressing, and tension in an aseptic wound or abscess cavity owing to imperfect drainage is believed to act similarly; yet it must be rare indeed for the tension under such circumstances to be greater than it often is in cases of effusion into joints and subcutaneous extravasations which do not lead to inflammation. Friction, again, delays healing, and keeps up an inflammation. 3. Physical Injuries.—Heat\s a frequent cause of inflammation as seen in burns, scalds. One must distinguish between destruction of tissue and inflammation, and certainly much of the latter which follows burns of the second and higher degrees is due to infection of the raw surface. A cautery plunged into a muscle produces no more inflammation than a subcutaneous injury, if the part is kept aseptic (Hiiter) ; for though an intense irritant, its action extends little beyond the tissues it kills and is of short duration. Cold is a very frequent cause of inflammation. Intense cold acts like intense heat; but numerous cases of bronchitis, pneumonia, Bright's, etc., are attributed to draughts, wettings, and such mild influences. Its modus ope- randi is unknown (see Green's Pathology, 6th edit., " Inflammation"). 4. Chemical Injuries.—Severe chemical irritants are, as a rule, per- mitted to act only for a short time; if the injured surface is kept aseptic, they excite little inflammation. But experimentally certain substances may be introduced into the body which will act strongly and continuously. These are the conditions necessary for suppuration, which follows when croton oil, for example, is thus used; no organisms are present in the pus. Again, granulating surfaces may be caused to suppurate by the prolonged action of very dilute antiseptics, as carbolic acid. Morbid tissues do produce mild irritants, such as urate of soda, but it is extremely doubtful whether they ever form bodies capable of exciting the formation of pus. Nevertheless, chemi- cal irritants are the great causes of suppuration, of wounds, and of the for- INFLAMMATION—ITS CAUSES. 49 mation of abscesses, as shown in the next two paragraphs, which are separated from this for convenience only. 5. Putrefaction of Discharges.—Many of the compounds formed in the putrid decomposition of wound-discharges are very irritating, and a con- stant supply of them is kept up by the bacteria which have gained entrance to the wound ; more or less free suppuration results. Certain of these irri- tants are absorbed and excite inflammation along lymph-channels; and others act as general poisons producing fever and other symptoms. 6. Presence of Certain Organisms in the Tissues.—Many inflam- mations are due to the action of various organisms—e. g., tubercles, erysipelas, abscesses of farcy, and probably hospital and spreading gangrene. So long as they are supplied with food, these organisms furnish a constant supply of irri- tant bodies of all degrees of intensity ; they may therefore excite any degree of inflammation. By invasion of neighboring tissues they cause spread of inflam- mation by continuity; when carried to distant parts by lymph or blood streams they may excite secondary or metastatic inflammations similar to the primary ; and finally they explain the infectiousness of certain inflammatory processes. It would seem that many specifically different organisms produce irritants of about equal strength, and consequently though each specific inflammation has its special characteristics of site, course, etc., no degree of inflammation can be regarded as peculiar to the action of any one organism. To take suppuration, the pus of ordinary acute abscesses invariably contains micro- cocci, sometimes singly, sometimes in chains ; Cheyne (B. M. J., 1884, vol. ii. p. 646) thinks that these are different forms. Pure cultivations of them excite suppuration when inoculated in healthy animals. The micrococci of acute osteomyelitis, of pyaemia, of gonorrhoea, the bacilli of farcy, differ again from each other; but all unite in producing suppuration. In chronic ab- scesses organisms are not found, in some perhaps because they have disap- peared, having been present early; but many of these abscesses are of tubercular origin. The fluid in tubercular abscesses excites tuberculosis when inoculated upon animals, but it contains no bacilli; Koch thinks that the bacilli have died, leaving spores, which cannot be stained by any process yet known. Acute suppuration therefore seems to be due, as a rule, to the presence of organisms; but occasionally the conditions required to cause it by ordinary mechanical or chemical irritants are actually brought about by surgeons; needless to say, they should always be avoided. Almost all the inflammation attributed to injuries of all kinds seems really due to secondary infection of the injured part by organisms. This necessarily occurs in in- juries accompanied by breach of continuity of skin or mucous membrane which are not treated antiseptically; much more rarely subcutaneous lesions become infected by organisms which, like the micrococci so constantly found in the pus of ordinary acute abscesses, have entered through mucous mem- branes. This accounts for the great clinical difference which formerly ex- isted between subcutaneous and compound injuries. 7. Abnormal Nervous Influence.—Certain inflammations, such as herpes zoster, rashes, and acute bedsores following injuries and diseases of the central nervous system, have led to the belief that irritation of nerves is a cause of inflammation. This is, however, by no means well established. In addition to the above exciting causes, there are many predisposing. Any conditions which lower the general health, and therefore the vitality of the tissue-elements, predispose to inflammation. As before noted, incapacity to resist certain causes of disease—e. g. that of tuberculosis—may be congenital and inherited. It is the experience of all, that inflammatory processes are common in people who are "out of health." Certain diseases, such as Brights and diabetes, specially predispose to inflammation. 4 50 INFLAMMATION. Process of Inflammation. Our knowledge of the process of inflammation, like that of its etiology, is due almost entirely to experimental pathology. The fundamental experi- ment is the observation of the changes which ensue in a transparent part of a living animal after or during the action upon the part of some irritant. The process as then revealed is essentially the same in warm- and cold-blooded animals, and it serves to explain the clinical symptoms of inflammation and the changes noted in the tissues of man after death. When the irritant chosen is of moderate intensity and allowed to act con- tinuously, the whole process of inflammation, from beginning to end, may be watched under the microscope. The first effect of most irritants is to produce an active hypercemia or determination of blood; the arteries dilate considerably, and blood rushes swiftly through them, being still bright red, and perhaps pulsating in the veins. At first the calibre of the vessels may vary some- what, being now smaller, now larger; but after a time, dilatation increases steadily. The acceleration of flow continues, but sooner or later gives place to retardation; the vessels are so wide, however, that in spite of this the dis- charge of blood from the veins is greater than normal. Dilatation with retardation of flow is the earliest effect characteristic of inflammation, and is due to actual damage of the muscular coat, extending thence to the inner, and increasing the resistance which is naturally offered by the vessel-wall to the passage of blood. As the inflammation progresses, dilatation increases up to a point beyond that caused by section of the vasomotor nerves; it affects the arteries chiefly, then the veins, and the capillaries but little. It varies with the blood-pressure, the muscle of the vessel being paretic or paralyzed. As the injury to the endothelium increases, the resistance to the circulation becomes greater and the flow slower; the dilated vessels act almost as rigid tubes, each heart-stroke is felt in the capil- laries or even the veins, and in diastole individual corpuscles can be recognized even in the arteries. So soon as retardation of the flow is established, the plasmatic zone in the veins becomes more marked, and the num- ber of white corpuscles (loiterers) naturally seen there increases rapidly. At first these corpuscles roll slowly along the wall, there they stick for a shorter or longer time, but are ultimately carried away by the current, finally they become fixed and gradually form an irregular lining to the vessel, one, two, or even three cells thick (Fig. 1). Necessarily they greatly obstruct the lumen of the vessels and increase the obstruc- After one of the original drawings in Dr. tion. To a less extent, they adhere also in W. Addison's Experimental Researches on In- the Capillaries. In the latter, as the cirCU- fiammation, etc., Lond., 1843-45. it shows lation slows, red corpuscles accumulate to the axial stream of red corpuscles, the plus- guch an extent tnat thev look like red COrds rtrr thTLT srss ™d appear muc.h lar^than nat-ai- ^ tiSSues. • before this stage is reached, all onward move- ment of the blood has ceased ; for a time the corpuscles sway to and fro with the pulse (oscillation), then become quite still (stasis), and ultimately clotting occurs (thrombosis), indicating death of Fig. 1. VASCULAR PHENOMENA OF INFLAMMATION. 51 the vessels. Stasis may, however, continue for a long time without passing into thrombosis; thus after three days' complete stasis, Paget found the contents of the vessels fluid. That the return of blood by the veins of a part in these advanced stages of inflammation diminishes progressively, goes without saying. By using an irritant of suitable intensity, any stage of inflammation may be produced almost instantly; a grain of mustard on a frog's web causes stasis in its immediate vicinity before the experimenter can get a view of the part; but passing outward from the centre he finds every stage of the above- described process—oscillation, full dilatation with very slow circulation, and copious heaping up of white corpuscles, then full dilatation with more or less retarded flow, and ultimately less dilated vessels with accelerated blood stream between the inflamed area and the normal. These conditions will not, however, be found in regular zones, as the cause does not spread uni- formly from the centre. The above are the vascular phenomena of inflammation; but if, during the course of an advancing inflammation, attention is directed to the tissues round about the vessels, it is early noted that they become cloudy or granular, soaked with fluid and infiltrated with cells, like white blood corpuscles; often fine threads of fibrin appear; here and there red corpuscles are seen singly or in groups. This exudation causes swelling if it remains within the tissues, but it may in great part escape from a free surface, and perhaps form a coagulum upon it, obscuring the view. Normally, lymph transudes from the capillaries and fine veins, and with it a few leucocytes, the vessel- wall acting as a kind of filter, even with regard to the soluble constituents of the blood, for lymph is not liquor sanguinis. In inflammation the filter is more or less altered by the action of the irritant upon the vessel-wall, and by the stretching to which the wall is subjected; and as a result the filtrate or that which passes out is more or less altered in quality and quantity. Albumen passes through the vessels of an inflamed part much more readily than through normal vessels. Injection under normal pressure shows that there are no apertures left in the vessel-walls, even after the escape of red corpuscles; and the microscope reveals no structural change. The effect of simple stretching by heightened blood-pressure is seen in the oedema of venous obstruction. Speaking generally, inflammatory exudation contains more albumen, phosphates, and carbonates than oedema fluid, and tends to coagulate; but in all these particulars it falls behind blood plasma. The more intense the inflammation the more nearly does the exudation approach the composition of plasma, the less intense the more like is it to oedema fluid. The number of leucocytes, too, increases with the intensity of the process, and in the most intense forms red corpuscles are found in excess of the white. As regards quantity of exudation, Lassar tied a canula into a lymphatic trunk of a dog's leg, and then excited acute inflammation of the paw by dipping it in hot water; almost immediately the rate of flow increased and soon reached eight times the normal. For a short time the lymphatics sufficed to remove the exudation, but then the latter became too great, and swelling of the foot occurred, whilst both lymphatics and veins (as we have seen) are fully dilated. Subsequently, the lymph-flow diminished as the lymphatics became blocked by coagula and compressed by oedema. At first clear, the fluid soon became turbid from white corpuscles with occasional red ones. The cells found in the tissues in inflammation are ascribed to two sources: multiplication of the fixed tissue-cells (Virchow, Strieker); and white blood corpuscles (Cohnheim). Few, if any, pathologists now hold the former to be their only source, but many look upon the white corpuscles in this light, 52 INFLAMMATION. whilst others think that the new cells spring from both tissue-elements and leucocytes. The vascular origin of a very large number, if not of all the cells, in ordinary acute inflammations, by escape through the vessel-wall of those cells which have become fixed against it, is certain. The escape may not begin for some time after the wall-zone has formed, and it may go on rapidly or slowly; but with patience.it is not very difficult to see. Leucocytes probably work out partly by their spontaneous movements, but they are much aided by intravascular pressure, which alone causes the exudation of red corpuscles, for compression of the main artery arrests the most active escape of corpuscles. Thrombosis has a like effect. Leucocytes pass out chiefly from small veins, red corpuscles chiefly from capillaries—i. e., each vessel lets out that which it contains (p. 50). No cells escape from arteri- oles. It has been seen (p. 50) that the capillaries do not become packed with stationary red corpuscles until an advanced stage of the process, long after the wall-zone has formed in the veins; in other words, the capillaries become packed and red corpuscles escape in quantity only in severe inflam- mations. A few red corpuscles pass out in almost all cases, and frequently several pass quickly through the same spot in the vessel-wall, forming a " punctiform hemorrhage " visible to the naked eye. The richer a tissue is in capillaries, the more numerous will be the red corpuscles in an inflamma- tory exudation. With regard to the tissue origin of pus-cells, whilst the adherents of Strieker have been able to find unmistakable evidence of the multiplication of the cells of most tissues when inflamed, the followers of Cohnheim have watched with equal care and have seen none. Thus, Dowdeswell for eight days made daily drawings of a group of connective tissue cells in a toad's tongue; they showed no change other than degenerative. Whenever cer- tain appearances in a tissue have been ascribed to multiplication of its cells, a portion of the tissue, dead some days, has been rendered aseptic and placed among living tissues; it there excites a little inflammation, leu- cocytes invade it and produce the appearances attributed to multiplication of its cells. But observations of this kind do not disprove the occurrence of the latter phenomenon. As inflammation is always due to some injury, it seems d priori unlikely that a damaged cell will at once begin to multiply, and Lister long ago showed that the functions of certain cells, especially pigment, muscle, and ciliated cells, were depressed and annulled by irrita- tion. Weigert, too, has demonstrated that in all except the mildest inflam- mations, proper staining and microscopic examination will reveal dead cells. But different cells, and especially cells of different kinds, resist injurious influences with varying power; and further, many causes which seem to act upon all the cells of a part do not really act so uniformly. Thus it is con- ceivable that an influence which damages one cell may merely stimulate another and excite it to make use of the abundant food-supply consequent upon the hyperaemia. It is in the less intense forms of inflammation, and on the confines of the more severe ones, that multiplication of the tissue ele- ments may be looked for. It is best seen in mucous catarrhs, in which the discharge contains numbers of cells believed to be epithelial, capable of per- forming movements upon the warm stage; the free desquamation, also, in many inflammations of the skin, indicates rapid multiplication of the cells of the rete. As above stated, the evidence is most conflicting concerning the multiplication of cells of deeper tissues; and the question has been rendered more difficult by Senftleben's account (p. 60) of regenerative pro- cesses in connective tissue cells, which Cohnheim regarded as distinct from inflammation, but as frequently occurring during that process. Multiplica- ANALYSIS OF THE CLINICAL SIGNS. 53 tion of cartilage cells undoubtedly occurs in rheumatoid arthritis, but all would not admit this to be an ordinary inflammation. However formed, small round cells accumulate in greater or less numbers in the tissues or pass off from a free surface. In the former case, the ele- ments of the infiltrated tissue frequently disappear before them, being prob- ably killed by the inflammation, and then eaten up by the leucocytes. Summary.—We learn from the above that inflammation is a process started by injury and tending to produce death of the affected part; that, as a rule, the causes of inflammation act upon all the tissues of a part, but the most striking results are vascular, and unless vessels are affected by an injury, no process recognizable as inflammation ensues. The vascular phe- nomena appear to be due to a " molecular change " in the vessel-wall, evi- denced by a paralytic dilatation under the intravascular pressure; by a resistance to the circulation which may be so great that, in spite of the fullest dilatation of all vessels, the circulation is brought to an absolute standstill, and which always causes some retardation of flow; and by the escape of the constituents of the blood in abnormal quantity and quality. The influence of intravascular pressure in producing dilatation of the vessels and in causing the increased exudation must be carefully borne in mind with regard to treatment. It must not, however, be thought that this pressure is increased in inflamed parts as a result of the dilatation of the arteries; on the contrary, it is diminished in the capillaries and veins, from which exudation occurs, in proportion as the resistance in the arterioles pro- duces slowing of the circulation. It seems probable that where the injury is so slight that it produces dilata- tion with only slight retardation of flow, multiplication of the more resistant cells may occur, but the evidence of this is very conflicting. In almost all inflammations damage of the tissue-elements is shown by their cloudy, gran- ular, and swollen appearance, by their softness, by the presence of more or fewer which are obviously dead, and by the actual disappearance of many before invading leucocytes; also by depression of the functions of each, per- haps following on a period of morbid exaltation from over-stimulation best seen in the case of sensory nerves. Analysis of the Clinical Signs. The cli?iical signs of inflammation are, redness, heat, swelling, pain (rubor, calor, tumor, dolor of Ceisus), impaired function (functio laesa), and fever. The last sign is a general one, the rest are local. Frequently all are not present; there may be only one—e.g., swelling, and the diagnosis from swelling due to new growth may be very difficult. It will depend largely on the history, the existence of a cause, and the result of treatment. 1. Redness is due to the following condition chiefly—to distention of the vessels with blood. It varies from bright red to almost blue (seen in the edges of sinuses, etc.) according to the rate of flow of the blood. Numerous small extravasations of red corpuscles (ecchymoses) give a red or purple color which does not disappear under pressure; often, too, the tissues are stained the color of raw ham by coloring matter derived from broken-down corpuscles, as is seen on pressing over many recent patches of syphilitic rashes. Lastly, a dusky brownish-red color is frequently noticed over hemorrhagic and gangrenous inflammations, due also to haemoglobin. Red- ness may be concealed by superjacent healthy tissue, a very thin layer often sufficing ; on the other hand, it may be present from simple hyperaemia. 2. Swelling is the most important sign of inflammation, often the only one discoverable clinically. Distended vessels produce a slight fulness, but this 54 INFLAMMATION. is insignificant compared with the effect of exudation. The swelling may be diffuse or circumscribed, and have either fluid or solid characters; it may be very slight or very great, due to exudation weighing several pounds. The exudation varies in quantity and quality according to the nature, intensity, and duration of action of the cause, and to certain vital and structural peculiarities of the parts acted upon. Thus serous membranes are prone to the formation of lymph and adhesions, mucous membranes to suppuration ; the more vascular a part and the looser its structure, the freer will be the exudation and the more likely is it to contain red corpuscles. Exudation is therefore most abundant from a free surface (serous or mucous), next so into loose connective tissue, and most scanty into the substance of solid organs, tendons, bones, etc. But the quality of the exudation depends very largely upon the cause of the inflammation. As the intensity of the latter increases the exudation changes in character (page 51), but peculiarities of the cause other than its irritant power come into play in this respect. The process of inflammation is continuous and no sudden change takes place in the exudation; never- theless certain forms of exudation are spoken of as though they were distinct, and similarly we speak of forms or stages of inflammation which derive their names from the form of exudation by which they are characterized. Arranged according to the intensity of the process from which they result, these forms of exudation are, the serous, sero-fibrinous, fibrinous, cellular ; sero-purulent, purulent; hemorrhagic. The serous exudation results from the action of the milder irritants. It occurs constantly around foci of intense inflammation—e.g.,acute abscesses, and as the early stage of advancing inflammations ; in other cases the inflam- mation never passes beyond the stage of serous exudation. But should the intensity of the process increase, the percentage of leucocytes rises, more ferment and fibrinoplastin are forthcoming, and fibrin in greater or less quantity forms. The exudation is sero-fibrinous and contains flakes or large loose coagula of lymph, or a layer of lymph covers the cavity in which the fluid lies, or threads of fibrin form in the meshes of connective tissue. Some- times the fluid is in great part or wholly absorbed, leaving the lymph, and the exudation then appears to he fibrinous. The lymph is yellow-white and consists of leucocytes in a fibrinous network ; it varies considerably in firm- ness, shading off into connective tissue on the one hand and into pus on the other. These forms of exudation are best seen in serous cavities, joints, etc., but they are frequent elsewhere, and especially in the union of wounds by first intention. Croupous and diphtheritic membranes occur only on mucous surfaces and surfaces of wounds. They were formerly regarded as layers of fibrin, but they differ from fibrin in their chemical reactions. They are said to be due to death of the tissue elements, which being bathed in exudation-fluid undergo a coagulation and very soon lose their nuclei and become unrecog- nizable as cells. Wandering leucocytes also undergo this "coagulation- necrosis." A membrane is called croupous when it involves only the epithelial layer of a mucous membrane, diphtheritic when it extends to the mucosa— an arbitrary distinction. Many causes produce the same anatomical result, so a " diphtheritic " membrane does not mean that it results from the action of the virus of diphtheria. Advancing a stage higher, and the exudation passes through sero-purulent to purulent—i. e., the number of leucocytes in the fluid increases greatly. But this is not all ; formation of fibrin no longer occurs, and it is this, really, which makes the difference between a purulent and the higher degrees of sero-fibrinous exudation. How coagulation is prevented is unknown. ANALYSIS OF THE CLINICAL SIGNS. 55 Weigert speaks of this peculiarity, common to all causes of suppuration, as the pus-poison (Eitergift) ; but as chemical and perhaps mechanical irritants, which, at first or when acting mildly, cause a sero-fibrinous inflammation, may later on produce suppuration, it is doubtful how far the description of a special property is justifiable. Coagulation never occurs on a mucous mem- brane until the epithelium is destroyed, and it is surmised that epithelial cells inhibit coagulation like the endothelium of vessels. Besides possessing this property, to induce suppuration the cause must be of considerable intensity and act for some hours. In the most intense inflammations, the capillaries are almost universally injured and filled with slowly moving or stationary red corpuscles and a few white. lied corpuscles are then pressed out in myriads, far in excess of the leucocytes, into the interstices of the tissue, and the exudation acquires a more or less blood-tinged aspect. Formation of fibrin is here also inhibited. Hemorrhagic exudations are best seen in cases of spreading traumatic gangrene (from intensity of the irritant) and in the tubercular or cancerous pleurisy (largely from impaired resistance of the vessels). Obviously, a hemorrhagic exudation as a rule renders the prognosis as regards the vitality of the part, and even the life of the patient, very grave, but it is not uncommon in cases of moderate cellulitis of the legs of old people to see the skin purple over large areas from escape of red corpuscles. Lastly there is a large class of cases characterized by cellular infiltration of the tissues, the leucocytes accumulating in and eroding the tissues whilst the fluid is absorbed as it escapes. These cases are typical chronic inflam- mations, many of them lasting for years. They are called productive (Cohn- heim), for they heal, if they heal at all, by the production of fibroid tissue (page 59). The causes of such inflammations must be constantly or fre- quently acting irritants of slight intensity. Thus we find granulation-tissue forming around embedded ligatures, splinters, bullets; on raw surfaces exposed to air or to the contact of dressings ; around subcutaneous injuries from contact with exudations and necrosed tissue undergoing changes preparatory to absorption. But perhaps the most typical inflammations of this kind are those which are classed together as infective granulomata, because they are general infective diseases characterized by tumor-like formations of granulation-tissue. Some of these certainly, and all probably, are due to the presence of organisms. The most important are the tubercular and syphilitic inflammations. 3. Heat.—As a rule, an inflamed external part is hotter than a symmet- rically placed but healthy part. Corresponding parts must, when possible, be compared; of course, under similar conditions. The temperature of external parts being naturally lower than that of internal organs, increased supply of arterial blood will cause their temperature to approach more and more nearly that of the interior, but it can never quite reach this point. In inflammations so severe that the quantity of blood passing through a part is less than normal, the temperature is depressed. Inflammation does not cause increased formation of heat in a part, for the chemical activity of inflamed tissues is depressed. The most careful measurements of the temperatures of blood going to and returning from inflammatory foci have led to this con- clusion, which is supported by the fact that the temperature of an inflamed pleura has often been found lower than that of the healthy one. Of course, in cases of fever, the temperature of an inflamed external part may be higher than the normal temperature of the interior. In very chronic inflammations no sense of increased heat may be perceptible, the rate of circulation may be so nearly normal, or healthy superficial parts may cover the morbid focus. 56 INFLAMMATION. 4. Pain.—The nerve-endings in an inflamed part are suffering with the rest of the tissues from the action of some irritant which keeps them more or less excited, so that there is often spontaneous pain, or a slight extra stimu- lus—as pressure, friction—produces pain. Frequently the finest nerve-fibres are exposed to a pressure greatly above normal from fulness of the vessels and effusion, and the latter must often contain chemical irritants—the results of the action of microorganisms or of morbid animal cells. These are ex- amples of the constant irritants to which nerves may be subjected. The effect of pressure in causing pain is well shown when an inflamed part is allowed to hang down, so that the effect of gravity is added to the heart- force and the vessels dilate. Pain from these causes is most marked in in- flammations of unyielding parts, or of parts confined by fascia: under such circumstances it is often " throbbing," the throbs coinciding with the heart- strokes and the injection of more blood into the part. Certain kinds of pain are characteristic of certain structures; thus bones and ligaments ache; skin smarts or burns; an inflamed pleura, when stretched, feels as if torn or stabbed. In the early stage of inflammations involving nerves of special sense, these become overstimulated ; thus, sounds in inflammations of the ear, and flashes of light in those of the eye, precede the abolition of function of the nerve in question. Pain may be absent even in acute inflammations, and not uncommonly is so in chronic cases in spite of the presence of exten- sive disease. In typhoid conditions, pain is, apparently, often not perceived. Being a subjective symptom, the patient's statements regarding it have fre- quently to be discounted. 5. Functio L.esa.—Impaired function is due chiefly to the injury done to the tissues by the cause of the inflammation and by the inflammatory pro- cess ; but partly to the fact that discharge of many functions brings fresh irritants, such as pressure, friction, into play ; there is therefore, when possi- ble, a voluntary avoidance of function. Thus an inflamed joint is fixed, and often no weight is borne upon it; inflamed gut is paralyzed and fails to pass on the contents ; and so forth. 6. Fever.—The term fever implies elevation of the body-temperature, such elevation being usually accompanied by secondary symptoms. It is so frequent and so important a symptom that the temperature of every surgical case should be taken every morning and evening at least, and in serious febrile cases every four hours. The normal temperature of internal parts un- dergoes tolerably regular diurnal variations: thus, the rectal temperature of adults usually reaches a minimum of 97.5°-98° F. between 5 and 6 a. m., rises to a maximum of 99°-99.5° between 5 and 6 p. m., and after 8 p. m. falls again slowly. A maximum over 99° is certainly uncommon. The total variation is generally under two degrees, and the times at which the maximum and minimum are attained vary considerably. The temperature of external parts varies greatly, and is always less than that of the interior. When the axilla is used for taking a temperature it is converted into a closed cavity by carrying the arm across the chest; it takes about twenty minutes to reach its full temperature, and even then may be several degrees below the rectal temperature in old people (imperfect cutaneous circulation, Charcot). The mouth is subject to many cooling and heating influences. So, to ascertain as nearly as possible the temperature to which internal parts are exposed, a thermometer should be introduced two or three inches up the rectum. Where great accuracy is not required, the axilla, closed for five minutes, may be used. Causes and Varieties of Fever.—Rise of temperature may theoreti- cally be caused by increased production or diminished loss of heat, or by both together. Diminished loss of heat is of altogether secondary importance; it ANALYSIS OF THE CLINICAL SIGNS. 57 occurs in fevers in which the skin is dry and pale, and especially during chills and the cold stages of rigors; but the skin may be flushed and moist during the highest fever. Increased production of heat is the great cause of rise of temperature; for a fever-patient raises the temperature of a bath more quickly, or to a higher point, in a certain time, than a healthy man, and in- creased CO. and urea discharge proves increased combustion of tissue. This oxidation is not due to direct combination of oxygen of the blood with the tissues; but the latter store the former and combine with it apparently in obedience to nerve-influence. Thus it is possible for the temperature in cer- tain cases to rise after death. There is probably a centre above the medulla which controls heat-formation, and certain cases of nervous fever seem due to interference, direct or reflex, with this centre or its efferent channels. Next, experiment and observation have shown that simple fractures and considerable contusions are followed by distinct fever (simple traumatic), and that this is due partly to absorption from the extravasation of fibrin-ferment which is pyrogenous, and partly to nerve-irritation. When the discharges of a wound become septic they excite more or less inflammation and fever until granulation is well established; this fever is due to absorption of pro- ducts of putrefaction, many of which are pyrogenous, and is called septic traumatic. Then come cases of simple inflammatory fever due to absorption of the products of inflammations not connected with wounds, though caused in many cases by locally infective organisms. The fevers (primary) of gen- eral infective diseases, which give rise to no local inflammation sufficient to account for them, follow; and of these, septic infection, typhus and inter- mittent fever may be taken as types. Lastly, there are several fevers of the etiology of which we at present know little—e. g., the fever of gout or of acute rheumatism. There is no line between the fevers of locally and generally infective diseases (p. 39), cases due both to the absorption of poisons from circumscribed foci of disease and to the growth of organisms in the blood itself being frequent. Symptoms and Course.—Fever of all degrees of severity is met with. It is called mild from 99.5° to 101° ; moderate from 101° to 103° ; severe from 102° to 104°; very severe from 103° to 106° ; above this point the condition is spoken of as one of hyperpyrexia; and the danger to life when the temperature rises above 106° is, in most cases, extreme. Whatever the severity of the fever, diurnal variation occurs, and generally as in health ; sometimes, however, the type is inverted, the maximum being in the morning and the minimum in the evening. When the daily variation is less than 2°, the fever is continued; when the variation exceeds 2°, the fever is broken or remittent; and when a non-febrile period intervenes between accessions of fever, the fever is intermittent; when the febrile and non-febrile periods alternate regularly, the fever is periodic. Three stages of fever are described—onset, acme, and decline; they are best marked in the acute specific fevers, which serve as types. The onset may be sudden or gradual, the temperature running up rapidly to a great height or mounting by a degree or so daily. It is accompanied, especially when sudden, by general malaise, and usually by nausea or vomiting, chilliness, rigor or convulsion, elevation of pulse, and more or less severe headache. The more severe symptoms occur in severe cases; vomiting is especially common in children, and in them convulsions generally replace the rigors of adults. A rigor is made up of three stages, cold, hot, and sweating. At first, the patient complains of cold, and shivers more or less violently for 5, 10, or even 30 minutes. The skin is pale, perhaps bluish at the extremities, but a thermometer shows that it is hotter than normal. Careful observation has shown that the temperature is generally 100°-101° before the rigor begins, 58 INFLAMMATION. and it continues to rise during the shivering. This is followed by a longer or shorter period of dry burning heat with high temperature (hot stage), after which the patient breaks out into a perspiration which may be very free, and just before and during this the temperature falls, sinking to or even below normal from a maximum of perhaps 104°-106° (sweating stage). The patient is left weak and exhausted. The ultimate cause of a rigor is unknown ; it frequently announces the formation of pus, but still more often it has nothing to do with suppuration. It is believed that some poison in the blood induces strong contraction of the superficial vessels and greatly increased production of heat; the sensory nerves of the skin under these circumstances actually convey to the heat-centre a sense of cold as compared with the tem- perature of internal parts. The pathology of a rigor is, therefore, much the same as that of an ordinary shiver from cold. A chill is a less severe form ; there is no shivering and no sweating, but a sense of cold water running down the spine alternates with a sense of heat and flushing. In the acme of a fever, the temperature is at its highest and shows to which type it belongs; skin hot and dry as a rule, but sweating is usual in remit- tent forms (hectic, pyaemia); thirst, anorexia, furred tongue, confined bowels generally; urine scanty, high colored, containing excess of nitrogen (gener- ally as urea) corresponding to the amount of fever; in high fever a little albumen is not uncommon, and sometimes there is marked albuminuria— many cases being probably infective, due to the elimination of the causes of the fever through the kidneys; pulse quickened, 100-120, full and bounding at first, becoming more compressible, smaller, and more frequent (140-180, even 200) as, the fever continuing, the arterial tone relaxes, and finally the heart fails ; respiration quickened to 25-30 per minute, considerably more frequent in children ; C02 in excess varying with height of fever. The increase in elimination of nitrogen and carbon bears witness to the heightened tissue-waste, which keeps up the fever and leads to proportionately rapid wasting and loss of strength ; and the alimentary tract being much disor- dered, repair is imperfect. Headache may be present; sleep is broken, or there is great wakefulness. After a time—varying with the nature, degree, and duration of the fever and the strength, idiosyncrasy, and previous habits (especially as regards drink) of the patient—delirium, at first nocturnal, comes on ; it is generally low and muttering, but in early stages may be violent. Continued fever produces more severe effects than remittent, even though the maximum of the latter be somewhat higher; for during the remission tissue-waste decreases, digestion and repair go on, and the viscera escape for a time from the high temperature which seems to play an impor- tant part in producing cloudy swelling and fatty degeneration of them. Blood drawn during this stage into a wide vessel is often buffed and cupped from rather slow coagulation and a running into irregular masses and con- sequent rapid sinking of the red corpuscles. The effect of continued high fever is generally to produce what is known as the typhoid state; but the cause of the fever and the constitution of the patient have much to do with it, for the typhoid state occurs cozteris paribus much sooner in some fevers and in some individuals than in others. In it the patient lies in a state of somnolence or stupor, with muttering delirium, noticing nothing, asking for nothing, but drinking when food is given, slip- ping down in bed and assisting himself in no way. The skin is hot and dry until the death-agony, when sweat breaks out; the face pale or flushed and dusky ; sordes collect on lips and teeth, and the skin is quite dry, brown, and often thickly coated, or it may be red and dry. There may be diarrhoea, and albuminuria is common ; the motions are passed unconsciously. The pulse is small, frequent, and compressible, and these characters become more TERMINATIONS OF INFLAMMATION. 59 and more marked. Respiration is frequent and shallow ; hypostatic conges- tion of the lungs and bedsores are frequent. In surgery the typhoid state occurs most markedly in septicaemia. The decline of the fever may be sudden (crisis), or gradual (lysis). Subsid- ence by crisis is often accompanied by free (critical) sweating, sharp diar- rhoea, or passage of urine depositing a copious precipitate of urates. When fever is gone, the patient is left more or less weakened and emaciated; but excessive waste has ceased, the tongue cleans, digestion and assimilation go on, strength is daily gained, and degenerate organs may recover completely. Sometimes albuminuria remains, having probably been due to an infective nephritis. But, instead of recovery, death may occur at any period from hyper- pyrexia ; from cardiac failure and collapse with a subnormal temperature; or from slow exhaustion. Prognosis.—Throughout the course of a fever we watch the temperature to learn how much waste is going on, and the pulse to note the effect upon the heart—a pulse becoming smaller, more compressible, and more frequent, with a steady or falling temperature, being of evil omen. Difficulty in taking food, sleeplessness, great loss of strength, and the presence of the typhoid state render the prognosis proportionately grave. Hyperpyrexia indicates imminent danger. Continued fevers are, of course, more exhausting than remittent or intermittent reaching the same height. Terminations of Inflammation. Resolution or return to the normal is the most favorable and the most frequent. The irritant is removed or ceases to act; then, by degrees the tissue-elements repair the damage done to their substance and resume the normal discharge of their functions, the vessels contract, the abnormal resist- ance subsides, the circulation quickens, escape of fluid diminishes, and loiter- ing corpuscles are caught up into the stream. Even though stasis have occurred at points, the apparently solid masses of corpuscles break up, bit by bit, and finally all move on. The fluid exuded is carried away by lym- phatics and veins, the corpuscles either find their way again into the circu- lation directly or through the lymphatics, or they undergo fatty degeneration and disintegration and are then absorbed. The many cells and small por- tions of tissue which may have perished are completely and perfectly regen- erated by the cells remaining. The extent to which the tissue-elements are capable of repairing losses is not known, and could hardly be expressed if it were. It is certain, however, that most tissues are possessed of regen- erative power—that epithelium gives rise to epithelium, connective tissue cells to connective tissue, muscle to muscle; but adult nerve ganglion-cells and the epithelium of certain glands are believed not to possess this power. Healing by Scar-formation.—Should the inflammation lead to exten- sive destruction of tissue, by ulceration, suppuration, gangrene, or cellular infiltration, healing, if it occur, takes place by the formation of granulation- tissue, and later, of a scar. This is often the case also after destruction of parts by injury. Granulation-tissue consists of cells and bloodvessels in a little homo- geneous matrix, the cells being chiefly, if not entirely, leucocytes, and the bloodvessels mostly of recent origin. Unless new vessels form, the tissue neither grows nor develops into fibrous tissue, but very probably under- goes fatty degeneration. So long as an inflammation is spreading fast, no new vessels form among the leucocytes which crowd the tissue at its edge; but as the irritant ceases to act or becomes very slight, new vessels form 60 INFLAMMATION. among the cells, which increase rapidly in numbers, and a line of granula- tion-tissue limits the inflammatory process (demarcating inflammation). But in some cases (gray granulation), although the inflammation is quite station- ary, no new vessels form—perhaps owing to some peculiarity in the cause. New vessels develop as offshoots from existing capillaries. A conical process springs from the wall of a capillary and rapidly grows out among the cells till it joins another process or a vessel. Solid and very thin at first, it thickens, nuclei appear in it, and finally a central canal forms and opens into vessels at each end. From it fresh offshoots may start, and thus vessels are formed rapidly. In granulating wounds they may begin as early as the second day. Ziegler states that among the round cells of the tissue are some like pus corpuscles with bi- or tri-fid nucleus; the rest have one large, round, obscure nucleus. The former are dead, and are either thrown off in discharge as pus cells or eaten up by the latter cells, which increase in size, whilst their nuclei become clear, oval, and vesicular. From their resemblance now to epithelial cells they are sometimes called epithelioid: fibroblast is a better word. The fibroblasts increase in number, partly by division; some are seen containing more than one nucleus, and after ten or twelve days giant- cells with many nuclei appear, formed either by division of the nuclei of fibroblasts without that of the cell-bodies, or by blending of multinucleated fibroblasts. Finally the fibroblasts outnumber the small round cells, they become spindle-shaped or branched, are pressed closely together in the deeper layers of the tissue, and perhaps coalesce. Then their ends and borders form fine fibrils, which join others from neighboring cells, to form longish bands ; more fibrils form in the matrix. Many cells disappear in this process, the rest lie on the surface of the fibrous bundles as connective tissue cells. We now have very vascular connective tissue, which accounts for the marked redness of recent scars. But they ultimately become paler than normal skin, for inflammatory tissue always contracts strongly, and the great majority of its vessels disappear in the process. This contraction may do great harm, producing much deformity, preventing movement of joints, causing stricture of mucous canals, destroying by its pressure the parenchyma of glands, compressing vessels, and causing dropsy, etc. The more chronic the process and the fewer the vessels, the less the ten- dency to form fibrous tissue, the more numerous the giant-cells, the greater the tendency to degeneration such as will be described under " Tubercle " and " Syphilis." The few giant-cells formed in healthy granulation-tissue are thought to fibrillate like the fibroblasts. In the formation of inflammatory tissue it is probable that the neighbor- ing connective tissue cells multiply and aid in the regeneration. By irrita- tion with chloride of zinc, Senftleben destroyed the central cells of the cornea, whilst the anterior lamina remained intact and prevented infiltra- tion with leucocytes from the conjunctival sac. After two or three days the cells round about sent long processes, upon which nuclei appeared, into the injured area, and the protoplasm thickened at these spots and formed new corneal corpuscles, the regeneration being ultimately complete. Similar processes almost certainly go on in tissues recovering from inflammation, but they are difficult to observe on account of round-celled infiltration. Non-absorption of Exudations — Desiccation — Degeneration — Elimination.—Sometimes resorption of a fluid or corpuscular exudation does not occur: as a rule, however, fluid is absorbed, whilst cells and fibrin undergo fatty degeneration and remain as a dry cheesy .mass which often calcifies in course of time. Such masses excite a chronic inflammation, and the formation round about them of a capsule of fibrous tissue. Caseous VARIETIES OF INFLAMMATION. 61 masses may soften and become irritating after long quiescent periods, and be eliminated by suppuration. Portions of tissues killed by inflammation or otherwise are, per se, irritants to living tissues ; they are practically foreign bodies. The fate of foreign bodies in the tissues varies with their nature and the amount of irritation they excite. By nature they may be capable or incapable of absorption : in the latter case they become encapsuled, or eliminated by ulceration and suppuration; in the former they are absorbed or eliminated according to the intensity of the irritation they produce. Speaking generally, all animal products are capable of absorption. This is carried on by fibroblasts which lie upon the surface and work into the substance of the foreign body, gradu- ally eroding it; thus portions of dead tissue—even bone—blood-clots, liga- tures, decalcified sponge, etc., are gradually replaced by granulation-tissue, for the growth of which they at first form a support. In such granulation- tissue, giant-cells are generally numerous. If, however, the foreign body be so irritant that cells cannot live in close contact with it; and this generally is due to the presence of putrefactive or other organisms, it is thrown off by ulceration. In other words, it excites the formation of a band of granulation-tissue in the living tissues round about it; these are softened and eroded, and the body loosened until it can be removed, or is pushed out by growth of granulations. When the body is a portion of the tissues—e. g., a piece of bone, its connection with the living parts is eaten through by the cells, and it is set free. The greater the density and the less vascular the tissue, the more slowly does it ulcerate; sloughs of tendons, fasciae, and bone are weeks or months in separating. Death.—Inflammation may cause death by affecting a vital organ—e. g., heart or kidney, and impairing its functions, by producing oedema and closure of the glottis, by ulcerating into vessels and causing hemorrhage and so forth ; by exhaustion from the accompanying fever or profuse discharge ; and, later, by the damage it leaves behind—e. g., thickened or contracted heart-valves or strictured urethra. Varieties of Inflammation. Although the pathological process of inflammation is always essentially that which we have described (page 50), and can only arbitrarily be divided into stages, there are many points which serve for classification. Etiologically,inflammations are separated into two most important classes: (a) the non-infective or simple, due to all ordinary injuries, including the action of products of putrefaction upon wounds ; and (b) the infective, due to the growth of pathogenic organisms in the tissue. The latter are distinguished mainly by their tendency to spread, either by infection of neighboring parts by continuity, or of parts at a distance; but an infective inflammation may be quite stationary. When virus from an inflammatory focus is conveyed by lymphatics or bloodvessels to distant parts and there excites inflammation, this latter is called secondary. Sometimes the appearance of a secondary inflammation is accompanied or preceded by disappearance of the primary disease, as if the morbid process had been transferred from one part to the other; such secondary inflammations are called metastatic. In many cases metastases are due to carriage of the cause of inflammation from the primary to the secondary focus, but we cannot as yet explain, for example, the sub- sidence of insanity, asthma, or severe pain in the heart or stomach, upon the appearance of an attack of typical gout. So constant and distinctive are the characters of certain inflammations that one is led to the belief that each of them has a special cause, and such 62 INFLAMMATION. inflammations are called specific. Many of them are infective—e. g., tuber- cular, syphilitic, glanders, erysipelas; but of others the nature is less plain— e. g., gout and rheumatism. According to their real or supposed causes inflammations are often termed traumatic, strumous, tubercular, syphilitic, rheumatic, etc.; or idiopathic or spontaneous when no cause is discoverable. The time-relations of inflammatory processes allow them to be roughly separated into acute (of quick course and generally of considerable intensity), chronic (the reverse of acute), and subacute, a vague intermediate class. According to their intensity, inflammations are divided into sthenic, gener- ally circumscribed and characterized by strongly marked symptoms, and asthenic, generally diffuse, tending to produce extensive sloughing, often pre- senting but slight local signs, whilst adynamic symptoms are frequent. The duration and intensity of inflammations vary with the duration and intensity of their causes, but the resistance offered by the tissues must also be taken into account. The seats of inflammation are generally indicated by taking the Greek name of the tissue or organ and adding the termination -itis; thus periostitis, myositis, hepatitis, orchitis, nephritis. Inflammation is said to be parenchymatous when its effects are manifested chiefly in producing degenerative changes in the essential elements of an organ, as in acute Bright's; interstitial, when the exudation occupies the connective tissue spaces between these cells; catarrhal, when it affects mu- cous membranes. According to the naked eye effects they produce, inflammations are spoken of as destructive, ozdematous, adhesive, gangrenous. The classification of inflammations according to the nature of the exuda- tion, into serous, suppurative, hemorrhagic, etc., enables us to describe most accurately the stage which the morbid process has reached. General Principles of Treatment. " The schools say," to quote from William Addison, "Find out the disease of the patient, classify, name, treat, and cure it." Experience and Nature say, " Find out the temperament, constitution, and habits of the patient..... Make the classifying of the disease subordinate to the study of the individual, and the treatment of the disease subordinate to the treatment of the man." The actual treatment of inflammation resolves itself into two parts, local and general, and the former may be preventive or curative. Preventive Treatment.—Such inflammation as results from accidental injuries or from necessarily inflicted wounds and other surgical procedures, we cannot prevent. It will be very difficult, probably impossible, to pre- vent inflammatory processes, the causes of which enter by the respiratory or alimentary tracts—e. g., spontaneous abscesses. But it is possible so to guard most wounds that they shall neither be irritated by products of putrefaction nor invaded by infective organisms; and success in this practically abolishes all dangerous inflammations, and those scourges of surgical practice, the general infective diseases of wounds. By a proper treatment of wounds the causes of simple inflammations also can be in great measure avoided. The antiseptic treatment introduced by Lister had for its object the pre- vention of putrefaction in wounds, and was based upon the assumption (at that time) that putrefaction, like fermentation, was due to the growth of organisms in putrescible material. But measures adapted to the above end had the advantage of protecting the wound from most pathogenic organisms also. As these and their effects upon the body became better known, the GENERAL PRINCIPLES OF TREATMENT. 63 object of antiseptic surgery widened into the protection of wounds from all organisms whatsoever, and the word aseptic has enlarged its meaning so as to express this state of freedom. Any mode of treatment adapted to prevent the growth of organisms is called antiseptic; to merit this title it is by no means necessary to work with carbolic acid and gauze dressings. The de- tails of antiseptic treatment will be given under the treatment of wounds; and there will be noticed also the means by which tension, friction, and other sources of irritation may be avoided. Here it may be said that every part threatened with inflammation should be kept absolutely at rest in the most comfortable position. Curative Treatment. — When inflammation has already set in, the following points must be attended to. 1. Removal of the Cause.—Foreign bodies, or irritating substances—e. g., urine, must be removed ; tension relieved by removal of sutures, punctures, incisions, or drainage; friction by absolute rest and perhaps uniform elastic compression of the part; septic irritation lessened by drainage and disinfec- tion of the wound. At the same time care must be taken that the part is not unnecessarily exposed to the irritation of antiseptic substances, frequent dressings, injections, or other evidences of meddlesome surgery. In some cases attempts have been made to destroy the causes of infective inflamma- tions after they have settled and begun their work, by injections of carbolic acid (1 in 20) or of tr. iodi—e. g. in erysipelas, acute abscess, and scrofulous inflammations; but the success has not been great. The disinfection of in- flamed wounds is commonly attempted and with excellent results, though absolute asepsis is not attained in many cases. Perhaps cold in some in- stances prevents the development of infective germs, as when a wounded joint is surrounded by ice. Again, in locally infective diseases, as hospital gangrene or soft chancres, especially when sloughing, attempts are made to destroy the whole inflammatory focus together with its cause by the actual cautery or powerful chemicals like chloride of zinc or fuming nitric acid. Lastly, certain drugs are known empirically to act curatively in certain in- flammations—e. g., colchicum in gout, the salicylates in rheumatism, mercury in early, and iodide of potassium in later lesions of syphilis; but whether these act by destroying the cause or preventing its development is unknown. 2. The Diminution of Intravascular Pressure and the Preven- tion of Tension from Exudation.—This has been shown (page 53) to be most important. It was formerly effected by bleeding the patient to faint- ness—i. e., to fifteen ounces or more in a healthy adult. But general bleeding has been almost completely abandoned, because the loss of large quantities of blood is not easily made up, weakens the patient, renders him more liable to septic disease and less able to bear prolonged illness. The effect of general bleeding can be produced without actual loss of blood by hot baths, by the administration of aconite (see page 67) in minim doses frequently, or by saline purgatives given freely to take fluid from the blood and cause dilatation of the intestinal vessels. All these methods are depressing. As a rule, local treatment by the following methods sufficiently reduces intravascular pressure and limits exudation. Elevation of the part is the first and a very important means to this end ; an inflamed part should always be raised. Then gravity diminishes the arterial pressure and renders the out- flow by the veins more easy, so pressure in the capillaries and veins of the part is markedly diminished. The arteries of a limb thus raised contract considerably and the veins tend to collapse. The removal of exudation by lymphatics is favored. Still further to diminish the intravascular pressure compression of the main artery has been practised, Neudorfer says, with much success ; and Campbell, of New Orleans, went so far as to tie the femoral 64 INFLAMMATION. to check inflammation of the knees. Gamgee recommended the following plan of uniform elastic compression for inflammation, especially of limbs, before suppuration has set in. Raise the part as much as possible for five minutes, then, while still elevated, place round it a large quantity of cotton-wool and bandage firmly over this. Dilatation of vessels and exudation are thus pre- vented, external resistance being increased to compensate for the loss of resistance by the vessel-wall. An elastic bandage gently and uniformly applied has been similarly used. The part should be slung high. Warmth applied by frequently renewed fomentations or prolonged local warm baths is most valuable. It dilates fully all the vessels of a part and diverts a portion of the blood which would be driven through the inflamed area ; relaxes the tissues, soothes pain, and promotes perspiration. Warmth may be suitably applied at almost any stage of inflammation. Fomentations are pieces of coarse flannel folded in four, wrung out of boiling water by means of a coarse towel or special wringer, applied as hot as can be borne, and covered by a layer of oiled silk one inch larger than the flannel in all directions ; this again is covered by plenty of cotton-wool and fixed by a bandage. When there is a wound, boracic lint should be used instead of flannel; by these a foul ulcer may be rendered quite sweet. Fomentations must be changed every two or three hours; they are much cleaner than poultices, which may however be Used when there is no wound. Cold pro- duces contraction of skin and vessels as a first effect, but after a few hours the superficial vessels become fully dilated, so ultimately intravascular pressure is probably reduced here also. Cold depresses the functions of living cells, both those of the body and those of invading parasites ; by its effect on the latter it may prevent their development and allow of the removal by lymphatics of the few which have entered, but it lessens the resistance of the tissues and checks repair. Warmth, on the other hand, stimulates the performance of function, quickens absorption, and, whilst encouraging growth of organisms, it renders more active the animal cells which oppose them in the struggle for existence. The patient's feelings often decide well whether to employ cold or heat, and should generally be respected. The usual prac- tice is to employ cold in the early stages of inflammation ; once an inflam- mation is well established, and especially if it be such that the circulation in parts may be actually less than normal, cold is inadmissible lest it cause sloughing. Cold is applied in various degrees. Bits of thin linen may be dipped in cold water or evaporating lotion (alcohol meth. and water aa), and laid upon the part, freely exposed: they must be frequently renewed. Cold irrigation acts more strongly ; place a bit of lint on the inflamed part, and suspend a jug of water over the part and let the water drip from a siphon rag. Mac- intosh cloth must be so arranged as to convey the water to a basin on the floor. Bladders or India-rubber bags of crushed ice may be packed round the part, but they are hard to apply closely and to keep in position. When applied to young children it is well to use India-rubber bags in flannel. The most perfect way of applying cold is by Letters lead tubes, coiled closely and accurately round the part, whilst a slow constant stream of cold or iced water passes through them and is regulated by a screw clip on the India-rubber tube connecting them with a can of water above the head. Astringents.—In inflammations of the skin, and especially of mucous membranes, astringents seem to cause contraction of the vessels and tissues generally, and therefore to act beneficially. The more acute the case the milder the astringent; acetate of lead is one of the least irritating. Most of these bodies are antiseptic. Local bleeding in certain cases—e. g., acute iritis, otitis media, and orchitis GENERAL PRINCIPLES OF TREATMENT. 65 has an excellent effect, quickly relieving pain, and being often followed by subsidence of symptoms. It may be effected by the application of leeches, by the opening of two or three small veins, like those of the scrotum, by cupping, punctures, or scarifications. How local bleeding acts is unknown; sufficient blood is not taken to depress the pulse, and even if it were drawn directly from the vessels of the affected part these would fill again imme- diately. The effect of scarifications and cupping is doubtless due in great measure to the escape of exudation and relief of tension, but this does not account for the effect of leeching. Some suggest that a reflex contraction of the vessels of the inflamed part is caused. Leeches should not be applied to loose tissues (eyelid, prepuce) or they will be followed by oedema. To make them bite, wash the part well and smear a little milk on it, or make some punctures with a lancet and apply the leeches to them. Hold the animals in a cloth, not with exposed fingers; or put them in a test-tube, and keep their heads thus applied to the skin. Never pull them off forcibly, but touch them with salt, when they come off. Bleed- ing may be encouraged by fomentation, if necessary. To stop it—and this should always be done before a patient is left for the night—use perchloride of iron or small bits of matico leaf pressed for a few minutes on the dried bites. A full-sized leech will draw two drachms, and another drachm may flow afterward. Wet cupping is never done now, but dry cupping is still used in inflamma- tion of internal organs, especially the kidney. Cupping glasses in which the air has been rarefied by holding them a very short time over a large spirit- flame are applied to the skin of the loin or other part; rapidly the skin rises into the glass as the air cools, the subcutaneous vessels become full of blood and many capillaries rupture. This is repeated several times. It appears to influence beneficially the circulation through the deep organs, but we do not know how it acts. Counter-irritation is another mode of treatment of which the action is obscure, but its chief effect is probably a reflex contraction of the deep vessels; for the few superficial vessels dilated by a blister and the amount of fluid in the brain can scarcely have any effect on the circulation at large, Brown-Sequard caused contraction of the renal vessels by irritation of the skin of the loin. It is a very different matter when dilatation of all the abdominal or cutaneous vessels is caused to relieve superficial or visceral inflammations respectively. Counter-irritation is used to check some acute deep inflammations—e.g., laryngitis, bronchitis ; or to promote absorption in chronic inflammations— i. e., chronic synovitis or arthritis. Never counter-irritate over pus nor near the seat of an acute inflammation until its activity has been subdued. The commoner counter-irritants are : lin. camph. co., tr. iodi, lin. iodi, lin. ol. crotonis ; ung. hydrarg. co. (Scott's dressing), ung. sabinae; liq. and empl. cantharidis; the actual cautery. 3. The Relief of Tension from Exudation.—Elevation, belladonna, and frequent fomentation, with uniform pressure if it can be borne, will fre- quently reduce very great tension from oedema in twenty-four hours. Should these means fail, should pain be great or sloughing imminent, multiple punc- tures with a lancet, or a fewer short incisions as long as a scalpel is wide, may be made here and there into the subcutaneous tissue, superficial veins being avoided. The part must then be well fomented, or placed in a warm bath, a little bleeding being beneficial. 4. The Alleviation of Pain.—This will be effected in many cases by measures undertaken for the foregoing reasons—i.e., the removal of all sources of irritation, the provision of rest, and especially the relief of tension within 5 66 INFLAMMATION. the tissues by elevation, punctures, or incisions. Both heat and cold have a numbing effect, and it is common to use, combined with heat, a mixture of equal parts of ext. bellad. and glycerine painted thickly on the surface (care- fully avoiding any broken skin), and renewed with every fomentation or less often. The belladonna is believed to have the additional advantage of causing contraction of the vessels. Used thus, even on large surfaces, it very rarely causes symptoms of poisoning. Cold lotio plumbi fort, as an evaporating lotion has a remarkably soothing and constringent effect, and Hutchinson's method of allowing a lead and opium lotion to drip on to lint covering a stump or operation wound acts well, lead being an excellent antiseptic. Should local means fail, bromide of potash, chloral, conium, hyoscyamus, belladonna, or opium may be given by mouth ; or, in place of the latter, which disturbs digestion, furs the tongue, and confines the bowels, morphia may be used sub- cutaneously, its ill effects being less marked. These are the remedies usually employed to combat inflammation. In the following pages the special use of each will be pointed out. General Treatment.—The patient's room should be quiet, thoroughly ventilated, and kept at a temperature of 60°-64° ; the patient should not be too warmly covered. Diet.—Waste is so rapid during fever, inflammatory or other, that the patient requires as much of the most nourishing food as he can take; but digestion is almost always disordered, and of this the state of the tongue and bowels and the patient's feelings are the index. Rarely, a patient enjoys even solid food when highly febrile. Always give most food when the tem- perature is low. In severe cases food must be given in small quantities and often, and all must be fluid ; meat broths, and jellies, whey, barley water, lemonade and acid fluid drinks, arrowroot, and similar farinaceous foods, milk, raw eggs beaten up in milk, egg and brandy mixture (B. P.), or egg- flip, peptonized milk gruel or beef-tea. Milk, eggs, and the peptonized foods are the most important. In milder forms, or with recovery, give first milk puddings containing eggs, boiled white fish, and then chicken, game, and roast mutton. Plenty of drink should be given throughout. The value of stimulants in large quantities to tide over a few hours of danger from cardiac failure seems established. But it is doubtful whether frequent stimulation of the heart and other tissues does good in prolonged fevers ; here stimulants should be used as sparingly as possible. It is the custom with many sur- geons, however, to give large quantities of alcohol in hectic fever and in the typhoid state. Small quantities with food may sometimes aid digestion and whet appetite. 1. The great majority of surgical fevers appear to be secondary to some local lesion whence pyrogenous material is absorbed into the blood ; in their treatment, therefore, attention is naturally first directed to the sources of absorption with a view to removing their cause. If a wound is present, always look to it first; see that it is well drained, that the discharges are kept as sweet as possible by use of antiseptics; endeavor to subdue any inflamma- tion; open any collection of pus. The prophylaxis of fever is even more important than its cure, and may be effected in the case of the septic and infective diseases of wounds by antiseptic treatment. 2. A rare cause of nervous fever is the direct pressure of a large clot upon the brain, and this must naturally be treated by trephining and removal of the clot. When local means fail or are unavailable, resort must be had in severe cases to general antipyretic treatment. Means of Reducing Temperature.—The general cold bath, the cold pack, cold sponging, and Thornton's ice-cap, consisting of Leiter's lead tubes ULCERATION. 67 coiled into the shape of a close-fitting skull-cap, placed upon the head and kept cool by the circulation of iced water. The latter is a very effective and most convenient method. In prolonged fevers these remedies should be used to prevent the rise to the maximum, not continuously. During the cold bath and cold pack especially, the rectal temperature should be carefully watched ; it will fall two to three degrees after cessation of treatment, and if too much depressed, marked shock may result. Of drugs, quinine in 5 gr. doses every three to four hours, or in one 20 to 40 gr. dose, is that most often used; the headache and deafness it causes are often distressing. Salicylic acid has a similar but less powerful effect, and is of value chiefly in rheu- matic affections. Aconite in doses of ny every five minutes, up to trixx or xxx, affords great relief in the early stages of inflammatory fever, softening the pulse, moistening the skin, and relieving headache ; it must not be given in prolonged fevers, nor where the heart is already weak. Confined bowels often increase fever, especially of the inflammatory type; and in most cases of this sort a saline purge acts well at the beginning. It must be remembered, however, that when a patient is taking little food, his bowels will not act naturally every day. In chronic inflammation, of tubercular origin especially, change of air is most beneficial, that of the seaside being generally preferable. So also after exhausting suppuration or fever, such change greatly quickens both general and local restoration. AVeakly patients must not be sent to cold bracing places at first; external warmth is as helpful to them as pure air. En- deavor in every way to strengthen the general health. CIIAPTEE IV. ULCERATION. Definition.—Ulceration means erosin of tissues, the destruction pro- gressing for the most part without the formation of visible masses of dead tissue, and being, therefore, molecular as contrasted with the molar destruc- tion which constitutes gangrene. An ulcer is an open sore formed by the above process, the epithelium being completely destroyed at some points, though here and there the inter- papillary portions may be left; but in the deeper kinds loss of substance may affect every tissue of a part down to the bones. This excludes cases of intertrigo and vesication in which the horny layer only of the epithelium is lost; also cases in which papillae covered by epithelium are enlarged, as in mucous tubercles, and the granular condition of mucous membranes which results from prolonged purulent catarrh. The term ulcer is applied also to erosions of surfaces other than cutaneous or mucous—e. g., of a cardiac valve or of articular cartilage. Molecular death is essential to the formation of an ulcer, and may be brought about by inflammation or by degeneration, as is best seen in malig- nant ulcers. Etiolo<;y. Predisposing Causes.—All influences which depress the vitality of the whole body or of the tissues of a part. Such are (general) 68 ULCERATION. the liability to tubercle or scrofula; gout, scurvy, severe syphilis, old age; malnutrition and anaemia : (local) distance from the heart (lower limb) ; incompetent heart, degenerate arteries, varicose veins ; the existence of the milder degrees of inflammation ; sudden and extensive lesions of the cord from injury, inflammation, or hemorrhage, resulting in acute paraplegia; rare lesions of the brain generally from hemorrhage or wound, producing hemiplegia; loss of sensation in a part from injury of sensory nerves. Exciting Cause.—Inflammatory ulcers are due to the causes of inflam- mation acting upon surfaces with intensity sufficient to produce slow death of the tissues. Ordinary injuries of all kinds, the irritation of septic dis- charges, and infection of the tissues by pathogenic organisms. As with abscess so with ulceration, it is probable that the cause in "spontaneous" cases is some microorganism ; many are due to some specific virus, as the tubercular or syphilitic. Lack of blood supply, from pressure of the multiplying cells on their vessels, is regarded as a main cause of ulceration of malignant growths; but short life and tendency to early degeneration may well be characteristic of the cells. Inflammation probably plays a part in the production of many malignant ulcers. The degeneration and disintegration of tubercle, an in- flammatory product, connects the inflammatory and degenerative forms of ulcer. Pathology of an Inflammatory Ulcer.—This is the pathology of the formation of an abscess, but the process occurs in a surface-tissue, not deeply in the substance of parts. Advancing from the margin toward the centre of an inflamed area in which ulceration is about to occur, we should find, first, active hyperaemia with increased fluid exudation ; then progressive slowing of the circulation in fully dilated vessels, arrest of leucocytes, and finally of red corpuscles, escape of both with fluid into the tissues, stasis, and finally thrombosis at the centre, which appears blue in contrast to the red skin round about. The cuticle here is raised by fluid and easily brushed off, leaving a raw surface. Fermentative changes will now probably in- crease the irritation, so also may improper dressing. Leucocytes in great number infiltrate the dying or dead central tissues, which quickly disappear before them ; then the cells also die and come away with exuded fluid and fine particles of dead tissue which have escaped absorption and have become detached. Living leucocytes, too, wander to the surface. If the irritation continue, ulceration will advance, either base or edges or both, breaking down and coming away in the discharge as above described. The irritation may at any time increase and cause the death of portions of tissue so con- siderable {sloughs) that white corpuscles fail to erode them and they adhere for a time to the surface of the ulcer. These cases connect ulceration with inflammatory gangrene. Fig. 3 really represents an ulcer. When extension of ulceration ceases either at certain parts or universally, granulation tissue develops and the surface cleans—i. e., all shreds or dead tissue are cast off and the base becomes bright red and covered with closely set rounded prominences, the size of small pins' heads, each of which con- sists of a central capillary loop surrounded by cells, and possessing neither nerves nor lymphatics. These structures are called granulations, and give the name to the round-celled vascular tissue of which they consist. They are not tender, and do not bleed readily. As they develop the discharge becomes healthy pus. Growing rapidly, probably both by multiplication of its own cells and by development of leucocytes escaped from its vessels, it fills up all irregularities and then advances almost to the level of the skin. When only a gentle slope is left from the margin to the floor, epithelium shoots in from the former and gradually covers the surface. The epithelial THE HEALING ULCER—TREATMENT. 69 cells most probably arise only from the epithelium at the margin, but some think that they spring also from flattened-out leucocytes. The granulation tissue in the deeper parts forms fibroid tissue rapidly (p. 59), and this con- tracts, drawing together the margins of the ulcer. The amount of contrac- tion possible varies with the mobility of the surrounding skin, but the ulti- mate scar is generally much smaller than the original raw surface and may be (as in the scrotum) comparatively insignificant. Clinically, ulcers are primarily grouped in three classes: 1. Simple or traumatic, due to injuries and probably to infection by common organisms. 2. Specific, due to a virus like the tubercular or syphilitic. 3. Malignant. The two former inflammatory groups will alone be dealt with now. Situation.—Ulcers may occur anywhere on cutaneous or mucous sur- faces ; on the latter they are generally specific, on the former often so. The leg is far more commonly affected than other parts, being rather imperfectly nourished, most exposed to injury, often the seat of varicose veins and of degenerate arteries. There are many varieties of the simple inflammatory ulcer, of which the following are the chief, with their characteristics. In describing an ulcer it is necessary always to note the condition of the base, the edge, the surround- ing parts, the discharge, and also pain and tenderness. Every ulcer has two stages, healing and spreading, and often a third when it is stationary. The healing ulcer is taken as the standard with which all others are compared. Its base is formed of healthy granulations (page 68), is not adherent to deeper parts, and passes gently into the edge. This is formed by a fringe of epithelium in which three zones are often seen on drying the edge. Starting from the granulations, first a narrow red line, contrasting with the moist granulations, and consisting of a single layer of cells; then a bluish band several cells thick; and lastly a white broader band of sodden epithelium, outside which is normal skin. The surrounding parts are normal to the eye and touch, and the discharge is good pus, unless the part is aseptic and carefully dressed, when a serous fluid only escapes. There is no pain or tenderness. The object of treatment is to protect from all irritation, and is best effected by using some absorbent substance impregnated with a mild antiseptic, and changing the dressing as seldom as possible. Wash the ulcer and parts around with carbolic or mercuric chloride lotion, cover the sore with protec- tive, and apply a good pad of gauze, salicylic or iodoform wool. Another excellent plan is to dust a sore with crystalline iodoform, and then cover it with a good pad of wool and leave it perhaps for days. Or the sore may be dressed once or twice a day with boracic or salicylic ointment, or with boracic lint and lotion. To apply the latter, or any moist dressing, cut a pattern of the ulcer in protective and diminish it as the ulcer heals. From this cut a bit of lint, wring it out of the lotion and lay it in the sore; two or three bits may be used if this is deep. Cover the lint with a bit of oiled silk, one-eighth inch to one-quarter inch larger than it in all directions. No bit of lint must be exposed or it will dry, and matter will bag beneath it. The latter dress- ings require changing once or twice daily to keep things sweet. At each dressing a little boracic lotion, or carbolic (1 in 40) if the ulcer is foul, should be run over the sore from a little wool steeped in it, and the surrounding parts should be gently cleaned. The wool should then be burnt. Occasionally the granulations are too luxuriant, projecting considerably beyond the level of the skin, and preventing epithelium from shooting in. Nicely adapted pressure, especially over the granulations at the edge, by means of a ring or two of lint placed outside the oiled silk, often suffices; a 70 ULCERATION. lotion of sulphate of zinc or copper may be used as an astringent: or the marginal granulations may be rubbed down every other day with caustic. As an ulcer heals it is often found that islets of epithelium appear on its base, where interpapillary portions of the rete Malpighii have escaped de- struction, and greatly hasten healing. In large sores on firm parts, a time is sooner or later reached when contraction, and with it spread inward of epidermis, ceases. The healing of such sores may be much hastened by Reverdin's skin-grafting. For this to succeed, the ulcer must be granu- lating, and the discharge moderate and not markedly septic. Little snicks of skin including just the tips of the papillae (the deeper cells of the rete being the essential part) are pinched up with forceps and cut off with scissors from the arm or other part, and placed here and there on the surface; each is covered by a bit of protective, and over all a wool or boracic dressing is placed and left for three or four days. Often the grafts seem to disappear as the opaque horny layer desquamates; but if successful, they reappear in three or four days as little white islands whence cuticle spreads. Unless contraction of the base goes on at the same time, the scars are always liable to break down. A case of syphilitic infection by a graft taken from a man suffering from early secondary syphilis has been recorded. In the treatment of every ulcer, rest with slight elevation of the part is favorable; at night the foot of the bed should be raised. Bandages must be carefully applied with uniform pressure, and constriction above the sore specially avoided, the roller being always pinned and not tied. The spreading ulcer. The base is smooth or irregular, covered by a thin gray or yellow layer of disintegrating dead tissue; edge sharply cut, irregu- lar, perhaps a little undermined, surrounding parts infiltrated and hyperaemic for a short distance round ; discharge watery, turbid from leucocytes and microscopic debris of tissue; pain and tenderness may be great. The inflamed ulcer is characterized by the above signs in a marked degree: redness, heat, and swelling spreading widely from the margin and the part being the seat of constant pain especially when dependent. The discharge is often sanious and small sloughs may form. The true sloughing ulcer is generally due to the irritation of a specific virus. Treatment.—If rest, elevation, some mild antiseptic, and uniform pres- sure do not remove these conditions, boracic fomentations, changed every three hours, are the best application. In some cases of ulcer slowly spread- ing without obvious cause and probably from an infective process, salicylic ointment containing gr. xx or xxx ad 3J, acts admirably. The irritable ulcer is characterized chiefly by severe nocturnal pain. Gener- ally situate near one or other malleolus, it is usually small, shallow, with a fixed irregular base—pits and prominences alternating; the edge and parts around are often chronically infiltrated; the discharge watery. On going over the surface carefully with the blunt end of a probe, one or more spots may probably be found which are exquisitely tender. A nerve exposed here is supposed to be the cause of the pain; and the irritation of it seems to inhibit healing. If ordinary treatment and the use of anodyne ointments, especially ung. plumb, acetatis, fails, the whole base of the ulcer may be destroyed with caustic, or the tender spots may be found and little cuts made just above them to divide the exposed nerves (Hilton). The weak or cedematous ulcer is characterized by large pale swollen granu- lations projecting above the level of the skin. It frequently results from poulticing. Astringent applications, or iodoform with a wool-dressing, and uniform compression will generally set matters right. THE INDOLENT OR CALLOUS ULCER. 71 The indolent or callous ulcer. This is one of the commonest forms in out- patient practice. The base is smooth and glassy, and of a pale ashy color, like a mucous membrane. Sometimes, however, it displays a crop of weak fungous granulations ; foul sloughs which take long to separate are common. The edge rises almost vertically, is very thick and hard from inflammatory infiltration, which extends widely into the tissues round about. Frequently too the base rests upon deep fascia, or dense infiltration extends between it and a subjacent bone ; so the ulcer does not move over subjacent parts. The discharge is ichorous, often very offensive, and produces an eczematous con- dition of surrounding parts. Pain and tenderness are slight or absent. These ulcers last for months or years, now better now worse ; in the early stages perhaps healing completely once or twice, but soon breaking down again. They may be quite stationary for long periods, but generally gain ground on the whole, ultimately covering many square inches and perhaps extending horizontally around the limb, producing a more or less complete annular ulcer. Treatment.—The two special obstacles to healing in this form are the irritation of the foul discharge and the rigidity of the base and edges from inflammatory thickening. It is very difficult to render the part sweet. The part may be thoroughly cleansed with sublimate lotion, dried, sprinkled with iodoform, covered with a uniformly thick layer of salicylic wool, and kept firmly bandaged from the foot up ; or boracic fomentations frequently changed will render a foul ulcer fairly sweet in two or three days, when some more permanent anti- septic dressing may be applied. A general application of caustic to the base and edges may precede the above treatment. Filling the cavity of the ulcer with ung. resinae or iodide of starch sometimes acts well. Rest and elevation are very helpful. Constant pressure is employed to remove thickening, either by careful firm bandaging with a calico bandage, by strapping according to Baynton's plan, or by the application of Martin's " strong rubber bandage." Before strapping an ulcer the discharge should be fairly sweet unless the strapping can be daily renewed. The part being quite clean and dry, place a pad of boracic lint, three or four layers thick, and considerably larger than the ulcer, over it. Then beginning one inch below the sore apply straps one and one-half inch broad and once and a half the circumference of the limb and pad in length, up to one inch above the sore. The centre of each strap should be placed opposite to (not over) the centre of the ulcer and the ends crossed over the pad ; each strap should cover two-thirds of the strap below it. They may be drawn pretty tight, but the compression must be uniform, and the parts below must be supported by a firm bandage. The strapping may be changed twice a week. Martin's bandage is applied on the naked sore. Before rising it is to be coiled around the limb, from foot to knee, only just tight enough to keep its position ; when standing the limb swells and the bandage gets tighter. If the discharge is very free a layer of antiseptic wool may be laid over the ulcer. At night, the bandage is to be sponged and hung up to dry ; the leg is to be well washed with boracic lotion and the ulcer dressed with it or with some other application containing no oil. In the morning the limb is to be again washed, dried, powdered with oxide of zinc and starch (aa), boracic acid, 3j ad 3j, and the bandage applied. The perspiration and discharge often excite a troublesome dermatitis, which may render the employment of this bandage impossible. The boracic acid and dusting powder are efficacious in preventing this; and after a time, a limb is often less irritated than at first. 72 ULCERATION. In the case of chronic ulcers affecting patients of the gouty, bloated, free- living sort, stout women at the menopause, or persons liable to congestive headache, purgatives should be freely used during the cure, and for some time after it, F. 112, 113. With these safeguards against the ill conse- quences of suppressing a habitual flux, ulcers on the legs may be safely healed—if this is possible. The varicose ulcer is one predisposed to and maintained by the presence of varicose veins. The impaired circulation in the part leads first to malnu- trition ; exudation is increased, and after a time chronic thickening of the connective tissue results. Slight causes then excite chronic inflammatory congestion of the skin in the lower half of the leg, whence the step to ulcer- ation is a short one. Or when an ulcer is produced by other causes, this congestion and heightened intravascular pressure prevent healing. Or an ulcer may remain after the bursting of a varicose vein; against the occur- rence of which accident every patient with varicose veins should be prepared by his surgeon. The actual sore may assume any of the forms found above and requires similar treatment, but rest and elevation are specially important in severe cases, or the use of an elastic stocking or Martin's bandage when the patient can walk about. In bad cases, it may be advisable to obliterate surrounding veins. Menstrual ulcer is the name given to ulcers occurring in chlorotic women, and exuding a sanguineous fluid at the time of their monthly discharge, if this be absent. Wounds made in operating may do the same. The chlorosis must be remedied and the ulcer treated according to its state. General Points in Treatment of Ulcers.—Seek carefully for the pre- disposing and exciting causes, with a view to removing or specifically oppos- ing them ; malnutrition, syphilis, tubercle, gout, and varicose veins are specially important among the former; among the latter, decomposition of discharges, specific irritants, mechanical injuries (friction, etc.),a dependent position, and garters. Many ulcers must be treated whilst patients go about, but in severe cases, or where it is important to heal the sores as speedily as possible, rest in the horizontal position with the leg a few inches above the level of the head should always be insisted upon, and will often change the course of an ulcer. Under any circumstances, long standing is worse than walking, and when sitting, an ulcerated leg should always be placed on the seat of a chair. The foot of the bed may with advantage be raised at night. Sponge-grafting.—When a deep ulcer is fairly sweet, its filling up may be aided by laying on its floor a very thin layer of de-silicized aseptic Turkey sponge; this will be invaded and subsequently eroded (page 30) by leu- cocytes among which new vessels shoot. As one layer disappears, others may be laid on. The dressings must be infrequent. The question of amputation occasionally arises in the case of ulcers of very large size, and especially when of annular form. A wide ulcer of this kind is scarcely curable. Again, these ulcers may, by pain and discharge, be wearing a patient out; or they may be capable of healing under favorable circumstances, but break down in spite of all possible care directly the duties of life are resumed—-perhaps because the scar is very tight and adherent to deep parts, or in a situation very liable to injury. Lastly, the healing of an ulcer situate in the flexor fold of a joint may reuder the limb useless by its contraction. SUPPURATION AND ABSCESS. 73 Fistula and Sinus. Fistula or sinus is an ulcer folded into the form of a tube, and it is gener- ally of the callous type; i. e., its surface is smooth and glassy, its surround- ings dense, and often of cartilaginous hardness. Large red granulations (" pouting") not uncommonly project from its orifice. A fistula runs-between a mucous and cutaneous or two mucous surfaces; a sinus simply penetrates among the tissues. Causes.—Destruction by wound or other injury of the wall of a mucous channel and of the skin-surface over it, or the bursting of an abscess which opens on one or other or both kinds of surface; and the openings fail to close. This failure to close may be due: (1) To excessive destruction of tissue, as in some cases of artificial anus. (2) To the presence of some irri- tant at the bottom, as a sequestrum or tubercular gland. (3) To irritation by friction from voluntary or involuntary movements of muscles. (4) Im- perfect drainage. (5) To the passage of irritant substances—saliva, feces— along the track. Treatment.—-(1) Remove any foreign body and prevent the passage of irritants through the aperture, as by drawing off all urine, or by providing free drainage in another direction. (2) Give rest by fixation, uniform pressure, or division of muscles (e. g., sphincter ani). (3) Provide perfect drainage by the insertion of tubes, enlarging existing or making fresh openings, or by slitting the sinus or fistula completely up. For sinuses running far up the rectum and in other inaccessible parts, it may be advisable to tie the tissue to be divided in an elastic ligature which will ulcerate slowly through. (4) Sharp-spooning the wall of a sinus is often useful in stimulating it to granulate and in removing tubercular granulation tissue. Small sinuses are sometimes healed by the application of a red-hot wire to their walls, burns being often followed by very exuberant granulations. (5) A plastic operation may be necessary. CHAPTER Y. SUPPURATION AND ABSCESS. Suppuration means the formation of pus. This may occur upon a free surface—cutaneous, mucous, or serous—or in the substance of tissues or organs. When, in the latter case, the pus occupies a distinct cavity, formed by push- ing asunder and destruction of tissues, an abscess is said to be present, but when it infiltrates the connective tissue more or less widely, the process is that of diffuse suppuration. Suppuration may be acute or chronic. Etiology.—Probably any kind of irritant of sufficient intensity would produce suppuration were it caused to act continuously. Thus, many think that tension is a great cause of suppuration in imperfectly drained wounds, 74 SUPPURATION AND ABSCESS. and that it causes the increase of abscesses. It is probable, however, that, in many cases at least, micrococci find their way into the fluids retained in wounds, and render them chemically irritating, or the cocci may themselves invade the tissues; and in acute abscesses, the original cause persists, and, together with chemical irritants, is forced by the high pressure into the sur- rounding tissues. Nevertheless tension is a constantly acting irritant of con- siderable intensity. Suppuration may occur round splinters, bullets, ligatures, and other foreign bodies, either soon after their introduction, or perhaps months or even years after they have been quietly encapsuled in the interior. In the first case, organisms probably enter with the body along its track ; the pathology of the second class is not known. Chemical irritants fulfil the above conditions when strong antiseptics act continuously on unprotected wounds (aseptic suppuration), and when the products of putrefaction of wound-discharges bathe raw surfaces ; in the latter case pathogenic organ- isms may also act. The cause of ordinary acute suppuration unconnected with wounds is, in all probability, the action of organisms. In acute ab- scesses, cocci are always present, usually in large numbers; they have been cultivated by Ogston and Cheyne, and suppuration has frequently resulted from inoculation with the pure cultures. But there are many kinds of mi- crococci, some of which do, others which do not cause suppuration ; and organisms other than cocci—e. g., the bacilli of farcy and the actinomyces— cause the formation of pus. The organisms obtain entry either through some wound or mucous membrane; and having done so they must settle, grow, and multiply before they can excite local inflammation. Often they are brought to a standstill by some local circulatory disturbance due to injury, cold, etc.; or, as in pyaemia, the cocci may form colonies which become im- pacted in small vessels; but in many cases there has been no obvious injury, and nothing is known to account for the localization of the morbid process. Diffuse suppuration may be due to impaired resisting power on the part of the tissues, but more probably the causes are of greater intensity than those of the circumscribed form. Chronic suppuration is most frequently tubercular or septic; or many causes may combine to keep up discharge, as in an ill-drained septic abscess, connected with spinal caries in a patient allowed to move freely. The cause of chronic strumous catarrhs and eczemas is uncertain. Predisposition.—Inflammation in some people, often scrofulous, but often not obviously so, is easily excited and tends to run on to suppuration; every scratch suppurates, and abscesses in glands, subcutaneous tissues, etc., are frequent. Chronic alcoholism predisposes to this. Characters of Pus.—These vary much, the classical description being taken from that yielded by a healthy granulating, but not aseptic sur- face. This is healthy pus—bonum et laudabile. It is a yellow-white, or greenish opaque fluid, of the consistence of cream, is neutral or alkaline, has a faint smell, and sp. gr. 1.030-1.040. Some pus readily becomes offensive, whilst other specimens do not seem at all prone to putrefy. Pus consists of two parts which separate on standing; the corpuscles which sink as a thick yellow deposit, leaving a layer of more or less clear liquor puris above. No fibrin forms in the latter; but a large clot of albumen forms on boiling it or ordinary pus. The addition of an equal quantity of liquor potassae to pus converts the latter into a gelatinous mass. Pus contains 87 to 93 per cent, of water, and the solid residue is -made up of various albuminoids, with a good deal of fat, some cholesterine and other complex organic bodies ; inorganic salts are also present, chloride of sodium being the chief in the serum, phosphate of potash in the corpuscles. Apart from tissue-waste from fever, free suppuration must, therefore, prove a great FORMATION AND COURSE OF AN ACUTE ABSCESS. 75 Fig. 2. a shows the amorbiform changes of living pus-cells ; after Beale. b shows common dead pus, with the effects of acetic acid, c shows the granular corpuscles which are the result of decay of epithelial and all other cells, and the crystals of cho- lesterine found in caseous degene- ration. drain upon the system. Fat and cholesterine increase at the expense of the albumen with the age of the pus. Microscopically the following elements are found in the pus of an acute abscess: (1) White corpuscles, living and dead. The living are recently escaped, and generally few as compared with the dead. They are finely granular, possess rather obscure nuclei, and throw out processes upon the warm stage. The dead cells are round or slightly irregular, much more granular, motionless, and show no nucleus until the granules are cleared up by dilute acetic acid; then a tripartite nucleus is generally seen (Fig. 2, b). In older pus some or many cells have undergone fatty degeneration, and may be mere aggregations of fat-granules breaking down atthe edge (Fig. 2, c); these are unaffected by acetic acid, dissolved by liq. potassae. (2) Free granules of fatty or albuminous nature. (3) Red corpuscles in varying number, generally swol- len," colorless, and hard to detect; their coloring matter may give the pus a saffron tinge. (4) Shreds of tissue of varying size. (5) Micrococci, either in chairs, pairs, or singly. They are dis- tinguished from other granules by their uniform size, by evidence of multiplication, by their resist- ance to acids and dilute alkalies, but chiefly by the intense manner in which they stain with methyl- violet and other aniline colors. These bodies are present not only in acute abscesses, but whenever pus possesses infective properties, as in gonorrhoea, soft sore, farcy, infective periostitis, microorganisms are found in it. It has already been shown that in gonorrhoea and farcy the pus owes its infective power to these organisms ; and it seems likely that similar proofs will shortly be forthcoming in other cases. The ingredients of pus may vary in the proportion which they bear to each other—e.g., it may be very thick, or very thin, when it is called ichorous. This quality probably depends largely upon general conditions, as it is com- mon for purulent discharges to become ichorous with the onset of general infectious diseases. Such pus is frequently sanious, as also is ordinary pus, from presence of many red corpuscles. In the second stage of catarrh, the discharge is mucopurulent. The pus of chronic abscesses* is usually more or less curdy or cheesy—i. e., it contains small masses, like curds, which consist of aggregated fattily degenerated cells. Material of this kind may line the cavity more or less completely. The pus itself is often thin, and is really an emulsion of albuminous and fatty granules—products of cell degeneration. Shrunken, deformed cells only are seen. Formation and Course of an Acute Abscess.—Suppose that a man has fallen on his elbow, and that some micrococci have been swept into the bruised and slightly inflamed tissues and settle there. They begin to mul- tiply, producing a constant supply of chemical irritants of considerable inten- sity,, which infiltrate the tissues round about and excite an inflammation that diminishes from the centre. Here the stage of retarded flow with free escape of fluid and leucocytes, together with some red corpuscles, is reached, and the tissues become crowded with small round cells. Passing outward, the retardation lessens and is finally replaced by accelerated flowT; the corpus- cles escape less and less freely, but excess of fluid passes out after the corpus- cles have ceased to do so, causing inflammatory oedema. Sooner or later, 76 SUPPURATION AND ABSCESS. the prolonged action of the irritant and pressure of the exudation lead to cessation of circulation at the focus and death of more or less tiss'ue. This, when death is gradual, is eaten up by living leucocytes; but when death spreads rapidly, sloughs of various sizes may be found in the pus. The embed- ding tissue being dissolved, the leucocytes now float freely in fluid which has escaped with them. The organisms grow into the surrounding tissues or are carried into them by lymph-streams, forming fresh centres in the vicinity of the primary focus (Fig. 3, a, c, to v); by annexation of these and by irrita- tion and separation of tissues by tension, the abscess increases, extension Section through a small abscess of skin (farcy), showing the round-celled infiltration around a c, the abscess cavity. being always most marked in the direction of least resistance. Whilst destruction of tissue is proceeding rapidly, no new vessels form; but as this ceases, and first on the deep aspect, a wall of granulation tissue is formed. This may be slowly destroyed on one side, while it extends on the other; and multitudes of leucocytes together with much fluid may escape from its vessels into the abscess cavity. Ultimately, in most cases the abscess reaches a free surface and points there; the tissues become thinner and thinner, bulge at one spot which becomes bluish, or dull red and glazed, and finally the epi- thelial covering is burst and the pus discharged. The walls then fall together; granulation tissue quickly forms at any spot where it does not already exist, and supposing that reaccumulation of discharge and other sources of irritation are avoided, opposed surfaces quickly adhere, as in union by second intention, and a scar results. From this result of opening, it would seem that tension has a good deal to do with the increase of ordi- nary abscesses ; for we cannot suppose that all organisms have escaped from the cavity with the pus, yet in a day or two under antiseptics and drainage the discharge will be serous. In some specific abscesses extension by ulcera- tion goes on after the abscess is opened. Symptoms.—These are such as we should expect from an inflammation of high intensity ending in the production of a distinct cavity full of fluid. To take a superficial abscess; the ordinary symptoms of inflammation mark its commencement—redness, swelling, pain, tenderness, and fever. At first bright red and firm, the swelling softens centrally and becomes more dusky, and as the pus increases and the skin progressively thins, it becomes more SYMPTOMS OF ABSCESS. 77 circumscribed and prominent and ultimately points—i. e., the skin near the middle bulges more than that round about, becomes darker and glazed, ulcer- ates through, the cuticle bursts and the pus escapes. As the swelling softens fluctuation becomes evident, and the early detection of this is one of the tasks of the tactus eruditus of the surgeon. Fluctuation is the sense commu- nicated to the fingers of one hand laid upon a bladder filled moderately full of water when the fingers of the other hand are pressed upon some other part; fluid is forced from the latter part into other parts and the resting hand is raised by the wave. To obtain the sign, the pulps—not the points— of as many fingers as can be accommodated should be placed on the area, and the further the two sets are apart the better ; steady, gentle, vertical pressure should then be made with one set of fingers, the other set remaining passive upon the surface (students often voluntarily lift up one set as they press the other down). Often one is able to place only two fingers upon the surface, or even one, when the relative softness only of the part can be taken account of; danger of error increases as the size of the supposed fluid collection lessens. Of course, true fluctuation does not prove the existence of pus, but merely of a circumscribed collection of fluid ; and a sensation so like it is yielded by very soft solids and by subcutaneous tissue of which the meshes contain a good deal of cedematous fluid, that mistakes are made even by the most experienced. Great caution is needed, therefore, in diagnosing, by touch alone, abscess in the granulation tissue of tumor albus or on the back of a hand swollen from oedema, or where blood has been effused. In cases of doubt a grooved needle should always be put in at the suspected spot, when pus if present will run up along its groove. When an abscess in a limb is subfascial, cedematous swelling is great and widespread, but it may, for many hours or even days, be impossible to deter- mine its exact site. The diagnosis of pus will then rest upon the intensity and persistence of the inflammation and the character of the fever. It may rest upon the latter alone, or upon the latter with pain and tenderness, in abscess of internal organs. Pain, varies much, being most severe when the pus is rapidly formed and tightly bound down—e. g., in the mamma or a tendon-sheath or the dense fibrous tissue of the finger. In the latter instance especially it is throbbing. Tenderness is generally marked, and the point of maximum tenderness is most useful in localizing a deep abscess. Fever also varies much. It may be slight with a large abscess, high with a very small one ; generally it is proportionate to the acuteness of the mis- chief, and is much more marked in subfascial and deep abscesses than in superficial ones. Not uncommonly the temperature is 102° to 104°, and continued in inflammations which end in suppuration. The occurrence of this is often indicated by chills or an actual rigor, after which the fever is maintained and perhaps rises higher; but if the abscess is not opened, the temperature generally falls a degree or two when a wall of granulation-tissue limits the spread of suppuration and absorption of inflammatory products. Ultimately it may become markedly remittent, as is most often seen in unopened empyemata. The lymphatic glands above an acute abscess are generally enlarged and tender, and there may be lymphangitis. Special symptoms arise from implication of special parts—e.g., oedema glot- tidis from abscess in the base of the tongue: By pressure on various pas- sages—trachea, gullet, urethra—others are produced, and abscesses may burst into these canals. Pressure on nerve-trunks often causes pain referred to distant parts, as seen in psoas abscess from pressure on the lumbar plexus. Small vessels become thrombosed before destruction ; large ones almost 78 SUPPURATION AND ABSCESS. always resist ulceration, even though isolated in the cavity of the abscess. Very rarely a large artery or vein (chiefly carotid or jugular) is eaten into by an abscess which is unopened. Terminations.—If left to themselves, acute abscesses burrow more or less widely in the tissues, and ultimately burst upon a cutaneous or mucous surface, rarely into a serous or synovial sac, exciting fatal or destructive inflammation of it; as a rule, abscesses of intraperitoneal organs become adherent to the abdominal or intestinal wall, and are discharged through one or other. Very rarely an acute abscess is absorbed. More often it becomes chronic, and rapid is changed for slow advance. Rarely a capsule forms round the collection ; the fluid is slowly absorbed, the solid parts caseate and may subsequently calcify or soften. In the great majority of cases they burst and then heal more or less rapidly, but sometimes sinuses or fistuloz (page 73) are left. Chronic or Cold Abscess. Causes.—Some result from acute or subacute abscesses, others from the breaking down of tubercular infiltrations or from the softening and irritation of old caseous stuff; syphilitic gummata and infiltrations give rise to others. Suppuration may finally occur round foreign bodies which have lain qui- escent among the tissues for months or years. A mechanical injury may sometimes be a predisposing cause. The most characteristic are the so-called gravitation abscesses, generally connected with disease of bone, especially the spinal column. A carious focus suppurates, and the pus, which is very slightly irritant, separates or causes absorption by pressure of the most yielding tissues in its neighborhood, and thus forms a sac for itself which extends in the lines of least resistance— within the sheaths of muscles (psoas), along the course of bloodvessels (lumbar arteries, profunda femoris, internal circumflex), whilst all fascial and connective tissue round about thickens considerably by inflammatory hyperplasia. Such abscesses have been known to extend from the spine to the internal malleolus; they are surrounded by a dense fibroid wall, of reddish-gray color, containing few vessels, and lined by a layer of cheesy stuff; large and small offshoots run in various directions, abscesses in the loins, groins, and buttocks being often continuous at the spine; the cavity is crossed by numerous strands containing large bloodvessels and nerves ; and the pus is thin, curdy, and contains few if any living cells, most being highly degenerate. Bits of bone and calcareous matter are often present. Organisms have never been found, but as the pus produces tuberculosis in animals, Koch supposes that the spores of bacilli, which cannot as yet be stained, are present. It will be noted that the pus runs from a small fociis in the direction of gravity and least resistance, the greater part of the sac forming little or no pus, but being simply a bag to hold it. Symptoms.—Ordinarily of slow formation, cold abscesses sometimes develop rapidly without any acute symptoms ; or gravitation abscesses may quite suddenly become obvious, as when they pass from the abdomen be- neath Poupart's ligament. The soft parts over them show no sign of in- flammation ; no pain, tenderness, or heat; but these may be present to a slight extent. Fever is absent or there is a slight evening rise. Fluctua- tion is the plainer the nearer the abscess is to the surface. Acute exacerbations occur in some cases, especially the chronic abscesses of the mamma and bone. Pain in abscess of bone may be frequent and severe. TREATMENT OF ABSCESS. 79 Progress and Termination. — Abscesses of this kind may advance slowly, and finally the skin over them inflames, ulcerates, and gives way. They may remain quiescent for years. Complete absorption may occur. Their fluid contents may be absorbed, leaving dry cheesy stuff encapsulated in the shrunken sac; this may act as a focus whence general tuberculosis may arise. Not uncommonly acute symptoms supervene in a chronic case, and the abscess runs on rapidly toward rupture. Treatment.—To prevent suppuration the ordinary treatment, general and local, of inflammation must be used—rest, belladonna, and fomenta- tions acting best as a rule. The bowels should be kept gently open. Such treatment hastens suppuration if it must occur. So soon as pus is known to exist, and can be reached without exposing the patient to danger, it should be let out; because, if left, the abscess will get larger, and, therefore, take longer to heal, destroy more tissue, pull the patient down more by pain and fever, and the scar left by bursting (ulceration of skin) is large and irregular. Sometimes a patient's fear of the knife may be yielded to, and the abscess allowed to burst, but in the following cases the surgeon's aid is imperatively demanded. 1. Whenever an abscess tends to spread and burrow rather than to come to the surface. This is the case chiefly when it forms beneath the dense fascia, such as the deep fascia, tendon sheaths, or the capsules of organs like the testis. These structures yield but slowly to inflammation, and the pus instead of coming to the surface burrows beneath them to great distances among the muscles and tendons (in axilla, ischio-rectal fossa, hand), often causing necrosis of the latter by pressure, and ultimately leading to irreme- diable matting of the parts, destroying the parenchyma of important organs (testis, mamma), and producing extreme pain and constitutional disturbance. Hence all abscesses beneath fasciae, among tendons, or under the thick cuticle of the fingers should be freely opened as soon as the existence of pus is determined. 2. In cases of diffused suppuration, especially that due to extravasation of urine, the incisions being quite as much to permit the escape of the cause of the morbid process as its products. 3. Whenever an abscess is so situate that it may burst into a joint, the pleura, or peritoneum, or beneath the deep fascia; or when it compresses and may burst into mucous channels. 4. When a large scar is to be avoided, as in the face or neck. In many of the above cases it is better to incise too early, before pus has formed, than too late. A whitlow taken early and properly treated, will, however, often subside, and a most painful incision is thus avoided. Abscesses may be opened by transfixion with Syme's sickle-shaped knife, o.r by incision with a narrow straight bistoury, when the abscess is deep. Either is to be introduced vertically till diminished resistance shows that a cavity is reached or till pus escapes along the blade which may be slightly rotated. The cut is then enlarged sufficiently as the knife is withdrawn. It should generally be made at the lowest part, that the abscess may drain naturally ; or, if the skin is too thin to live at any spot, the opening may be made here, a counter-opening being used if necessary. Its direction should be that in which it is most likely to remain open—e. g., vertical in the groin, and it should be parallel to any considerable vessels or nerves. If no chloroform is given the knife must be held short like a pen to prevent its entering too far, and the surgeon must be prepared for any sudden move- ment of the patient. When there is the slightest danger of wounding a deep vessel, Hilton's method should be employed; by it pus may be safely evacuated much earlier than in any other way. With a knife cut through 80 SUPPURATION AND ABSCESS. Fig. 4. the skin and deep fascia; then push on a director through the deep struc- tures till pus runs up along it. Now pass a pair of sinus forceps along the director, and by opening its blades tear a sufficient opening in the abscess wall; and by withdrawing the instrument with the blades open leave a lacerated track which will not readily unite. Thus may be opened deep abscesses in the orbit, axilla, neck, abdomen, and thigh. The matter may now be gently pressed out by sponges on each side of the incision, or discharge will come through the dressing very shortly. Having emptied the cavity, steps must be taken to keep it so. This may, in some cases, be effected by a thoroughly free incision and sub- sequent uniform pressure, a little bit of the dressing being tucked in between the lips of the cut for twenty-four hours. But usually it is better, and often absolutely necessary, to employ one or more drainage tubes. The opening need then be only large enough to admit a tube of calibre sufiicient to drain the cavity. The tubes should be of red rubber, and be kept in 1 in 20 car- bolic lotion, of all sizes, cut and threaded as in Fig. 4. The deep end is generally best cut obliquely, the superficial must be cut square or more or less obliquely, so as to lie exactly on the level of the skin and in the plane of the wound, or the pressure of the dressing will push the sides of the tube together and prevent drainage. It is a great mistake to carry a tube across a cavity, leaving an inch too much at each end and tying the ends to- gether. The length of the tube is found by introducing some blunt instrument along the track it is to occupy and marking the point to which it enters. The tube may be pushed in alone with a rotatory movement, or it may be placed in position with Lister's sinus forceps (Fig. 5). If there is any difficulty in in- troducing the tube, or in the case of a fresh wound, it is often advisable not to remove it till the third day, when it will have formed a track for itself; otherwise it is well to remove it at the first dressing, to free it from clot. Too much care cannot be given to the arrangements for drainage; and several openings may be required for one abscess. Some kind of antiseptic dressing should always be used. In out-patient cases, salicylic or the more expensive iodoform wool is very convenient: it must be one and one-half to two inches thick if the abscess is of any size. Small dressings about the face and neck may be fixed on with collodion. These dressings need be disturbed only when some moist discharge appears on the surface, when pain or fever make it prob- able that something is wrong in the wound, or when a tube needs shortening. Fig. Irister's sinus-forceps In the absence of these indications the dressing may remain until all is sup- posed to have healed. Pads of carded oakum are another reliable and cheap dressing, but they discolor the skin. For large abscesses gauze dressings are best. In all cases the diseased part and everything brought into contact with it should be thoroughly puri- fied. 9 TREATMENT OF STRUMOUS ABSCESS. 81 Inflammation round an abscess generally subsides after the pus is let out; but where the abscess is only a small part of a spreading inflammation, no ocal treatment is better than boracic fomentations changed every three hours. Iu strumous nodules, subcutaneous and glandular abscesses, remove as much as possible of the granulation tissue containing cheesy foci with a sharp spoon ; it may be done very thoroughly in many cases through an opening of small size. Bleeding is slight and soon checked by pressure. Some crystallized iodoform should then be spread over the interior of the cavity, a tube inserted, and the dressing applied. In the larger abscesses, especially those formed by gravitation, little can be done in this way ; and in examining the interior with the finger, which it is right always to do, great care must be taken not to tear the bands of vessels crossing the cavity. Any cheesy material within reach may be removed. The opening of these abscesses was formerly regarded with dread by sur- geons, for the discharges putrefied and bagged in the cavities, many patients died within a few days of septic poisoning, and many more later on of hectic, albuminoid disease, and exhaustion from profuse discharge. Billroth, ten years ago, said, " Be thankful for every day that they remain closed." Con- sequently they were allowed to reach sizes which are never seen now, for they are dealt with immediately they can be reached. Their successful treatment may indeed be regarded as one of the greatest triumphs of anti- septic surgery, for frequently it is impossible to drain the irregular cavities thoroughly, and everything depends upon keeping them aseptic. Under this treatment patients with long sinuses leading to large cavities are kept almost or quite afebrile, even for years, in excellent general condition—the health beginning to improve immediately the abscess is opened, and dressing being required only once a week or less frequently. Every now and again aspiration cures a chronic abscess, but success is so rare that the instrument is not often employed for this purpose. A syringe aspirator, with a graduated glass barrel, is the best; a cheaper form, the bottle aspirator, is shown in Fig. 6. The needles should vary in size from The bottle aspirator. that of a fine hypodermic needle to that of a No. 6 English catheter; most should have only a terminal aperture, for the vacuum cannot be turned on till all openings are buried, but one or two large ones may have a couple of lateral openings near the point. Before use, the entire instrument should be filled with 1 in 20 carbolic and then emptied. The vacuum is then produced. The part is washed with 1 in 20 lotion, the needle pushed into the abscess and the vacuum turned on. If there is doubt as to the depth or presence of fluid, 6 82 SUPPURATION AND ABSCESS. turn on the vacuum so soon as the aperture of the needle is buried and then push it slowly on ; when reached, the fluid rushes into the syringe. If the abscess is large and deep and the pus curdy, a needle with lateral apertures may be used, and should these become blocked, the piston may be gently lowered and some pus forced back into the cavity. The insertion of a glass T-tube, with a clamped India-rubber tube on the foot of the T, in the pipe connecting the needle with the aspirator, enables the operator to start with aspiration and to end with siphon-action. After use the aspirator should be thoroughly washed, first with water a,nd then with 1 in 20 carbolic. If the abscess is already open and septic, most perfect drainage should be established, and the discharge received in an antiseptic dressing. An attempt may be made to render the cavity aseptic by slitting it up, if small, cutting away blue thin edges, scraping out the granulation tissue with a sharp spoon, rubbing the wall with solution of chloride of zinc (gr. xx ad §j), and apply- ing crystallized iodoform to it; or large cavities may be distended under some pressure with 1 in 40 warm carbolic lotion, care being taken not to force the lotion into the surrounding tissues. An anaesthetic must be given for this treatment, which generally fails. If drainage cannot be made per- fect, advantage may be derived from daily flushing the cavity with iodine lotion (tr. iodi 3J, ad aq. Oj), or other mild antiseptic. After-treatment.—Rest and dressing as required. The tube is taken out and cleaned at each dressing, and the part carefully wiped with carbolic lotion lest any organisms may have entered a short distance along the line of discharge. The tube must be shortened as the discharge diminishes, and removed as soon as possible, for in some cases it keeps a sinus open. Often, however, it is necessary and very difficult to keep a sinus patent to prevent bagging, as when the sinus leads to a carious spine. Steady diminution of discharge without signs of bagging will then show when a tube may be short- ened ; experimental withdrawal is sometimes permissible. Premature con- striction of deep parts must be got over by dilatation with French bougies or graduated steel sounds, cautiously used. Rise of temperature, malaise, and perhaps local pain, especially if at all persistent, necessitate careful examination of the abscess. The discharge may have become septic, and the fever be due to septic absorption. Or drainage being imperfect, bagging may have occurred, tension and absorp- tion of inflammatory products being the results; on relieving this the fever subsides. The fever may be due to causes at a distance from the abscess; and in cases of chronic abscess one must never forget the possibility of the occurrence of general tuberculosis. Rarely in septic abscesses, and chiefly in the thigh and neck, ulceration extends into a large artery or vein : the accident has sometimes been attrib- uted to the pressure of a tube. When possible, the cavity should be freely opened, the circulation being controlled and a determined attempt made to tie the bleeding point. Should this be impossible, plugging only remains in venous hemorrhage; but in arterial, ligature of the main trunk nearer the heart has been successful, and should be practised before having recourse to amputation where this can be done, unless indeed the part is already de- stroyed by inflammation. Hectic Fever (£ktik6q) habitual). Causes.—The chief is the continued absorption of poison from decompos- ing pus; the larger the surface the greater the likelihood of hectic, but im- perfect drainage and tension render it much more certain. It is the rule to find hectic with ill-drained septic cavities, whilst foul ulcers of equal extent ALBUMINOID degeneration. 83 do not generally cause it; improvement of drainage affords relief in the former case. Remove the cause—e. g., an ill-drained cavity or disorganized joint—and the fever ceases. So long as chronic abscesses remain unopened and sweet, hectic fever never occurs ; but (p. 78) the fever accompanying an acute suppuration— e. g., empyema—may, if prolonged, assume this type. Fever of hectic type occurs also in malignant lymphadenoma, and occasionally in other malig- nant growths. Many prolonged fevers tend to assume a remittent character. Symptoms.—Remittent fever is the chief, the temperature varying from 99° to 102.4°. The evening rise is accompanied by heat and thirst, and may be preceded by chills or even a rigor; the early part of the night is restless; toward morning with fall of temperature come sleep and most profuse sour sweating. The pulse is 90-100, becoming softer, smaller, and more frequent as the case goes on. Loss of flesh and strength is marked; the eyes become sunken and very bright; a bright red patch on the cheeks, especially in the evening, contrasts with the anaemia of the general surface. The tongue becomes strawberry-red at the tip and edges, and there is great tendency to diarrhoea. The urine deposits urates copiously, and often con- tains a little albumen. The mind remains clear for a long time, then wan- dering at night occurs. The patient sinks from sheer exhaustion, generally becoming quietly unconscious a day or so before death. Or the end may be ushered in by more acute septic poisoning with typhoid symptoms. Before this, bedsores are common. Treatment.—Establish the freest drainage and combat decomposition. If the part can be removed entirely, this should of course be done before the patient has sunk too far. All the most nourishing food the patient can take should be given, and chiefly in the morning when the fever is low : there is no objection to a little wine with food to stimulate and aid digestion, but the enormous quantities of alcohol sometimes given are probably worse than useless. For diarrhoea, look carefully to diet; give raw meat, and everything cool; aromatic sulphuric acid (F. 2, 61, 64, 6Q), with small doses of opium, and sometimes chalk, bismuth, gallic acid. Sulphuric acid relieves sweating also (F. 3, 43, etc.). Albuminoid Degeneration. This is, surgically, the most important degeneration, so frequently does it assist hectic in causing the death of patients suffering from chronic suppura- tion. It is doubtful whether it is to be regarded as a metamorphosis or an infiltration. Causes.—Albuminoid degeneration is almost always secondary to some primary disease, generally prolonged suppuration from some cavity, much more rarely from the surface of a simple or malignant ulcer; it sometimes occurs in severe syphilis, malaria, and a few other diseases. Almost all its causes are due to infective processes, and Birch-Hirschfeld suggests that the degeneration may be due to an infective cause. Morbid Anatomy.—In certain cells of certain organs a substance appears which is firm, almost colorless, homogeneous, waxy-looking, translucent in thin sections, takes a mahogany-brown color from a watery solution of iodine (healthy parts being pale yellow), and a red color from a watery solution of methyl-violet (1 in 10). The substance is nitrogenous, differing from albu- men chiefly in its color reactions, resistance to digestion, and slighter ten- dency to putrefaction. The earliest stages are discoverable only by the microscope: a little later, 84 mortification. in some organs pale waxy points may be seen—e. g., the glomeruli in the kidneys, Malpighian corpuscles in the spleen (sago-spleen). Finally, the degenerate patches enlarge and blend, and the whole organ becomes con- siderably swollen, stiff, somewhat brittle, and looks like white wax; it pre- serves its general outline. The change begins in the media and intima of small arteries and in capil- laries, whence it spreads to the connective tissue of the organ; lymphoid cells and smooth muscle-fibres also undergo the change; but statements vary as to whether the epithelial elements of glands are subject to it. The most recent authors say that these merely atrophy. The chief seats are the liver, spleen, kidneys, adrenals, lymphatic glands, and the mucous membrane of the intestine, especially the large ; in advanced cases other parts may be affected. The above organs are not affected in any constant order. Symptoms.—Greatly impaired blood-forming power, albuminuria, diar- rhoea, even intestinal ulceration and hemorrhage, with anaemia, marasmus, and death as the ending. The course is slow. The spleen can usually be felt uniformly but not greatly enlarged ; so also the liver, its edge being sharp and in consistence like India-rubber, and its size often great. Advanced disease of this kind is generally held to contraindicate serious operations. A very few cases of advanced disease have, however, been recorded in which removal of suppurating foci by amputation has been fol- lowed by great improvement; it would, therefore, seem right to operate in spite of marked albuminoid degeneration when the primary disease can be completely removed and the patient seems able to bear the operation. CHAPTER VI. MOKTIFICATION. Mortification and gangrene are clinical terms expressing the death of parts in considerable mass. Necrosis in its pathological sense means simply death—of a limb or of a cell; but, clinically, it is used to describe death of firm tissues—bone or cartilage—the dead part being called a sequestrum. Sloughing, on the contrary, applies to soft parts. Gangrene is sometimes called constitutional when it arises without any, or from very slight local cause; cardiac weakness, disease of vessels, or some other remote condition being its chief cause. Local gangrene is due to local causes, as when a limb is crushed, a piece of gut is strangulated, or a main artery is torn across. Signs of Gangrene.—These are change of color—to tallowy pallor, to this mottled with purplish-red, or to general lividity ; and loss of all signs of life—warmth, sensation, spontaneous motion, power of secretion. These must persist for a considerable time to render death certain; and it must be remem- bered that temperature may be artificially maintained, and that a living muscle may move a dead finger or toe by means of a tendon inserted into the gangrenous part. The next changes that take place render death imme- diately certain, for the part either dries and shrivels or it remains moist and SYMPTOMS AND CAUSES OF GANGRENE. 85 undergoes putrefaction. When the former changes occur we speak of dry gangrene or mummification; when the latter, of moist gangrene. Mummification arises from causes which obstruct the entry of blood whilst the exit is unimpeded or assisted by elevation ; and it is favored by all con- ditions which favor drying—e. g., exposure to air or envelopment in absorbent dressings, thinness of the part affected, plenty of bone and tendon, no muscle or fluid effusion. When, on the other hand, a large portion of a thick, fat, fleshy limb, gorged with oedema or inflammatory fluid, suddenly or rapidly dies, there is little chance of its drying. The distinction of these two forms is usual, and their differences depend largely upon accidental rather than upon pathological circumstances, and every gradation between the dry and the moist is met with. The extremes only will be described. In dry gangrene the part is at first generally pale or mottled, and not swollen; then shrinks and the skin becomes wrinkled, dry, and of color varying from brown to black, at first perhaps somewhat transparent, showing tendons, etc., through, but ultimately opaque. The living tissues, as a rule, show signs of only moderate inflammation, and the part really dead is soon fairly defined. In moist gangrene the part is more or less swollen, livid, or pale from ten- sion, and bloody bullae are numerous on its surface. These signs pass grad- ually into those of health above, perhaps into those of obvious gangrene below. The superficial veins may be marked out by purple staining; the cuticle loosens everywhere and is easily brushed off, leaving a moist surface of various colors—dark red from haemoglobin, olive-green or ash-gray as decomposition advances. A putrid odor soon becomes strong and the part crackles, being distended with offensive gas. General Symptoms.—Putting aside such as are due to any general state which may have been present in so-called spontaneous gangrene or to shock in traumatic cases, and also special symptoms connected with the functions of the part—e. g., bowel—involved, the subject of extensive gangrene is sure to be in a condition of great weakness, and the exhaustion is often increased by anxiety and pain. Otherwise gaugrene produces marked general symp- toms only by throwing septic products into the blood. The symptoms are those of more or less severe septic poisoning, and frequently fatal. They are much more severe in the moist than in the dry form, but even in the latter there is necessarily a zone of dead tissue in contact with and kept moist by the living, in which decomposition can occur. Etiology.—The causes are general, for the most part predisposing, and local or exciting. General Causes.—All influences which depress the health and impair the resisting power of the tissues favor the death of the latter. They act most directly, however, by inducing cardiac weakness and failure of the circu- lation in distant parts—especially toes and feet, then finger-tips, nose, and ears. • Among such may be mentioned insufficient and unwholesome food often coupled with exposure, loss of blood, and exhausting diseases, especially with prolonged fever and typhoid symptoms. Under these circumstances gangrene—usually dry—may arise, without local cause : thus Brodie men- tions the case of a drunken man who was largely bled, and his feet became gangrenous. Mortification may occur similarly during diabetes, typhoid, typhus, and, less often, other acute specifics. But local causes may have their share: hence the gangrene of the feet of the starved soldiers after standing in wet and cold trenches before Sebastopol, and the sloughing which is apt to follow the application of blisters to children after measles and scarlatina. Ergot of rye produces gangrene of extremities and rarely of pressure points. The gangrene is generally dry and preceded by symptoms like those which 86 MORTIFICATION. indicate the presence of calcareous arteries; and the whole disease presents a striking likeness to that form of gangrene which is due to slowly progres- sive arterial thrombosis. The starvation sure to accompany a diet of spoiled corn is a powerful predisponent. It seems impossible that ergot can produce spasm of arterioles enduring until the parts supplied are dead, as has been asserted. Wood (Therapeutics, 2d edit., p. 547) believes that in decidedly toxic doses ergot lowers the arterial pressure, acting as a direct depressant of the heart and vasomotor centres. The gangrene would, therefore, seem to be due simply to anaemia of extreme parts. Bright's disease, and tricuspid regurgitation, deserve mention as predis- posing or even exciting causes of gangrene of the legs, from the tense oedema which they cause. Local Causes.—All act immediately in one, or both, of two ways: (1) they directly destroy the life of the cells of a part; or (2) they arrest or render insufficient the blood-supply—(a) by obstruction of arteries, (b) by obstruction of veins, or (c) by obstruction of all vessels. Injuries of all kinds either destroy the vitality of a part outright, or, if less intense, excite inflammation which may end in gangrene—usually moist— from both injury to the tissues and arrest of their blood-supply. Gangrene from inflammation has already been described, and will be again referred to under phlegmonous erysipelas and spreading traumatic gangrene. It is due partly to direct injury of the tissues by the cause of the inflamma- tion, partly to arrest of circulation by tension and stasis, and to these causes in varying degree in different cases. It is always of the moist kind. The great majority of inflammations leading to gangrene are probably infective. Inflammation (often called erysipelas) frequently arises and runs into slough- ing in intensely cedematous legs, either after puncture or without any local injury. Arterial obstruction is a common cause of gangrene, and is produced in many ways—e. g., rupture, ligature, pressure, spasm, endarteritis obliterans, thrombosis, and embolism. Ordinarily, when a main artery is thus blocked, collateral vessels dilate and carry on the circulation in its area (p. 42); but if this does not occur, gangrene must follow. Often this is of the dry kind, but still more often it is moist; for though unable to maintain the circula- tion, collateral vessels are frequently able to pump sufficient blood into the part to keep it from drying subsequently, and the dead part is often large. With the exception of endarteritis obliterans and thrombosis the above causes do not tend to produce a spreading gangrene, but these two often spread, and gangrene mounts up the limb pari passu. Forms of gangrene due to injuries of arteries will not be further referred to here; of those due to disease, thrombosis and embolism are by far the com- monest causes. 1. Thrombosis results from disease, usually atheromatous (see " Disease of Arteries"), of the inner coat. Gangrene from this cause is, therefore, met with chiefly after middle life, and in the legs. The term senile gangrene is frequently employed to indicate dry gangrene in the aged, due to thrombosis of calcareous arteries; but, as gangrene in old people may be due to other causes, and thrombosis of such vessels may result in moist gangrene, it should be abandoned. There seem to be two causes of gangrene—thrombosis and inflammation— of frequent occurrence in the aged, and each depends upon the existence of calcified arteries. Degenerate arteries often give rise to the following pre- monitory symptoms: itching, formication, numbness and coldness in the feet and legs, with painful cramps, especially of the calf muscles; the tibial pulses are feeble, the arteries rigid. CAUSES OF GANGRENE. 87 The irregularity and abnormality of the surface of such vessels and the slowness of the circulation predispose to thrombosis, which, starting at any point, slowly spreads. At first, perhaps, only a toe mummifies, then others, and then the gangrene slowly creeps on to the foot. It frequently halts for some days, only again to advance. But little inflammation precedes its advance, and general symptoms are slight, but pain is often extreme. The thrombosis is very extensive; to cause gangrene of half the foot, the clot probably extends into the popliteal, and blocks the vessel so completely that scarcely any blood drips from an amputation wound in the upper third of the leg, and no vessel requires tying, The malnutrition of tissues thus poorly supplied with blood must be extreme. Very slight injuries excite inflamma- tion, and this easily spreads and causes death of the part affected. The second form of gangrene special to old people is inflammatory, being predis- posed to by malnutrition of the parts; it starts from some slight injury, cutting a corn, treading on a nail, etc., and is either a septic or locally infective process. The swelling is usually slight, but may be considerable ; the part, usually one or more toes, becomes purple, and moist gangrene sets in; but the part is so small that it often dries. The signs of inflammation along the advancing edge are strongly marked, and the part is the seat of much burn- ing pain, especially at night. The general symptoms are marked in propor- tion to the putrefaction that takes place. These cases generally run a much more rapid course than the former; both forms may cease at any spot, often only to recur. 2. Embolism.—Bits of fibrin from aneurismal sacs, vegetations from car- diac calves, calcareous plates from arteries and other bodies, are occasionally swept away by the arterial current and lodged in the main artery of a limb, often at its bifurcation ; thrombosis soon renders the occlusion complete. A sudden severe pain is felt in the limb, and this is rapidly followed by gan- grene, which is generally dry, but may be moist. It extends up to the point of the arrest of the embolus. 3. Endarteritis obliterans (see " Disease of Arteries") is very rare. An extreme degree of endarteritis may cause such swelling of the intima as completely to occlude the lumen of an artery, or thrombosis may be induced. The disease tends to spread from the periphery toward the centre. It occurs at or before middle life, and without obvious cause, syphilis especially being negatived. It may affect either limb, and runs a chronic course of months or years. The symptoms are like those of progressive thrombosis of calcareous arte- ries above described ; and are preceded by similar warning signs. But the disease occurs usually in younger patients in whom there is no evidence of general arterial degeneration, and the affected vessel can be felt to become progressively harder and to pulsate more and more feebly until it is left a solid cord, which ultimately shrinks. The pain along the artery may be extreme. If gangrene results, it is very limited in proportion to the arterial obstruction. (See a case by Pearce Gould, Clin. Soc. Trans., 1884.) The disease may subside spontaneously. 4. Raynaud's disease, or symmetrical gangrene.—This is a rare disease, char- acterized by the sudden formation of cold, rather tender, gray-blue, ill-defined, rather painful patches upon the limbs, most commonly of young children, but also of adults. Such areae are often symmetrical; in other cases one foot or hand only is affected. In the majority of cases the parts become normal after half an hour or a few hours; in the most severe the color deepens to black, bullae rise, aud the skin sloughs, or perhaps a whole finger dies and shrivels. The attacks are paroxysmal, not periodic, may begin with vomiting and yawning, and be followed by passage of urine containing albumen and granular blood 88 MORTIFICATION. pigment; it is quite a cold weather affection, but attacks occur without special exposure. Post-mortem, a hemorrhagic infiltration of the discolored tissues has been found. The disease has been ascribed to spasm of arterioles due to excitation of sensory nerves by cold and the conveyance of this stimulus to a very hyper- aesthetic cord. (T. Barlow, Clin. Soc. Trans., 1883.) Obstruction of veins is rarely a cause of gangrene, the anastomoses between veins are so free; the common femoral vein is a rare exception. When, however, a main artery is obstructed, even partial obstruction of its vein becomes very serious, and moist gangrene is probable. In strangulation, which does not stop all circulation, the veins are much more affected than the arteries, and the part consequently becomes extremely congested (p. 47), swollen, and ultimately falls into a state of moist gangrene, as often seen in strangulated bowel. Arrest of Gangrene.—The cause ceases to spread and its effect simi- larly ceases to advance. Frequently we cannot tell how an inflammation is arrested, why a thrombus ceases to extend, and so forth ; but upon points like these the arrest of advancing gangrene depends. Gangrene from anaemia —i. e., dry—often ceases just below a joint (ankle or knee) around which the arterial anastomosis is more free than lower in the limb. When progress of the gangrene is arrested a bright red line of inflamma- tion (called the line of demarcation, p. 61) separates the living parts from the dead. And the appearance of this line is most important as a means of prognosis, because it shows that the mischief has ceased, and that there is a disposition to repair its ravages. Separation of the Mortified Part.—It is at this bright red line of demarcation that the dead part is separated by ulceration. A narrow white line, due to elevation of the cuticle by vesicles, appears along the edge of Fig. 7. Separation of the dead part in dry gangrene from exposure (King's Coll. Mus.). living tissue. Separation of the cuticle occurs here, and a chain of minute ulcers is seen under it. These gradually unite and form a chink, which widens and deepens till it reaches the bone (Fig. 7). Granulation tissue forms in and eats away the living tissue wherever it is in contact with the dead; even the bones are at last ulcerated through, and the dead part is cast off (see p. 61) leaving a granulating and suppurating surface. Thus TREATMENT OF GANGRENE. 89 the whole of a mortified limb may be amputated; the bone and tendons separating lower down, and being more slowly detached than the skin, muscles, and bloodvessels, which retract, the resulting stump is irregularly conical. When granulation has duly occurred, this process of separation is unattended with hemorrhage, the vessels being closed by firm adherent thrombi; but when, as in hospital and other forms of moist gangrene, putre- faction or other intensely irritant and mycotic processes are going on close to the thrombi, these may form imperfectly, or soften and break down when formed, and the separation of the slough may be attended with severe hemorrhage. Diagnosis.—It is often impossible to tell at once whether a part is or is not dead. It may be pale, cold, insensitive, and motionless from injury, cold, and other causes, or swollen, dark blue, and covered with bloody bullae, and yet recover. The signs which render death of a part immediately certain are due to drying and putrefaction ; but these do not set in for some time. Treatment of Gangrene from Disease.— General: Treat any general morbid state which may have predisposed to gangrene, and endeavor to improve the health and strength of the patient. Apart from specific treat- ment of Bright's, diabetes, etc., the most nourishing and easily digestible diet should be given ; a little alcohol with meals may aid digestion. Whilst paying every attention to local hygiene, see that surrounding conditions are favorable, and especially that ventilation is good. Pain, irritability, and restlessness must be allayed by opium in regular small doses, or occasional large ones (gr. j of the powder or wlxxx of the tincture) as required. A mixture of ammonia and bark (F. 15), is useful. Treatment.—Remove any local cause, as pressure, a strangulating band, or tension. The latter may very frequently be done, and with the best effect, in all spreading inflammations, in those which so commonly arise in the tensely cedematous legs of cardiac and nephritic subjects, and in cases in which venous obstruction plays a prominent part, by a sufficient number of well-placed incisions, one to two inches long (see "Phlegmonous Erysipelas"). These gape and act probably as much or more by affording a ready means of exit for the causes of inflammation, which are being forced into the tissues, as by relieving tension. All parts in which gangrene is threatening should be elevated, very slightly in cases due to arterial obstruction, considerably in those from obstruction of veins or inflammation. The preservation of warmth in the affected part is another important point, and is best effected by wrapping the part in a large quantity of cotton-wool and maintaining a comfortable external tem- perature. Of the highest importance is the prevention of decomposition in parts, should they die. Threatened tissues should therefore be well washed with soap and warm water, and then with warm sublimate solution ; breaches of surface should as far as possible be disinfected with sublimate thickly dusted with crystals of iodoform, and the whole part should then be enveloped in a thick covering of salicylic wool, if this be at hand, and a silk handkerchief sewn over all. It requires changing only when the patient presents symp- toms which may be relieved at the wound, or when an offensive smell or any discharge comes through. When gangrene is established before the patient is seen, the above meas- ures will still be best to arrest its advance, but septic decomposition will have set in and must be kept in check. An antiseptic absorbent wool dressing will favor drying. In moist gangrene it should be changed fre- quently and be less thick than in aseptic cases, and free and numerous in- 90 mortification. cisions should be made into the dead parts to favor the escape of fluids. It is well in moist gangrene to reduce the size of the putrid part as much as possible, so absolutely dead parts may be cut away. All gentleness must be used and a good margin left between the section and the living tissues, any interference with the latter readily lighting up fresh inflammation. To the surface and through cuts antiseptics may be freely applied to the dead parts —iodoform or powdered boracic acid being perhaps the best. When the soft parts have ulcerated through and retracted, much time may be saved by very gently retracting them with the aid of lateral incisions and dividing the bones with a saw; otherwise natural separation will take many months, and a stump incapable of healing soundly will then be left. Amputation in Gangrene.—The above may be called the expectant treatment. If successful, it leaves the patient with the longest possible stump: but no line of demarcation may form, and in severe cases the chances of death from septic absorption, pain, and exhaustion are many. Removal of the diseased part has therefore to be considered. In gangrene from injury primary amputation immediately above is the proper treatment. In rapidly spreading inflammatory gangrene, unchecked by incisions etc., the only hope lies in high amputation (see "Spreading Gangrene"). In extending gangrene from thrombosis of calcareous arteries high ampu- tation has been practised in a few cases with good result. Hutchinson pro- poses that amputation through the lower third of the thigh be done when the patients are so bad that they must keep abed. But to obtain viable flaps it is usually unnecessary to go so high. Hutchinson would apply the same treatment to the inflammatory form of senile gangrene, and here again it is probable that amputation below the knee would answer the purpose, anti- septics being used. The prognosis in these gangrenes of old people is very bad when they have passed the ankle. In gangrene from embolism, amputation should be done immediately above the line of gangrene so soon as this is well established. In all cases the general state of the patient must be considered and so far as possible improved, before resorting to amputation. Hemorrhage during the separation of sloughs is best treated by the cautery, simple pressure, or acupressure; these failing, amputation will probably be required. Mortification from Pressure, Bedsores, Etc.—When a patient is confined to bed with some very tedious and debilitating malady, as a fever —and especially if he has no strength to shift his posture occasionally—the skin covering various projecting bony parts (as the sacrum, brim of the ilium, or great trochanter) is apt to inflame and rapidly ulcerate or slough, and more particularly if irritated by neglect of cleanliness or by the contact of urine. The first thing complained of by the patient is often a sense of pricking, as though there were crumbs or salt in the bed. The part looks red, then becomes excoriated and ulcerates, or turns black and mortifies frequently right down to the bones. This accident is particularly liable to happen if the spinal cord has been injured. Often these sores do not cause the patient to make any complaint. Similar ones often form where splints or bandages press on bony prominences—e. g., malleoli, iliac spines, inner condyles of humerus. These points should always be guarded by " ring " p'ads of gauze, wool, or lint. Treatment.—When long confinement to bed is expected a water-bed should be had if possible. Strong spirit or Eau de Cologne should be regu- larly applied to the skin of the back and hips, to harden and enable itTto bear pressure better. Light friction of dependent parts with the hand SCROFULA AND TUBERCULOSIS. 91 greased with some ointment (boracic) should be performed night and morn- ing for five to ten minutes upon all patients unable to change their position freely. If the part seems likely to suffer, in the absence of a water-bed, air pillows, or water-cushions, shaped like a ring, should be arranged to relieve the parts from all pressure, and the patient should be made often to lie on his side or face. Boracic ointment is the best application for excoriations; for deep sloughs boracic fomentations, and dusting with iodoform if they are very foul. Balsam of Peru is recommended as an excellent stimulant antiseptic in these cases—either pure or diluted with an equal part of vaseline ; resin ointment is also very good. CHAPTER VII. SCROFULA AND TUBERCULOSIS. Definition.—Scrofula, or its equivalent, struma, is commonly defined as that condition of body in which the tissues are prone to inflammation of low intensity and protracted course. Description.—It has been held that certain types of organism manifest the scrofulous tendency or diathesis; but knowledge of temperament, habit of body, complexion, is too indefinite to permit of trustworthy description, and it will therefore be safer to await in each case the manifestations of scrofula rather than venture to predict on such grounds.1 The manifestations of scrofula occur in most of the tissues of the body, but foremost comes the absorbent system. Here the lymphatic glands are singled out, and they yield the indolent swellings—enlarged glands—so com- monly observed in the neck, and, by suppuration, lead to the puckered scars which point to past inflammatory action. Other tissues which may suffer are, the skin and mucous membranes; of the former, witness the eczema, frequently pustular, which is common about the head and face (impetigo of the scalp, tinea tarsi, suppurative discharge from the external ear); of the latter, witness the conjunctivitis, coryza, ozaena, otitis media, also the catarrhs of the bronchial tubes, the intestine, the bladder, the vagina, the vulva. Then connective tissue structures are often affected, witness the frequency of strumous nodules in the skin, subcutaneous abscesses, arthritis, osteitis. Or the several organs of the body, in particular the lungs, kidneys, and testicles, may show the above tendency to chronic inflammation. In all these cases, wherever the inflammation may localize itself, its char- acteristics are: (1) that it is apparently easily provoked,2 (2) that it is 1 Many, indeed, still hold to the view that a special type of body is found with the scrofulous diathesis. Sir W. Jenner's description of this type (Med. Times and Gaz., I860, Lecture I. on Rickets) may be given : "Temperament, phlegmatic ; mind and body, lethargic; figure, heavy; skin, thick and opaque; complexion, dull pasty-look- ing; upper lip and al a? of nose, thick; nostrils, expanded; face, plain ; lymphatic glands, perceptible to touch ; abdomen, full; ends of long bones, rather large: shafts, thick." 2 We are dealing with the clinical features of scrofula, and this easy provocation of inflammation is undoubtedly a clinical fact, though it may admit of a different patho- logical interpretation, as we shall see later on. 92 SCROFULA AND TUBERCULOSIS. rarely sthenic, (3) that, once started, the inflammation runs a chronic course. From these general features we may pass to more special ones character- istic of scrofulous inflammation and easily deducible from the above. First, easy provocation of the inflammation means that we shall often fail to dis- cover an exciting cause—the swelling of the gland or joint seems to arise spontaneously—it "comes of itself." Next, from the fact of the local action not running high, we miss the heat of inflammation (hence the name "cold " applied to scrofulous abscesses), also the redness over the scrofulous abscess which in pointing lacks the vividness of acute inflammation and is more purplish in hue; further, pain is comparatively slight or may be entirely absent. Lastly, owing to the chronicity of the process, there is time for organization of the inflammatory products which have invaded the tissues around the focus proper of the disease, hence the firm thickened base of the scrofulous ulcer with its infiltrated everted edges. This infiltration is some- times extremely marked in the neighborhood of a scrofulous joint, and may almost fix the joint. Passing to the morbid anatomy which underlies these manifestations, one must separate the affections of skin and mucous membranes from the affections of deeper parts, for this reason, that there is in the former no ten- dency toward accumulation of the products of inflammation which escape from the surface. But in the deeper affections, these accumulate; and in cases of long duration, examination will commonly show, occupying the centre of the inflammatory focus, be it in lung, kidney, testicle, or lymphatic gland, a material which from its consistence and color has been aptly likened to cheese. Its consistence truly varies much between a puriform liquid on the one hand and a mass of mortary or chalky hardness on the other ; but very commonly indeed the cheesy character obtains, and hence the cheesy or caseous nodule belongs to the classical description of scrofulous lesions. Without further examination of this cheesy mass, we may say this—that it consists of an amorphous debris, the yellow tint of which it derives from the presence of fatty particles; these fatty particles are the result of degener- ative changes and themselves argue chronicity. AVe shall recur to this point. Etiology.—Scrofula is highly hereditary, and in very many case^ it will be possible to discover a history of some one or other of the above-men- tioned lesions on the side of the father or mother. In like manner, the brothers and sisters of the patient may be expected to show in varying degree the same tendency. The manifestations of congenital scrofula do not, as a rule, appear during the first year of life, but from the second year onward during the whole period of active development, they are common ; the first two decades of life would cover the period of most active manifesta- tion. In middle age, and thence on, scrofulous lesions are not common. But scrofula may be acquired as well as handed on, and the conditions which tend to engender it are, briefly, improper or insufficient food, over- crowding, damp dwellings—in fact, all those conditions which are included under " Faulty Hygiene." These conditions will clearly have most effect during the period of active growth of the body, and hence another reason for the prevalence of scrofula during the first two decades of life. It is not uncommon for scrofulous affections to make their appearance for the first time shortly after some recent exhausting disease—e. g., some one of the acute specifics—measles, scarlet fever, smallpox, typhoid ; but these must rank rather as accidental predisposing causes, bringing to light a tendency which else might have remained latent. The relationship of syphilis to scrofula is probably of the same kind—viz., TUBERCULOSIS. 93 predisposing; but be this as it may, it is certain that many of the manifesta- tions of scrofula occur in the children of syphilitic parents. The children of parents of tender years, also those of parents advanced in life, are liable to scrofulous affections. Tuberculosis. Whilst scrofula is a term used in a clinical rather than in a pathological sense, or at least includes much of the clinical element, tubercle is essentially a pathological term, and hence the subject of tuberculosis will be best ap- proached from the side of pathology.1 The term tubercle is applied to certain morbid products which are found in the body. These to the naked eye certainly do not present great similarity; they include: (a) Masses of very variable size, ranging from the size of a pea or lentil to that of a billiard ball, rarely beyond this, which masses are of a yellowish color and somewhat cheesy consistence. (b) Minute seed-like or shot-like bodies, which may vary from the size of a pin-head downward, and in color may be either gray and semi-translucent, resembling then a grain of boiled sago, or opaque and white, or yellowish- white. The former (a) go by the name of crude, or sometimes yellow tubercle; the latter (b) by the name of miliary tubercle, or of gray granulation. The term yellow tubercle for the large masses is bad; for the smaller masses, we have seen, may also be yellow, and for this same reason the name " gray granulation " cannot be used as synonymous with miliary tubercle, for it names only a stage of the miliary tubercle. The grounds on which these two forms are both named tubercle are the following: First, the two forms may frequently be found associated : either miliary tubercles are scattered round about the cheesy mass of crude tubercle, or a patient will be taken with a rapidly fatal illness, and at the post-mortem, miliary tuber- cles will be found scattered through the tissues of the body, and with them in some organ or tissue of the body a caseous nodule. Next, it is frequently possible to trace the passage of the miliary tubercle from the gray translu- cent stage to the opaque, white, or yellow stage, and we may readily perceive how from such transformation, and from a confluence of adjacent miliary nodules, it would be possible to build up the larger yellow mass. Lastly, we may actually witness this building-up; for close examination of a nodule of crude tubercle, such, for instance, as we meet with in the brain, will reveal the following structure surrounding the large caseous mass — a delicate grayish-pink layer of granulation tissue, and in this layer minute nodules, answering to the description of typical miliary tubercles. The relationship is so close here that there is no doubting that the large caseous mass is a conglomeration of miliary tubercles which have passed into the yellow stage. The fittingness of the term "conglomerate" tubercle, introduced by Vir- chow, to designate the mass of crude tubercle, will be apparent, and, indeed, we shall best keep in mind the relation of the two forms of tubercle by speaking of them as discrete miliary tubercle and conglomerate tubercle. In 1 We may, however, refer here to the type of organism which is held to manifest the tendency to tuberculosis. The following is Sir W. Jenner's description: Nervous system highly developed ; mind and body active ; figure slim ; adipose tissue small in quantity; organization generally delicate ; skin thin; complexion clear ; superficial veins d^tinct; blush ready; eyes bright; pupils large, lashes long ; hair silken; face oval, good-looking ; ends of long bones small, shafts thin and rigid ; limbs straight; teeth cut early ; children run alone and talk early.—Med. Times and Gazette, loc. cit. 94 SCROFULA AND TUBERCULOSIS. Fig. 8. '■'■:£>'*>.•?■. addition to these, which constitute the nodular tubercle of Laeunec, we have the infiltrating variety. In this there is a diffuse cell-infiltration (Fig. 8), transforming the synovial membrane of a joint, for example, into a layer of granulation tissue half an inch thick or more. This variety is very impor- tant in surgery, for it is the pathological lesion in many cases of local tuber- culosis. Structure of the Miliary Tubercle. — In the earliest stage, this minute body, which is not bigger than a millet-seed, and is of a translucent gray color, shows under the microscope a dense clustering of cells into which no vessels penetrate. The cells are round and quite like leucocytes. We have thus before us a structure which may be likened to a bead of non-vas- cular granulation tissue (Fig. 10). At a later stage, the tubercle being now somewhat bigger, will show, besides the above, cells (epithelioid) of larger size, with well-marked oval nuclei resembling epithelial cells; in addition huge multi- nuclear masses of protoplasm may be found, more especially in the central parts of the knot; these are the so-called giant cells (Fig. 9). Traversing this cluster of cells may be found the re- mains of the connective tissue of the part as a supporting reticulum. In the infiltrating form the microscope usually shows the presence of numerous collec- tions of large cell forms similar to those of miliary tubercle, embedded in the granulation tissue (Fig. 8), in which they are quite invisible to the naked eye. Sometimes these collections are scarce; the granulation tissue is tuber- cular because of its cause, not because it contains tubercles. Now all the ele- ments above described, round cells, epi- thelial cells, giant cells, may be found in any granulation tissue (p. 61), and so far there is nothing specific in the structure; but though this is so, the life-history of the miliary tubercle is specific, for the tendency is always toward necrosis—the gray bead becomes ?S'.:. X TO. Section of capsule of hip in a case of hip-joint disease. In the granulation tissue are uniformly distributed tubercles with central giant cells and degenerating epithelioid and small cells. The upper giant cells contained two bacilli Koch). FlO. 9. Fig. 10. :'? - -7^x& : X TOO. A giant cell with radially arranged ba- cilli ; from a cheesy bronchial gland in a case of miliary tuberculosis (Koch). X 700. Cellular tissue from the margin of a men. ingeal tubercle; very numerous bacilli lie among the cells, of which only the nuc ei are stained (Koch) • opaque at its centre, the opacity spreads till it involves the entire bead and a yellow tinge is acquired. Examined now, the cells may be found in large part replaced by a detritus of albuminous and fatty granules, or may PATHOLOGY OF TUBERCULOSIS. 95 present blocks of homogeneous hyaline appearance (coagulation-necrosis of the cells). As a key to this tendency to necrosis the extravascular nature of the structure, which persists throughout, must be remembered ; but it is possible that the action of the bacillus (Cheyne) is still more to blame. The , caseous mass may remain dry and ultimately calcify, or it may more or less rapidly soften into a puriform fluid, excite inflammation, and tend toward the nearest surface. Pathology of Tuberculosis.—We now come to a very important point. What is the significance of the scattered miliary tubercles which are found so commonly immediately around the caseous nodule? And what is the meaning of the sudden outbreak of an acute disease which reveals, on the death of the patient, the tissues of many, perhaps most, organs strewn with miliary nodules; and then in some out-of-the-way corner, perhaps, a yellow focus of conglomerate tubercle which obviously is of much older date than the scattered miliary bodies? The demonstration of the structural relation- ship of crude and miliary tubercle is a step toward answering this question, but only a step. The answer would, however, be forthcoming, supposing we could prove the presence of the same poison in the yellow focus of con- glomerate tubercle, and also in the discrete miliary tubercles: for then the occurrence of miliary bodies immediately around this focus would find its explanation in an escape of the poison into the parts around—while the sudden outburst of the general disease would be explained by the escape of a particular poison into the blood, the particles being arrested at many points in the tissues. A chemical poison would not produce the localized secondary inflammations. Arguments based on such reasoning led to the theory of the infectiveness of the caseous mass, and the demonstration of the conglomerate nature of this mass, whose essential unit of structure was a minute bead or granule, led up to the classification of tubercle as one of the infective granulomata (p. 55). The infectiveness of tubercle has now been well established (1) by the inocu- lation experiments, especially of Cohnheim and Salomonsen, who placed fragments of tubercular material in the anterior chambers of rabbits' eyes and produced a local tuberculosis quickly becoming general, and (2) by the investigations of Koch, who has isolated the virus upon which the infective- ness of tubercular stuff depends. The steps in the proof were these: 1. The demonstration, by a special mode of staining, of the constant pres- ence of a specific organism in a tubercular foci. 2. The separation from morbid products and pure cultivation of this organism. 3. The inoculation of animals with the pure cultivation—i. e., with the organism only—and the invariable production in suitable animals of tuber- culosis. Koch's results have been confirmed by other observers, and it may now be considered as well established that the organism (Bacillus tuberculosis) described by him is the specific irritant productive of tubercle.1 1 Character of the bacilli: Motionless rods, measuring in length from one-fourth to one-half the diameter of a red blood-corpuscle ; in breadth one-fifth to one-sixth the length. Frequently slightly curved. Multiplication takes place by spores ; these are oval bodies, two to six, as a rule, in each bacillus. They are most common in the giant-cells (Fig. 9), much less so between the smaller cells (Fig. 10); they are less numerous in chronic cases of infiltrating tubercle, and may be very rare. The bacilli are not known to occur normally outside the animal organism. Cultivation experi- ments have shown that they are of very slow growth, thut to flourish they require a temperature of over 30° C. (86° F ), and that the medium must be either blood serum or meat liquor. Obviously the animal body yields the required conditions. -*s From the King's College Museum. College Hospital Museum. Some of these growths (chondro-sarcomata), especially in glands and the medulla of bones, consist of well-developed hyaline cartilage with much spindle-celled tissue; there is no capsule, and round cells infiltrate the neigh- boring tissues. These growths behave with all the malignancy of sarcomata. Secondary changes are common : calcification, especially in chondromata of fingers; ossification, especially in subperiosteal specimens which may (?) show a skeleton of light papery plates (Fig. 19); mucoid softening leading to form- ation of cysts. Rarely these ulcerate. BONY TUMOR, OR OSTEOMA. 133 Causes.—Chondromata are often hereditary, especially when multiple. Tho^e growing from medulla of long bones are believed to start from islets of cartilage left unossified (Virchow) ; Cohnheim suggests that those of the parotid and testes may begin from misplaced bits of the cartilage whence the jaw or vertebrae grow. They sometimes follow injuries and are most common in early life. Seats.—Bones most commonly, especially the phalanges and metacarpals, and the shafts of the long bones ; sometimes from the ribs and pelvic bones. They occur also in the parotids and testes, but almost always mixed with mucous or gland tissue; rarely in subcutaneous tissue, rarely also from car- tilage, as of larynx or ribs (ecchondroses). In bones they may be of medullary or subperiosteal origin ; in the former case, as the old bone is absorbed a thin shell of new is laid down by the peri- osteum, and the bone " expands;" in the latter the growth may envelop the bone—e.g., tibia or femur. Clinical Characters.—As occurring on the fingers (Fig. 20), they are firm, smooth, rounded masses of slow growth, and rarely larger than a good Tangerine orange ; the skin is unaffected for a long time, but may redden over very large, soft, and degenerate growths; they are usually multiple. On the long bones they cannot be diagnosed with certainty. From a cyst an aspirator may draw off recognizable cartilage cells. Rarely these growths reach a great size; one of femur, three feet round, in five years (Frogley, Med. Chir. Irans., vol. xxvi.). When soft, but not from mucous softening, and of rapid growth, chondrosarcoma must be thought of. The presence of cartilage in gland tumors can be told on inspection only. Treatment.—Removal from connective tissue or parotid ; castration, if in the testis ; amputation when on a long bone, complete removal otherwise being rarely possible; but it may be attempted, especially in the fingers. Amputation of a finger is required only to remove a deformity, unless the growth is in the way. BONY TUMOR, OR OSTEOMA. These consist of compact or spongy bone; hence the two varieties: com- pact or ivory, and cancellous or spongy exostosis. The ivory exostosis consists of extremely dense, white, ivory-like bone, Haversian canals being scarce; it grows from periosteum, especially of the bones of the calvaria, orbit, face, and the bony part of the external auditory canal. It forms a low, smooth, rounded swelling, absolutely sessile and fixed, and of very slow growth. The spongy exostosis, much the commoner, is really an ossifying chondroma which grows from the shafts of long bones near their epiphyses, most com- monly from the lower end of the femur, and the upper of the tibia or humerus. On section they show spongy bone continuous with that of the parent bone; and, so long as they are growing, are capped by cartilage. Often pedunculated and clubbed, they may have broad attachments and very irregular surfaces; one above each inner condyle of the femur is not uncommon. Their position on and fixation to bone, and their occurrence before manhood, are the characteristic points. Osteomata are often hereditary and multiple. They rarely occur as pri- mary growths, except in relation with bones. They are innocent; but sarco- mata may ossify all but their growing edges. Osteomata may become carious or necrose and exfoliate, especially the ivory form, the result being a cure. Treatment.—Removal, if pressure symptoms, deformity, or other incon- venience requires it. 134 TUMORS. lymph gland tumor, lymphadenoma ; hodgkin's disease. This tumor consists of lymphoid tissue which has a very general distribu- tion in the body. It is made up of a network of homogeneous fibrils, with nuclei here and there at points of junction (Fig. 21) ; in the meshes lie cells Fig. 21. Lymphoma. Delicate reticulum : the corpuscles have been pencilled out. From a cervical gland in Fig. 22. exactly like white blood-cells. The network may be very fine or very dense, the tumor being correspondingly soft or hard; the fibrous septa of the gland remain and may thicken greatly. Firmness generally goes with age and slow growth. A soft gland is yellowish or pinkish-gray, uniform, pulpy, and yields milky juice on scraping; a hard one is obviously more or less fibroid. Fatty degeneration, caseation, and suppuration are rare. Lymphadenomata start in lymphatic glands: only one gland may be affected, and the health be unimpaired ; or every gland in the body may be Fig. 22. Lymphadenoma. Showing the enlarged glands on both sides of the neck, and in each axilla. The child was greatly emaciated, and died very shortly after this sketch was made. involved, the spleen enlarged, the lymphoid tissue everywhere—tonsils, alimentary canal, liver, kidneys, testes, marrow of bones, etc.—overgrown, whilst anaemia progresses with the disease. This is Hodgkin's disease. In MYOMA — NEUROMA — ANGIOMA. 135 some cases, otherwise apparently similar, leucocythozmia occurs, the white corpuscles being smaller than normal. Enlargement of the first gland or group of glands may start without ob- vious cause or from absorption of some irritant; it is impossible in this stage to say the disease will not become general, and this may occur after a single group of glands has been enlarged and stationary for years. The diagnosis from scrofulous glands may be very difficult. Symptoms.—The groups of glands are affected in the following order of frequency; cervical, axillary, inguinal, retroperitoneal, bronchial, medi- astinal, mesenteric. Smooth, painless, and, at first, freely movable, the glands ultimately blend into an irregular lobulated mass by bursting of the capsules and blending of the contents. The swelling may increase rapidly or slowly, other glands may enlarge simultaneously or not for years. Symp- toms arise from pressure on nerves, veins, oesophagus, bronchi, thoracic duct, bile-duct, etc.; also from lack of red corpuscles. The patient may die of marasmus, starved, or comatose after convulsions and delirium. Remittent fever (2°-6°) is frequent, and generally indicates a rapid course. Fig. 22 shows a child with Hodgkin's disease, formerly under Mr. Haward at the Hospital for Sick Children. Treatment.—When only one group of glands is diseased, removal may delay advance or even prevent it, but diagnosis at thi8 stage is doubtful. When all the glands cannot be removed or the spleen is enlarged, operation does no good. None should be undertaken with less than sixty per cent, of red corpuscles. Arsenic in the largest possible doses is the only drug of much value. Coddiver oil, iron and tonics, and change of air are always useful. (See article by W. R. Gowers, M.D., in Reynolds's System of Medicine.) the muscular tumor, or myoma. Muscular tissue includes two varieties—the striped and the unstriped. Tumors may occur in either kind. The striped are exceedingly rare, but have been found in the heart and tongue of newborn infants. Tumors of unstriped muscle occur chiefly in the uterus. They are found also in the oesophagus, stomach, and prostate gland; in the scrotum in man, and in the labia majora of women. Mixed with much fibrous tissue they constitute what is known as the "fibrous tumor" orfibro-myoma of the uterus. They may be subperitoneal, submucous, or intramural—i. e., in the substance of the uterine wall. On either surface they tend to become pedunculated. They are generally enclosed in a capsule; do not invade other structures ; and, histologically speaking, are perfectly innocent growths. nerve tumor, neuroma. This name has been given to fibromata, myxomata, etc., growing from the fibrous tissue of nerves. Tumors of nerve tissue are very rare. The bul- bous ends of nerves in a stump are sometimes called amputation-neuromata. They may contain rolled-up nerve fibres from regenerative attempts of the nerve fibres; often they consist of fibrous tissue only. When a nerve is divided and does not unite, the central end may become similarly bulbous. vascular tumor, angioma or n^evus. This consists of bloodvessels, some of new formation, many apparently formed by dilatation of preexisting ones. Increase takes place by budding from the vessels of the growth, and can be followed best in fatty tissue. 136 tumors. There are two kinds: 1. The simple or capillary, which consists of very large capillaries with thick walls lined with cells, one to three deep, very much like those lining gland-ducts (Fig. 23). 2. The cavernous, which re- sembles erectile tissue, consisting of freely anastomosing irregular spaces, separated by fibrous septa lined by venous endothelium. Capillary naevi occur in the skin and subcutaneous tissue. On the skin they form the mother's " marks" and "port wine stains" which are so com- mon—bright red or purple patches sometimes a little raised above the skin and sometimes covered with long coarse hair. They are probably always Fig. 23. Horizontal section of a rapidly growing narvus of the back. The centre is an enlarged hair follicle ; round it are the hypertrophied bloodvessels, probably the plexus greatly enlarged, which is normally found round each hair-sheath. congenital, and may grow rapidly and cover a very large surface. When subcutaneous they form soft, rather ill-defined roundish swellings, emptied by compression, filling when pressure is removed, swelling up when the child cries or strains (erectile), and often having a bluish color through the skin. These are the clinical signs of cavernous naevi of the subcutaneous tissue, which occur also in bones, muscles, liver, kidney, and very rarely in the rectum. Often a naevus is both cutaneous and subcutaneous. (See "Dis- eases of Bloodvessels.") B. Mesoblastic Tumors, Embryonic Types. Sarcomata. The tumors hitherto described have all been formed of fully developed tissue; we now pass on to consider those which consist of embryonic tissue —the sarcomata. Embryonic connective tissue is well represented by granulation tissue, de- scribed at p. 59. Sarcomata have the structure of granulation tissue-cells (round, spindle, branched, or giant) in a matrix which may be homogeneous, mucous, fibrous, calcified or ossified. Much stress is laid upon the presence of matrix between sarcoma cells, as distinguishing these growths from epi- thelial ones, in which the cells touch: it is doubtful whether the distinction holds. Microscopically, sarcoma tissue often cannot be diagnosed from gran- ulation tissue; but the tendency of the sarcoma to grow without ceasing dis- tinguishes them. All sarcomata are very liable to fatty degeneration and to hemorrhage into their substance, sometimes destroying all but a capsule of new groAvth (blood-cyst). The chief varieties of sarcoma are named accord- ing to the dominant shape of their cells, but all varieties may be found in SARCOMATA. 137 one specimen. Other names spring from changes in the matrix and secon- dary changes in the cells—e. g., pigmentation. Sarcomata always spring from connective tissue, and may occur wherever this is found. They are common in skin and subcutaneous tissue, fasciae, muscles, bones. 1. The round-celled sarcoma consists of a very delicate intercellular sub- stance, in the meshes of which are contained small round cells; many of them are indistinguishable from lymph cells; they vary in size, and contain nuclei and nucleoli. The intercellular substance also varies, being either homogeneous, gran- ular, or fibrillated. Fig. 24 represents a typical round-celled sarcoma. 2. Spindle-celled sarcoma, formerly called " fibroplastic." The cells are Fig. 24. mm ~ "^ y% 1mm ' Mm II ?m m Wr Round-celled sarcoma. Showing large round cells, and a very delicate network of connective tissue stroma. fusiform, long and narrow, terminating in " tails," and contain oval nuclei and nucleoli. They are arranged more or less compactly, and parallel to each other in bands and whorls. When closely packed they resemble fibrous tissue (Fig. 25). Recurrent fibroid tumors were small spindle-celled sarcomata, often springing from fascia. 3. Giant-celled or myeloid sarcoma, so called because of the presence of a Fig. 2-r>. Spindle-celled sarcoma. number of large, many-nucleated cells (Fig. 26), resembling those of embry- onic marrow. On section they are often of decided maroon tint (Paget). They are more especially found in the osteo-sarcomata springing from the interior of bones, especially the jaws, and are the least malignant of sarcomata. 138 TUMORS. 4. Glioma.—Virchow has described a peculiar form of sarcoma, which is found in nerve structures—chiefly in the retina and brain—as glioma. It occurs in the connective tissue framework which supports the nerve tubes, and is characterized by the presence of a number of small round cells, em- bedded in a very faint homogeneous intercellular substance. Though locally malignant, they rarely generalize. Fig. 26. Tig. 27. 5. Alveolar sarcoma resembles cancer in having a well-marked alveolar stroma; the microscopic distinction rests upon the discovery of some inter- cellular substance between the individual cells. These are much more closely related to the stroma than in cancer. 6. Melanotic Sarcoma.—This (Fig. 28) as it occurs in man is a very malignant kind of sarcoma; the cells are usually spindle, but may be round; Fia. 28. Nodule of melanotic sarcoma in the true skin, King's College Museum. dark brown pigment is seen in them and also in the matrix, but many cells escape. White horses are extremely liable to pigmented fibrous tumors, but possessing no malignant quality. Melanosis in man is very serious, generally beginning in the eye or in the skin, exceedingly liable to return after extir- pation, and to be disseminated over the body; thus in a certain case it was found in skin, areolar tissue, muscles, pleura, lungs, heart, liver, mesentery, spleen, kidneys, and womb. 7. Myxoma.—In this, by some error of original development, or subse- quent degeneration, that which should have become fat or connective tissue, becomes a soft gelatinous stuff like the umbilical cord, mixed with more or less sarcomatous growth. Probably the majority of myxomata are innocent; they are often classed with the fibromata. Mixed-celled sarcomata, in which no form of cell predominates, are common. EPITHELIAL GROWTHS: WARTS; ADENOMATA. 139 Peculiarities which are reproduced in secondary growth constitute varieties —e. g., lipo-sarcoma, fatty infiltration of sarcoma cells; calcifying and ossify- ing sarcoma. The latter changes occur in connection with bones, sub- periosteal sarcomata frequently having a bony skeleton like that in Fig. 19, said to have belonged to a chondroma; these are most malignant growths. Mixed forms occur—e. g., chondro-, adeno-, myo-sarcoma. The latter are tumors of early life containing striated and non-striated cells, and occurring in the kidney or testis. As regards clinical characters, the sarcomata are malignant growths. They occur for the most part in early and middle life, seldom (except in bone) in later life. They are rapid in growth, and infiltrate neighboring tissues widely; they therefore are very liable to recur in loco after extirpation. Their vessels having very thin walls into which tumor cells easily pass, they generalize usually by the blood rather than by the lymph stream ; and secondary growths are, naturally, most frequent in the lungs. But, strange to say, sarcomata of the tonsil, testis, lymphatic glands, and some fasciae generally infect lymphatic glands (Butlin). The degree of malignancy varies: it is most pronounced in the melanotic, and least so in the myeloid variety. Sarcomata may be extirpated completely and never recur, or may return in loco several times after operation, as the name recurrent fibroid indicates, and finally become disseminated in distant parts of the body. C. Epi- and Hypo-blastic Tumors. Epithelial Growths. Warts. Papillomata.—These hardly merit a class to themselves; they seem to be fibromata which have become papillary by the accident that they are on a free surface. They consist of a connective tissue basis which sends vascular papillae toward the surface, each covered by more or less epithelium. Warts may spring from cutaneous, mucous, or serous surfaces. They are generally pedunculated and " papillary" on the surface, but dense epithelium may fill in the irregularities. On mucous surfaces the papillae may be very long, delicate, and branching, covered by little epithelium and easily torn ; they then bleed profusely—e. g., villous tumors of bladder and rectum. They are often due to irritation, as seen in soot-warts on the scrotum, venereal warts on the genitals, and warts on the hands of workers in paraffin. Papillomata are innocent, though they are very troublesome to get rid of, even by excision. Their epithelium is all on the surface; in epithelioma it has invaded the connective tissue. Warts may be starting-points of epithe- lioma ; development or irritation of one after forty is ground for uneasiness and watchfulness. GLAND TUMORS, ADENOMATA. Adenomata are new growths of gland tissue, in structure more or less unlike that of the gland they spring from. Some appear to be mere hyper- trophies of preexisting structures. Probably all glands give rise more or less commonly to a tumor of glandular nature, but some do so very rarely. Adenomata are of two kinds : racemose and tubular. Of racemose adeno- mata, the common chronic mammary tumor may be taken as the type. It consists of acini lined by epithelium embedded in a fibrous stroma ; slit-like spaces (ducts) also are seen (Figs. 2'J and 30), but there is no efferent duct from the tumor and no evidence that it performs any function. The stroma may be largely infiltrated with round and spindle-cells (adeno-sarcoma), or consist of mucous tissue (myxo-adenoma). 140 TUMORS. Dilatation of acini and ducts into cysts, which may be large and contain yellow or brown mucous fluid, is common, especially in oldish women. Into these spaces papillary growths may project from the walls. For clinical characters of these growths, see " Diseases of Breast." Fig. 29 Fig 30. Adenoma, from a girl of sixteen. Showing Adenoma. X 240 Cross-sections of acini, showing arrangement of gland structure in fibrous epithelial lining and nuclei of stroma. matrix. X 50- Mucous glands (e. g., of the soft palate) and the parotid may give rise'to acinous adenomata; in the latter, the gland tissue is usually mixed with mucous, sarcomatous, or cartilaginous. Tubular Adenomata.—As type'of these may be taken the glandular polypus of the rectum seen in children (Fig. 31). The drawing shows Fig. 31. hypertrophied tubules, cut across, lined with columnar cells in a loose con- nective tissue stroma. Microscopically, it is impossible to distinguish be- tween these growths and columnar epithelium. Many ovarian tumors are of this type; also some mixed tumors of the testis. CANCER, CARCINOMA. Cancer may be defined as a new growth consisting of epithelial cells in the alveoli of a fibrous stroma: the latter being of secondary importance. It invariably originates from epi- or hypo-blastic structures, and is char- acterized by the tendency of its epithelial cells progressively to force their way into neighboring connective tissue along the paths of least resistance SQUAMOUS OR PAVEMENT EPITHELIOMA. 141 (lymph-channels). As a rule, they infect the nearest lymphatic glands, and frequently distant organs also, by means of the blood-path. Cancers are divided into groups according as they spring from the epithe- lium of skin or mucous membranes (epithelioma), or from that of glandular organs (acinous cancer). The cells of any cancer may undergo colloid de- generation, producing colloid cancer. Structure. Cells.—Any of the different types of epithelium (except ciliated) may be found in cancer, varying according to the source whence they spring: from the skin squamous, from intestinal mucous membrane cylindrical, from acinous glands more or less cubical. From the form of the cells, epithelioma is divided into squamous and cylindrical. Epithelial cells vary greatly in shape and size, and cannot thus be distinguished from mesoblastic elements, but they lie in immediate contact, separated by no matrix, their relation to the fibrous stroma is loose, and vessels never pass between them. There is usually a well-marked line between cells and stroma; but it may be obscured by a cloud of leucocytes which precede the advancing epithelial cells, and from which the epithelial cells have been supposed to spring. The epithelial cells grow in irregularly swollen branch- ing and intercommunicating cylinders, the swellings forming probably at points of least resistance; hence the variety in shape of the alveoli. The stroma is formed of connective tissue and bears the supplying blood- vessels. It consists of the original connective tissue of the part, generally much thickened by fibroid tissue apparently of inflammatory nature, derived from the round-celled infiltration which precedes the spreading edge of a cancer, and seems due to the irritation of the epithelial cells forcing their way along the lymph-paths. Two varieties of acinous cancer are based on the amount of stroma: scirrhus or hard cancer, when the stroma is dense and in considerable or large amount; encephaloid or soft cancer when there is but little stroma, and that loose. Sooner or later the cells of all cancers undergo fatty degeneration, forming yellow areas on the surface of section: this may be from pressure of the multiplying cells upon the vessels, or from contraction of the stroma, or from an inherent peculiarity of the cells. In superficial cancers this necrosis leads to ulceration (p. 67). squamous or pavement epithelioma. This form starts from skin or mucous membranes with squamous cover- ings. It may occur at any part of the skin, but is especially frequent at points of union of skin and mucous membranes, such as the lower lip, pre- puce, vulva, anus; it is found also on the tongue, gums, cheeks, tonsil, oesophagus; on the vaginal surface of the os uteri, and in the bladder. Epithelioma usually begins as a hard pimple or knot in the skin which soon ulcerates; or a fissure may be first noticed. It soon presents itself as an oval or roundish ulcer, with thick, hard, raised, irregular edge, a pale red or grayish warty base, which bleeds easily and discharges a thin, opaque, yellowish, foul, and often sanious fluid containing epithelial cells and debris. The surrounding parts are red, more or less swollen, and in- durated for a considerable but very variable distance. The early ulcera- tion, warty appearance, and induration are the special points in diagnosis; and to these must be added early involvement of lymphatic glands. The very characteristic structure of epithelioma is well shown in Fig. 32, which represents a section through the lower lip. From the epithelium above the interpapillary portions are growing down into the connective tissue, and the cylinders can be followed for a short distance as such. Then 142 TUMORS. their ramifications take them from the plane of section, or they cease, single cells are swept on, and fresh rods start; below they are frequently cut across, and show as dark circles, some with white centres. In the latter, epithelial evolution has gone on to cornification and the production of a " nest " of squamous cells. One of these, but not very typical, is shown in Fig. 33. In some squamous epitheliomata no nests form. The stroma is Fig. 33. Fig. 32. Epithelial cancer. X 40. Columns of epithelium cut across at various levels in the corium. Mucous glands below. plentiful, and contains leucocytes in proportion to the rate of growth and ulceration. Fig. 34 is from a case of primary epithelioma of the tonsil, and shows invasion of the deeper structures by epithelial cells. The tonsil throughout contained similar ingrowths. Its gland structure was much altered and its stroma enormously hypertrophid (R. W. Parker). To the naked eye an epithelioma presents a grayish-white granular surface on section dotted with yellow points which start out, like the contents of sebaceous follicles, when pressure is applied; the little cylinders consist of fatty epithelium. Sometimes epitheliomata of mucous surfaces become markedly papillary, ulceration being slight; induration at their base distinguishes them from simple warts. Fig. 35 shows a papilla from the bladder, and Fig. 36 sepa- rated cells. Rodent ulcer is a variety of epithelioma, occurs almost always upon the skin of the face—especially nose and eyelid—and usually as a pimple which is often scratched. It may begin between thirty and forty, but about fifty is more usual; is more common in men than women, and is characterized Epithelial cancer. X 250. An ingrowing cylinder showing rudimentary neet. RODENT ULCER. 143 clinically by its very chronic course (even twenty to thirty years) and slight tendency to infect lymphatic glands. It spreads by slow invasion of neigh- boring tissues, and ulceration follows so closely upon infiltration, that the Cancer of tonsil. X 240. Shows the great proliferation of epithelium and its invasion of the deeper structures. edge is not much thickened. It destroys everything—bone, cartilage, eye- ball—that it comes to, till the orbits and nose may form one cavity, with the brain pulsating at the bottom. Yet no gland will be involved, no internal organ affected, and the general health remains good for many years. Fig. 35. Fig. 36. A representation of a papilla, or the apex of a granulation, found in the urine, in the case of epithelioma of the bladder. Internally it con- tained a loop of vessel; outwardly it was clothed with scales of exuberant epithelium. About 200 diameters. Epithelial cells infiltrating the deep tissues of the lip. Microscopically the growth differs from squamous epithelioma in the small size of its cells, and the slight tendency to formation of nests. But some tumors on the face having the above history are, microscopically, typical squamous epitheliomata. 144 TUMORS. Columnar or Cylindrical Epithelioma. This springs from mucous membranes covered with columnar epithelium and provided with tubular glands. It is by ingrowth of the latter into the connective tissue that the cancer originates. The rectum, large intestine, and uterus are its seats, but it may occur in the stomach, and very rarely in the small gut. It forms prominent vascular growths which break down in the centre and present ulcers with firm, thick, irregular edges which overlap the surround- ing mucous membrane. It is soft, pinkish-gray, and semitranslucent in sec- tion, and often striated vertically to the surface. It consists of tubules lined by columnar epithelium, just like crypts of Lieberkiihn, but often much larger (Fig. 37). The stroma is soft and round-celled. In tumors of rapid Fig. 37. Cylindrical epithelioma of the rectum. X 350. growth the tubules are imperfectly formed and the cells small. The lumina in some growths become completely filled up, and a section then resembles one of acinous cancer. These epitheliomata are very liable to colloid degeneration, infiltrate sur- rounding parts, do not affect glands very early, and rarely generalize widely. Secondary growths in the liver are not uncommon. Scirrhus and Encephaloid as seen in the Breast Cancer of the breast will next be considered. The epithelium of its ducts is directly continuous with that of the skin, but it changes its character as it passes from the lactiferous tubes into the interior of the gland substance. Cancer, according to Billroth, begins in the acini of the gland by multiplica- tion of the small round epithelial cells which line them, and by an infiltra- tion of the surrounding connective tissue with leucocytes. The chief varie- SCIRRHUS, OR HARD ACINOUS CANCER. 145 ties are the hard and soft cancers, and, as before said, these variations depend on the relative amounts of stroma and cellular elements. Scirrhus is characterized by the large amount of its stroma, which in- creases with the age of the tumor. It was to this variety that the word cancer was first applied, on account of a supposed analogy between the long fibrous prolongations of the stroma and the outspread claws of a crab. It occurs, for the most part, in the breast, but is found also in the alimentary canal, uterus, prostate, and elsewhere. Comparatively slow in growth, it is nevertheless malignant in all its tenden- cies—i. e., it invades all structures with which it comes in contact, affects the lymphatic glands, and is carried by the blood to distant parts of the body. Fig. 38 represents an average scirrhus of the breast. It consists of a fibrous stroma, the alveoli of which are filled with very granular epithelial cells, many undergoing fatty degeneration. The drawing shows also the spreading edge of cancer, preceded by irritative round-celled infiltration of the fat and fibrous tissue, which it is invading (p. 141). Cancers are not encapsuled ; though fairly defined to the naked eye, the microscope shows the true state of matters. Scirrhus cuts crisply like potato or cartilage. Its surface of section is often slightly cupped, and has been likened to that of an unripe pear, being gray, slightly tinged with pinkish-yellow, and marked with streaks and patches of distinct yellow from fatty degeneration. The section yields, on gentle press- ure, a copious juice of a milky character, readily miscible with water. This contains abundance of cancer cells (Fig. 39), which, like the epithelium of Fig. 39. •noi i Cancer cells traced with the camera ; magnified 200 diameters, o, nuclei; scale of 0.001 inch. the bladder, present great variety of form and size, and usually contain a very large oval nucleus, with one or two nucleoli. The largest are found in old slowly growing scirrhus, smaller and less perfect ones in the more rapidly growing encephaloid. The cupping is due to the contraction of the newly formed fibrous tissue, as also, most probably, is the fatty degeneration of cells. This shrinking leads to important clinical signs—e. g., retraction of the nipple, by fibrous tissue developed along the ducts. Chronic inflammations may obviously produce the same effect. Puckering of the skin wherever invaded by cancer is another result. 10 Fig. 38. Scirrhus of breast. X 240. Showing the alveoli filled with epithelial cells, and the com- mencing infiltration of the fat with leucocytes. 146 TUMORS, Cancer "En Cuirasse."—This is so called because it converts the skin of the chest into a hard and rigid mass inflexible as a breast-plate. It begins in the form of small nodules in the skin, which spread round about the primary focus, enlarge, and coalesce. Generally it occurs after extirpa- tion of the breast. Internal organs are not very frequently affected. In consequence of its tendency to spread and to contract, the breathing becomes much interfered with, and death may result from this cause. The disease is chronic; it is allied to those forms known as atrophic scirrhus, characterized Fig. 40. ® . Medullary cancer. by great shrinking of the breast and long course—eight to twelve years being not uncommon. Both forms give rise to crater-like ulcers which dis- charge a very fetid ichor. Encephaloid, or soft acinous cancer, differs from scirrhus chiefly in the rapidity of its growth, and the consequent preponderance of its cellular Fig. 41. Colloid cancer of stomach and omentum. X 240. elements. Indeed, it is often made up entirely of cells, the amount of stroma being almost inappreciable. Fig. 40 represents a typical case ; the large size of the cells, their number and arrangement, and the small amount of TREATMENT OF MALIGNANT GROWTHS. 147 stroma, contrast with the scirrhus shown in Fig. 38. It must not, however, be supposed that they are radically distinct; the differences between them are simply due to the rapidity of growth, perhaps also to the age of the patient attacked. Many cases present intermediate stages between the two forms, and the deposits which are found in internal organs, secondary to primary scirrhus of the breast, are often of the encephaloid variety. When cut into, degenerate parts resemble brain-matter, and hence their name; but the growing parts are pinkish-gray and translucent. Hemor- rhages into their substance are frequent. Fibrous bands are rare or absent in the section, which is probably convex and soft. Colloid Cancer.—Cancers are very liable to retrograde changes, of which the most frequent is fatty degeneration. Few are free from this. Another form, not unfrequently met with, is colloid or gelatiniform degenera- tion. In this form the protoplasm of the cancer cells becomes converted into a substance called colloid (glue-like). Fig. 41 represents alveoli containing the colloid substance. The indi- vidual cells have been converted into colloid masses, which have coalesced, and the intercellular substance has atrophied and formed cyst-like dilata- tions, in which the colloid has collected. Colloid cancer is most frequently found in the stomach (pylorus) and rectum, occasionally in the breast. It is generally rapid in growth. Sarcomata also may undergo this degeneration. treatment of malignant growths. The only treatment that holds out any chance of success is early and complete removal of every abnormal cell—one left behind probably means re- currence. This statement shows implicit faith in the local origin of malig- nant tumors (p. 126), and is justified by the results which surgeons have of late yea|s obtained in the treatment of such cases by earlier and more radical operations. These have been planned in the belief that it is necessary in all cases of cancer, and in those special ones of sarcoma (p. 136) which generally involve glands, to remove not only the whole primary growth, but also all the glands which receive lymph from the affected part, whether they can be felt enlarged or not. These operations are more difficult and much more extensive than the older kind, and the immediate mortality from shock has risen in consequence; but in disease of this kind it seems right to advise a patient to undergo an operation of greater, rather than one of less, danger, when the former holds out the chance of cure against the palliation of the latter. But palliative operations also are required when cases have gone too far for cure to be thought of. A patient's last days may be rendered easy by the removal of an extremely painful or foully ulcerating growth, death from recurrence in internal organs being often comparatively easy. Caustics are employed in the treatment of malignant disease only under special circumstances, as when, after clearing out an orbit, it is thought well to cause exfoliation of the bones lest they be infiltrated by growth. Some- times, too, they are used to destroy extensive growths, like rodent ulcer, which are known not to be very thick. But they are very uncertain weapons and intensely painful, the pain lasting even for days. The acid nitrate of mercury, F. 333, arsenic, and chloride of zinc, are the most useful. Arsenic is generally employed in the form of Mance's paste, composed of fifteen grains of white arsenic, seventy-five of cinnabar, and thirty-five of burnt sponge, made into a thick paste with a few drops of water. There is danger of arsenical poisoning, especially if the paste is used 148 TUMORS. timidly. Chloride of zinc is made into a paste with three or four parts of flour and a few drops of water. Sometimes a mass of cancerous tissue may be destroyed by inserting into it small lozenges or stilets composed of chloride of zinc, oxide of zinc, and flour make into a putty with water and baked till hard. Sir J. Y. Simpson recommended dried and powdered sulphate of zinc made into a paste with a few drops of glycerine. Whichever is em- ployed should be thinly spread on the surface to be destroyed, and* covered with cotton-wool. We may observe that the skin should never be attacked with these caustics, only an ulcerated surface. Other remedies to check the growth of cancerous tumors—congelation, firm compression, powerful astringents, and tonics—have been tried repeat- edly, but in vain. A good but light diet and light tonics, and especially the preparations of iron and quinine, may be used at the surgeon's discretion to keep up the appetite and combat the cachexia. F. 8, 10, 25, 153. The smell of most malignant ulcers can now be kept within bounds by the use of antiseptic powders, lotions, and wool dressings. Pain may be relieved, sometimes by the section of sensory nerves, sometimes by the application of anodynes (F. 238-240), including lead lotion, sometimes only by opium given freely by mouth or subcutaneously. It is a singular fact, that with some patients certain preparations of opium disagree violently without relieving pain, whilst other preparations relieve the pain and agree perfectly. Many patients can take only morphia, others find the solid opium or the purified extract best. Battley's sedative solution of opium, Squire's meconate of morphia, the black-drop, and other special preparations may have to be tried in turn. As local applications, before ulceration, fine cotton-wool, belladonna plaster, and chloroform liniment, relieve the neuralgic pain. cystic tumors and cy. and in wi.dth from Tsm t0 Timr* inch> with perfectly square-cut ends; they are easily found in serum by a power of 500 diameters, even without staining. In the living body they multiply rapidly by simple transverse division ; but in suitable soils, such as the blood of a dead animal, with a free supply of oxygen, and an appropriate temperature (15° to 42°), 1 See Med. Times and Gaz., Aug. 23, 1884; Gazette des Hopitaux, Aug. 9, 1884. 2 Consult Gowers's Art. Hydrophobia, Quain's Dictionary of Medicine ; also, Ross's Dis. of Nervous System, 2d edition, vol. ii. pp. 818 et seq. s There are three errors often refuted, but which revive from time to time. One is the notion that there is no such disease as hydrophobia, but that all the symptoms and consequences depend on the fright and worry of the patient. This is refuted by the Account of the Effects of the Bite of a Wild Jackal in a Kabid State, as the same occurred at Kattywar, in the East Indies, in 1822, by Mr. Hewitt, Surgeon in the Bombay Medical Establishment. Several native soldiers and others who were bitten died of hydrophobia, although entirely ignorant that there was such a disease. Med. Chir. Trans., vol. xiii., 1825. The second error, which is well called a hoax in Sir Thomas Watson's Lectures, is that certain vesicles are found under the tongue, and that if tbese are cauterized, hydrophobia is prevented. The third is the notion of relieving the spasm by tracheotomy. This was proposed by Mr. Herbert Mayo, forty years ago, and later by Dr. Marshall Hall; but death from laryngeal spasm is too rare to justify the measure. SYMPTOMS OF MALIGNANT PUSTULE. 209 the rods grow into long filaments, and in these numbers of oval spores form. Whilst the bacilli are easily destroyed, these spores possess wonderful powers of resistance; and it is chiefly by them that the disease is spread. It must be remembered that immediate burial of an animal, dead of this disease, at a depth of more than one metre prevents development of spores by lack of oxygen and of warmth. Varieties.—There are two chief varieties, resulting apparently from the mode of inoculation. If the poison enters through the pulmonary or ali- mentary mucous membrane, internal anthrax or woolsorters' disease results. It occurs chiefly among those who are engaged picking and sorting wool and fur imported from countries where splenic fever prevails, but has been known to arise from eating the flesh or butter, or drinking the milk of diseased animals. It is characterized by symptoms of acute blood-poisoning, usually ending in early death ; the stress falls sometimes upon the pulmonary, some- times on the gastro-intestinal tract, and during its course diffuse or car- buncular inflammations may appear upon the skin. This form belongs to internal medicine. When the poison finds entry through some cut or abrasion of the surface, especially of the face, neck, hands, or forearms, a malignant pustule or anthrax edema will probably result. This accident is most common among butchers, tanners, and laborers employed in carrying hides at the docks and factories. Symptoms of Malignant Pustule.—After an incubation period, which varies from a few hours to twelve days, and which is most often two or three days, some burning and itching are felt at the seat of inoculation, and a small pimple, upon the apex of which a vesicle soon rises, develops. Both pimple and vesicle increase with much itching, and the contents of the latter become red and then purple. Finally it bursts or is burst, and leaves a dry brown or black eschar depressed somewhat below a swollen, brawny, red or purplish areola which usually rises abruptly to one-eighth to one-sixth inch from the surrounding parts. Upon this areola, close round the slough, is a ring of small vesicles. All these parts increase, the central slough attaining perhaps a diameter of one inch, the ring of vesicles behaving like the primary one. Around it there is much and increasing swelling, which in two or three days may involve the whole side of the head and neck, or the greater part of a limb; red streaks of lymphangitis often run up to the nearest glands, which swell early. Much pain in the part is suffered. The appearance of the pustule is, as a rule, very characteristic; but sometimes we find no eschar, only one or more vesicles, on an inflamed base; or both eschar and vesicles may be absent, and there is only a pale yellow cedematous swelling —anthrax edema. In case of doubt, examine microscopically a drop of serum from a vesicle or of blood. A history of exposure to contagion is a very important aid. In this form there are at first no general symptoms. Such may appear and kill within forty-eight hours, but do not as a rule come on for two days or even longer. Up to this time fever has been slight or absent; but now the temperature usually runs up suddenly, perhaps with shivering, general pains, vomiting, and sense of great weakness and illness; diarrhoea comes on, cramps occur, dyspnoea becomes very marked, the patient gets delirious, and dies comatose, almost always before the seventh day. Sometimes there are few symptoms, and the patient dies rapidly with signs of cardiac failure, the mind remaining clear. Sometimes the "pustule " ceases to spread, the slough is cast off, the ulcer heals, and the patient recovers spontaneously. Greenfield says that the mortality is probably one in three. The disease is most dangerous in the head and neck, least so on the limbs. 14 210 POISON GENERATED BY DISEASED ANIMALS. Morbid Anatomy.—Much like that of septic disease; blood dark and liquid, subserous and submucous ecchymoses, hemorrhages into the skin and viscera, blood-stained effusions into serous cavities, hypostatic congestion of the lungs, patches of simple oedema, especially of the submucous tissue of the intestine, and sloughing ulcers of the gastrointestinal mucous membrane may occur (Mahomed, Trans. Path. Soc, 1883); the spleen is often swollen and friable or diffluent. The malignant pustule shows all stages of inflammation up to the hemor- rhagic in its centre ; it extends into the subcutaneous tissue; the surrounding swelling is due to a serofibrinous, often hemorrhagic infiltration. Bacilli anthracis are found in the blood everywhere, and chiefly in the capillaries, where the circulation is slowest. Treatment.—This consists in complete excision of the pustule, with sub- sequent free application of sublimate lotion (1 in 1000), or 1 in 20 carbolic, to the raw surface. On the face, injections of 1 in 40 all round the swelling have been successfully used; but excision is preferable, and should always be practised unless the patient is absolutely moribund. Davies-Colley on the third day excised a pustule on a man who was voiding numbers of bacilli in sputum, urine, sweat, and feces. The patient recovered slowly, and a month later the urine still contained a few bacilli (Trans. Path. Soc, 1883). It would seem, therefore, that it is never too late to try excision, but that its success will be greater the earlier it is practised. Reliance should never be placed on the possibility of cure without operation. In all cases liberal diet must be allowed. When general symptoms are marked, quinine has been recommended, and also corrosive sublimate (p. 38). Charters Symonds reports a case (Brit. Med. Journ., vol. i., 1885) in which the latter treatment failed. When the inflammation is not circumscribed, and in arthrax oedema, long free cuts should be made into the subcutaneous tissue and a sublimated fomentation applied. The results of early excision are very good. The analogy is obvious between malignant pustule with secondary general symptoms and all gen- eral infective processes starting from a focus of local infective disease—such as syphilis and the general infective diseases of wounds; and the success of excision in malignant pustule shows the reasonableness of thorough disin- fection or removal of primary foci of disease. PART III. INJURIES AND SURGICAL DISEASES OF VARIOUS TISSUES, ORGANS, AND REGIONS. CHAPTER XXII. SURGICAL DISEASES OF THE SKIN. Hypertrophy of the entire skin of a part, so that it hangs in pendulous flaps, or projects in folds, is sometimes congenital, sometimes appears later without obvious cause. The masses thus formed may be very large and the area involved extensive. The subcutaneous tissue shares largely in the process. If inconvenient, the knife is the remedy; the masses are very vascular. Hypertrophy of skin from congestion with blood or lymph, as seen in cases of varicose veins, or of true elephantiasis, and that which frequently results from chronic or repeated inflammation, has been described. Boil (furunculus).—A circumscribed, round, hard swelling depending on inflammation of one spot of the true skin, almost always around a hair, and most common on hairy parts; usually attended with acute pain and tender- ness ; and ending in suppuration, and the discharge of a small sloughy shred of areolar tissue, which forms what is called a core. Sometimes no suppura- tion or sloughing occurs, but the boil dies away and is said to be blind. Hard swelling may cover several square inches around a bad boil. Some- times quickly, sometimes not for several days, the most prominent central point becomes bluish, thins and bursts, leaving a yellow adherent slough exposed. This is slowly thrown off and the cavity then heals. Usually the nearest lymphatic glands are swollen and painful, but do not often suppu- rate ; lymphangitis is not uncommon. All symptoms quickly subside once the boil is fairly open. Frequently boils keep coming out, fresh ones appear- ing as the older heal (furunculosis). They are especially common in spring, and are sometimes almost epidemic. They are evidently due to some strong irritant, but this probably varies in its nature. Sometimes the general state seems potent in their production, as when they occur after acute fever, after a period of dyspepsia, in the half starved, diabetic, or albuminuric, or in the over-fed and bloated. In other cases the patients are in robust health ; they frequently form on the buttocks of men training for boat races. Here friction probably has some influence. In other cases they seem to be due to the entry of septic material into the hair follicles. Treatment.—In cases accompanied by much pain and swelling, a moder- ately free incision with a lancet will give much relief, and should be employed especially when lymphangitis and lymphadenitis have arisen. Nothing is more soothing or hastens the course of a boil so much as the free use of gly- 212 SURGICAL DISEASES OF THE SKIN. cerine and belladonna, and frequent hot fomentations; but moist applications sometimes bring out a crop of pustules. When this treatment cannot be followed out, keep constantly applied the glycerine and belladonna and some cotton-wool. Look carefully for any indication for general treatment and endeavor to meet it; starvation, over-feeding, and want of exercise, anaemia, dyspepsia, and constipation frequently require attention. For furunculosis in people apparently in good health, change of air and a critical examination of the diet and habits of life suggest themselves. It is said that sewer gas poison- ing is a cause. Sulphide of calcium, ^ gr. every two or three hours, sometimes cuts an attack of boils short; tinct. arnicse and tinct. belladonnas are also recom- mended ; whilst as a general tonic ammonia or acids and bark act well. Carbuncle is an exaggerated boil. The inflammation is more widely spread, and ends in the production of a much larger slough of subcutaneous tissue and cutis, which is discharged in shreds through multiple openings. There is no line clinically between boils and carbuncles. A more or less oval patch of skin and subcutaneous tissue becomes infil- trated, forming a hard, characteristically brawny dull red swelling, very tender, with heavy aching pain. After a few days of gradual increase, soft- ening and suppuration occur at several points which become bluish, more prominent, fluctuate obscurely, and ultimately burst. The openings ulcerate, forming round sharp-edged holes, from which a thin ichor escapes; but a thick glutinous matter may often be squeezed out. The apertures coalesce, large white sloughs slowly separate, and a large gaping cavity is left which granulates and heals. The patient may suffer much or little pain; he is generally a good deal pulled down in appearance. Carbuncles appear in much the same constitutional conditions as boils; some people suffer repeat- edly from them. They are most common upon the back of the neck and upon the shoulders, but may occur anywhere. There is a disease, by some called facial carbuncle, though by others the correctness of the name is called in question, which appears on the lips or other parts of the face, causing much swelling, quickly followed by multiple points of suppuration, and complicated from an early date with septic symp- toms. It is extremely fatal. So also are carbuncles of the head. Else- where, the prognosis varies with the strength and age of the patient. Death from septic disease may occur. Treatment.—Attend to any defect of health that admits of remedy; a very nutritious, easily digestible diet should be prescribed, alcohol being given if required to aid digestion or whip up appetite ; or a bitter tonic may do this. Pain must be allayed by local applications or opium; of the former, belladonna and fomentations are the best. A free incision right through the brawny tissue in one or two directions should be made when there is much tensive pain and spreading; often none is needed, or not until suppuration has set in—to let out the pus and insure free drainage. Separation of the slough is hastened by resin or creasote ointment, which may be plastered into the cavity. Lupus Vulgaris.—Lupus affects chiefly the skin of the face, especially the cheeks and alse nasi, whence it may spread to the adjacent mucous mem- branes, which may also be primarily involved. The disease may, however, attack any part of the skin. It begins in childhood, but by relapses often lasts into adult life; women are rather more often attacked than men, and the scrofulous are especially liable. . The disease begins by the appearance of minute nodules, deep in the corium, the red color of which is seen through the cuticle. They slowly en- THE SCROFULIDE OR TUBERCULAR NODULE. 213 large, project as reddish-brown tubercles a line or so across, and blend into larger slightly raised patches. These may long remain unchanged and finally disappear, without ulceration, but with a little scaling or crusting of the surface, leaving a thin, smooth, white scar. More often ulceration occurs and is very chronic, spreading superficially by the development and break- ing down of fresh tubercles round the inargin, and in depth by a similar process. Thus all the soft parts, including cartilages of the nose, may be destroyed ; or parts of the lip or ear may disappear. When healing occurs, the scar may cause ectropion or other deformity. Healing at one spot and spreading at others is common. Even when a scar seems to have covered the whole surface, tubercles appear beneath it and break down, and thus the disease lasts for years In very scrofulous subjects distinct nodules may not form, but from the beginning a diffuse infiltration which spreads and breaks down more rapidly than usual (Scrofuloderma). Pathology and Etiology.—The nodules and infiltrations consist of granulation tissue, in which are often seen bodies having the structure of miliary tubercles (p. 93). On this ground Friedlander regarded lupus as tuberculosis of the skin ; a view strongly supported by Hiiter and Scniiller, who inoculated animals with lupus tissue and produced a disease like tuber- culosis. Finally, Koch (" Aetiologie der Tuberkulose," p. 68) demonstrated tubercle bacilli in the giant cells of the nodules, but in small numbers only. In each of seven cases examined, however, Koch produced tuberculosis by inoculation, and from one he obtained a pure cultivation, with which he inoculated successfully. The tuberculous nature of lupus is denied by Kaposi, because he believes that phthisis is very rare in patients with lupus. Besides its very slight ten- dency to produce general infection, it is more vascular than ordinary tuber- cular infiltrations, and has little tendency to caseate or to infect glands. But Koch's results are too strong to be shaken by such difficulties (see Pro- ceedings of International Congress, Copenhagen, 1884; Brit. Med. Journ., vol. ii. p. 419). Treatment.—When lupus is getting well, iodovaseline on rag should be constantly applied. The course may be hastened by destruction of the tuber- cles by scraping, cautery, caustics, or excision, and one or other should always be used in ulcerating cases. It is then best to destroy thoroughly with a small sharp spoon every tubercle and patch of soft tissue, and to repeat the process as fresh nodules appear. Chloride of zinc (1 in 2) may be applied freely to the raw surface, which is to be dressed with powdered iodo- form and boracic ointment, or with iodovaseline. No operation to remedy deformity due to lupus should be undertaken till the parts have remained sound for two years. The Scrofulide or Tubercular Nodule—This is frequent in young children. It begins as a small hard painless nodule in the skin, which slowly reddens and breaks, giving exit to a thin discharge, which often continues for months, or perhaps the sore heals and breaks out again. Treatment.—If seen quite early, when small, excision would probably give the best result. Later, incision, if necessary, and the free use of the sharp spoon and iodoform, together with general treatment, are the proper measures. Callosities are hypertrophies of the horny layer of the cuticle due to fre- quent intermittent pressure; they are semi-transparent, yellowish white, lens- shaped swellings lying in the cutis, slightly concave on their deep aspect, or moderately convex, as on the surface. Callosities occur chiefly on the hand 214 SURGICAL DISEASES OF THE SKIN. and fingers, often showing by their site the nature of the possessor's employ- ment. Corns differ from callosities only in the presence of a tongue-like process on their deep aspect, which is driven by pressure into the skin, producing pain and atrophy of the subjacent papillae. They form usually over the first joints of the toes from pressure of boots or of other toes. Sometimes they ap- pear between the toes, and are then soft because kept moist; they are found also upon the sole, and often without obvious cause. Treatment.—Removal of pressure and all irritation is the first point; boots should be made upon a new last. Radical cure can be obtained only by softening the epidermis with potash solution, soft soap, or some such sub- stance, and scraping the mass away completely, which will probably induce some bleeding. This proceeding is dangerous in patients with degenerate arteries. Palliative measures are; bathing in warm water and frequent paring with a knife to keep the horny layer thin and supple, and the wearing of a perforated corn plaster. If the corn is on the sole of the foot, a piece of felt or small fold of flannel may be arranged so as to relieve it from pressure. For the soft corns be- tween the toes, and for very irritable corns, the nitrate of silver is the best application. When a corn inflames it should be poulticed. If matter forms beneath it, there will be oedema and redness round about; the pain is most excruciating, and to be relieved only by paring down the corn and letting out the fluid. These thickenings may slowly disappear if all irritation is stopped. Horns (cornu cutaneum) in look closely resemble those of animals; they may grow almost anywhere, reach a length of several inches, and last for several years, or, if they are knocked off, grow again. Elongated papillae penetrate their base for a varying distance; the horns are therefore closely analogous to warts, the papillae being bound together by a dense covering 01 epithelium. Sometimes they lie in a hollow, again on level skin, and they are often connected with a sebaceous follicle or cyst. They may be removed by two elliptical cuts ; if springing from a cyst, its wall must be removed also. Epithelioma has developed from the base of a horn. Warts (verruce) consist of hypertrophied papillae covered by more or less dense epidermis. A good number are congenital, are then often darkly pig- mented, covered with long hair, sometimes naevoid, and of very various form and extent. Most warts appear later, and chiefly in young people. V. vul- garis is most common on the hands and faces of children ; it is flat or hemi- spherical, usually smaller than a pea, dry, firm, with a surface which may be fairly smooth or much cleft. Their cause is unknown, and there is no ground for the common belief that they are infective. If necessary to inter- fere, warts may be snipped off, tied, or touched with caustic; but they often return obstinately, in spite of treatment, and disappear of themselves after months or years when let alone. Perhaps the best plan is to divest them as much as possible of cuticle by soaking them in soda and water, and then to paint them with ethereal tincture of tannin. F. 335. Small, dirty brown warts not unfrequently appear on the face of old people. Venereal warts form another variety. They are most frequent after gonor- rhoea, but may grow on the site of a healed chancre, and are obviously the result of irritation ; mucous tubercles and condylomata again are the result of syphilitic irritation. The latter are wide based, whilst the former are pedunculated. These warts occur on the glans and inner aspect of the pre- puce, at the orifice of the vagina, round the anus, on the perineum, and on the thighs. They may bleed easily or be pale and indolent; they discharge MOLLUSCUM CONTAGIOSUM ; KELOID. 215 a thin ichor. There is no evidence that gonorrhceal warts can of themselves produce warts on another person; but syphilitic warts are highly infective. The treatment of this variety should consist in frequent washing with some astringent lotion, careful drying of the part, and the application of the ace- tate of lead, alum, savin powder, and verdigris in equal parts, or other strong astringent. If the masses are very large, snip them off and touch the bases with carbolic acid or nitrate of silver. Other warts from irritation are the soot-wart, the tar-wart, the warty tumor of cicatrices (C. Hawkins, Med.-Chir. Trans., vol. xiv.). These are the be- ginning of epitheliomata, and should be removed completely with the knife. Wens are most common on the head, face, and shoulders, and are sebaceous cysts due to obstruction of sebaceous glands, or are erratically developed cutaneous cysts. They occur most commonly after mid-life, and are often numerous upon the scalp. The matter contained is a collection of epidermic scales with oil-globules and crystals of cholesterine, and has received the name of atheroma or steatoma, from its resemblance to gruel or suet. These cysts commonly vary from the size of a hen's egg downward; they are round or ovoid toward the surface, tense, elastic, quite smooth, as a rule, adherent to the skin, but not to deeper parts, and their ducts may often be found as a black spot or crust; the skin over them long remains of normal appearance; and when pressure is made upon their edge, no thick mass is felt to slip away. These points will usually enable the diagnosis from chronic abscess and fatty tumor to be made. Suppuration, ulceration, and fungous granu- lation of the interior of the cyst sometimes occur. Treatment.—On the face the duct may be enlarged, or a very small opening made, the contents expressed, and a fine sharp spoon freely used over the interior; a cure without a scar may thus be obtained, but it is un- certain. Elsewhere, it is best to extirpate the cyst by freely transfixing it, seizing its base or edge with forceps, and gently tearing it out. On the back, the adhesions may be so tough as to require careful dissection. A pad of salicylic or other antiseptic wool is the best dressing, the edges of the wound being in no way united. Suppurating and fungating cysts must be dissected or scraped out. Molluscum Contagiosum.—This consists of one or very many tumors, from the size of a pin's head to that of a pea, hemispherical or spherical and pedunculated, of a white, pearly, translucent appearance, the larger present- ing a slight umbilication superficially; firm and solid to the touch. When squeezed between the thumb nails the little body is torn off and leaves a bleeding furface. They may be scratched off, disappear spontaneously, or remain for years if uninjured. They are most common in children and chiefly on the face. Kaposi, " Hautkrankheiten" (p. 177), regards them as distended and hypertrophied sebaceous follicles; but other views are held. They are by some thought to be contagious because they frequently occur in several of a number of children thrown much together; but others regard contagiousness as non-proven. I have seen it on the foot of a sucking child and on the mother's breast. Squeeze off the little growths with the thumb nails, and touch the base with the nitrate of silver. Keloid.—The true keloid tumor of Addison consists of dense fibrous tissue, and presents itself in the form of one or more projecting tumors, or thickened reddish patches, in the substance of the skin. It occurs without obvious cause, and usually on the chest near the sternum, sending out pro- cesses between the ribs. It is very rare. False keloid tumors having their seat in scars are much more frequent; they are most common in people of color, and soldiers after flogging, but may be developed in any scar—even on leech bites, or on the ear that has been pierced for earrings. They are 216 INJURIES AND DISEASES OF BURS.E. extremely liable to return after extirpation. Iodine and arsenic should be cautiously tried. Moles.—Oblong patches of imperfectly developed pigmented skin, small vascular patches, and other congenital imperfections, should be extirpated if at any time they seem inclined to spread and become irritable, because it is possible that they might become the starting-point of melanotic sarcoma (see p. 138), or of cancer. Some moles have a most malignant structure under the microscope, though clinically quite innocent. The malignant growths of the skin may be primary or secondary. Primary cancer is always squamous epithelioma (p. 141); but any other kind may occur secondarily, either by extension or by embolism. Round or spindle- celled, alveolar, or melanotic sarcoma may be primary or secondary. CHAPTER XXIII. INJURIES AND DISEASES OF BURSAS, TENDON SHEATHS, MUSCLES AND TENDONS. Injuries and Diseases of Burs.e. The diagnosis of injury or disease of a bursa depends so largely upon knowledge of the fact that a bursa is present at the affected spot, that the student will do well to acquaint himself with the position of the chief bursae, and to remember that bursae frequently develop at usual points of pressure, and are liable to disease. Contusions may cause a bursa to fill with blood ; sometimes suppuration follows, especially if the skin is in any way injured. Wounds, if diagnosed, require no special treatment. The diseases of bursae are all inflammatory, acute, or chronic. The bursa patellae serves as a type. Acute Bursitis.—Often there is no discoverable cause; but injury and extension of inflammation from surrounding parts not uncommonly act. • Its usual seats are: the bursa patellae, that over the olecranon, and, much less often, those beneath the ligamentum patellae and over the great trochanter. Symptoms.—These vary in degree according as the disease is serous or purulent. They are: redness, heat, swelling with more or less fluctuation, and pain, all localized to the seat of a bursa or radiating from it; more or less fever, reaching 102°-104° in cases of suppuration. If pus forms and is not let out, it may burst through the skin ; but there is much danger that this will prove too resistant, and that a subcutaneous or subfascial rupture will occur, and diffuse cellulitis, with sloughing of con- nective tissue, result; the bursa beneath the ligamentum patellae may burst into the knee. It is not very uncommon for ulceration to extend from an open, septic, suppurating bursa to a bone on which it lies. Treatment.—Rest on a splint and ice, or belladonna and fomentations. So soon as it is probable that pus has formed, incise antiseptically and drain. If subcutaneous rupture and cellulitis have occurred, many incisions will be DISEASES OF TENDON SHEATHS. 217 required for drainage. If the case is septic when seen, boracic fomentations are most useful. Chronic bursitis may cause simply serous effusion into the cavity, with slight thickening of the wall; or marked thickening, with little or no effu- sion, until the cavity is all but obliterated and the bursa a solid mass which rarely calcifies; commonly warty growths and bridle-like structures project into the cavity from a slightly thickened wall; rarely, loose bodies—chiefly fibrinous " melon-seeds "—occur in the cavity. The cause is chronic irritation, generally friction or contusion; and the common seats are: the bursa patellae (housemaid's knee) and those over the olecranon (miner's, student's bursa), the tuber ischii (weaver's bottom), and the two malleoli (tailor's bursa). Of the deep bursae, that between the semi- membranosus and gastrocnemius is most often affected, and usually by simple effusion only. The symptoms vary much, as is evident from the pathological varieties. The bursal swelling may be soft or extremely hard, fluid, lax or tense, or solid; the skin over it may be normal, thickened or stretched till trans- lucent ; warty growths may be felt on pressing the walls into contact, or loose bodies may yield a soft crepitus though they often escape detection. Treatment.—In early cases strong counter-irritation with tinct. iodi or blisters may do good. Later, aspirate, repeatedly if necessary, and keep up firm pressure against a splint. This failing, try very firm compression with a flannel roller against a splint on the opposite side of the limb (Volkmann), reabsorption takes two to eight days ; or, use antiseptic drainage or dissect the bursa out. When loose bodies are present, they should be completely evacuated through an antiseptic incision ; and warty growths, or marked thickening of the sac, must be treated by excision of the latter, if relief is needed. The deep bursae which may open into joints are the most difficult to treat, especially those in the popliteal space. If counter-irritation, aspiration, pressure, and rest fail, and something must be done, antiseptic drainage is that something. Diseases of Tendon Sheaths. These are so similar to the diseases of mucous bursae that they will be next described. Acute tenosynovitis is usually serous or fibrinous, rarely suppurative except from wound. It presents along the line of a tendon the signs of an acute inflammation. The surfaces of the sheath are often coated with lymph, so that when they move upon each other a soft crepitus (tenosynovitis sicca or crepitans), felt both by patient and surgeon, occurs. In many cases the sur- faces are separated by effusion. Movement is painful. Wound, strain, and over-use are the chief causes. The tendons most affected are the extensors of the fingers, thumb, and toes, and the peronei. Treat like acute bursitis, immobilizing the affected tendons. Chronic Teno-synovitis.—There are several forms: 1, distention of the sheath with serous fluid or gelatinous stuff; 2, dropsy with loose bodies, generally fibrinous " melon seeds; " but sometimes cartilaginous, calcifying or ossifying nodules occur, having separated from synovial fringes; 3, fun- gous teno-synovitis, in which the sheath is lined by granulation tissue, and in which the contents may turn out quite unexpectedly to be (4) pus. The two latter forms are very chronic, and often cause disease of bones or joints by extension. They all impair movement considerably. 218 DISEASES OF TENDON SHEATHS. Uropsy of the sheath of a flexor tendon of a finger. The causes are the same as for the acute disease, but less intense. Four- nier describes a syphilitic form. All the long tendon sheaths may suffer. When the sheaths are crossed by annular ligaments, as in front of and be- hind the wrist, so that a bilobed swelling forms, it is called a compound ganglion. This is most common in front of the wrist, and loose bodies may almost fill the sac. Treatment. — Counter-irritation and pressure are of little value. Injection of iodine, after the contents of the sac have been well washed out, is much used abroad in dropsy, simple or with loose bodies. Antiseptic incision and horsehair drainage are preferable. Should the cavities become septic, suppuration will probably lead to sloughing of the tendon or tendons; very free slitting up of the sheath gives the best chance. Dense adhesions will almost cer- tainly form. The involvement of bones and joints will usually require excision or amputation. Paratendinous Cysts or Simple Ganglia.—These are bursa-like cysts frequently found in the immediate vicinity of tendon sheaths; they are generally believed to be her- nial protrusions from the sheath, but their contents are very rarely reducible into the sheath, and upon dissection their connection with the sheath is generally very slight. But their constant association with tendon sheaths is almost proof of an original connection. Paget regards them as due to cystic dilatation of synovial fringes. The similar cysts due to protrusions of the synovial membranes of joints, especially the wrist and knee, cannot in many cases be diagnosed from these tendinous cysts. The treatment of ganglia must therefore be conducted with great care, lest a communication with a joint exist. Ganglia are infinitely most common upon the dorsal surface of the wrist, but may occur in connection with any tendon sheath. They contain gener- ally a yellow colloid material varying somewhat in consistence and depth of color. The causes are unknown. Symptoms.—A rounded swelling, varying in size from a pigeon's egg downward, tense and elastic, not tender, and covered by normal integuments; when so small as to require full flexion of the wrist to render them promi- nent, they seem of almost bony hardness, and resemble the head of the os magnum. Some weakness of the wrist may be complained of; often they cause inconvenience only by their appearance and size, or from slight pain owing to pressure on nerves. The appearance of such swellings may be the first sign of chronic arthritis. Treatment.—The simplest method is rupture by strong pressure with the thumb ; the contents must be squeezed out into the subcutaneous tissue, and spread through it as far as possible. A flat piece of lead wrapped in washleather must then be firmly strapped over the bursa, and several times a day for the next week the patient should firmly squeeze and rub the part, with the idea of irritating the bursal wall, and keeping open the tear in it for a little time. The plan is not very effective; often it is impossible to rupture the sac by such pressure. A fine tenotomy-knife should then be passed through the skin at a little distance from and along one side of the swelling, and a sweeping cut made into the cavity through the whole of one side; the contents must next be squeezed out, partly along the blade ; and finally, the whole inner surface should be scored and scraped with the point INJURIES AND DISEASES OF MUSCLES AND TENDONS. 219 and end of the blade. The after-treatment is that before given. The results of this method are much better than those of rupture. Should it, however, fail, and further treatment be necessary, the ganglia may be laid open freely, under antiseptics, and a bit of gauze placed in the cavity to prevent superficial union ; or the whole or greater part of the cyst may be excised. For fear of accidents, these operations should not be in- considerately undertaken. Compound Ganglion.—The situation and form of the swelling, bulging above and below an annular ligament, fluctuation beneath this band and perhaps soft crepitus from loose bodies, and the limitation of movement of the tendons affected render the diagnosis easy from everything except the rare lipoma arborescens (Midler), due to overgrowth of synovial processes. Treat by antiseptic incision, removal of loose bodies, and drainage for seven to ten days. Injuries and Diseases of Muscles and Tendons. Contusions of muscles cause more or less effusion of blood with pain, ten- derness, and inability to use the part. Complete absorption generally occurs, though it may be slow. Rarely suppuration, the skin having usually been damaged by the injury or leeches, follows; it is diffuse and difficult to treat with good result. Sometimes progressive atrophy, said by Volkmann to be inflammatory, re- sults from even slight contusions, or even from not very prolonged pressure —e. g., lying on arm for half an hour. It occurs chiefly in the deltoid and rectus femoris, and must be met by the constant current. The result of a blow may be to cause rupture of the sheath of a muscle and hernia of the muscular substance. The swelling is often taken for a cyst or tumor, and is most common in the thigh and belly wall. No symptoms result. Dislocation of muscles and tendons rarely occurs ; the peronei behind the outer ankle and the biceps from its groove are most frequent. The displace- ment is caused by some violent movement, and may be permanent, or occur with only certain movements. Prolonged rest may do some good for the peronei, but dislocation of the long head of the biceps is irremediable. Rupture of Muscles and Tendons.—This is frequently caused by vio- lent muscular contraction, especially if, after illness or long inactivity, the muscles are subjected to sudden and severe exertion; also by contusing force, the skin often escaping. The muscles which are most frequently ruptured are, the gastrocnemius, the rectus femoris, which sometimes is entirely de- tached from the patella, and the biceps flexor cubiti; but more frequently the tendons give way, especially the tendo Achillis and flexor tendons of the wrist. The symptoms of this accident are sudden pain, and sometimes an audible snap; hence the French term coup defouet. The patient cannot extend the tendon as he can in the opposite limb. A depression may be felt with the fingers at the ruptured part. Repair takes place by the development into fibrous tissue of a round-celled exudation from the divided ends and surrounding soft parts. A splice of varying length is inserted in the muscle or tendon; in cases of this kind, the shorter it is, the better. The latest results show that in muscle a new for- mation of muscle-cells from the preexisting ones occurs, so that ultimately a short scar in muscle may be obliterated. At first the new bond is adherent to surrounding parts; it works free as the muscle contracts. Usually when 220 INJURIES AND DISEASES OF MUSCLES AND TENDONS. the thickness of a muscle is torn, the ends remain at some distance apart, and can be felt ultimately as rounded swellings. Treatment.—The main point is to keep the injured part in a state of constant rest and relaxation, to briug the severed ends into close approxi- mation, and to prevent any extension till union is firm. When the tendo Achillis or the gastrocnemius muscle is ruptured, the knee may be kept bent by a string passing from the heel of a slipper to a bandage round the thigh. For ruptures of the extensors of the thigh, the limb must be placed in the same position as in fracture of the patella. If the biceps is ruptured, the elbow must be kept bent to its utmost; if the tendons about the wrist or fingers, the forearm must be confined by a splint with the fingers extended or bent as the rupture is on the extensor or flexor side of the limb. The even pressure of a roller over the part is also beneficial. After three or four weeks of rest the surgeon may use passive motion—i. e., to bend and extend the joints of the injured limb with his hands several times successively. But the patient must be cautious in using the muscle for a long time; and, if it be the tendo-Achillis, must walk with a high-heeled shoe for two or three months; so that the recent callus may not be stretched and lengthened, which would cause permanent weakness. Sometimes no position will approximate the torn ends; nothing can be done for muscles, as sutures will not hold in them when freshly torn; but important tendons should be sutured at once. In old cases of rupture, with long union and much loss of power, an at- ' tempt to bring the ends together by suture would probably fail. Division of the bone to shorten the limb temporarily has been suggested. But it seems probable that reparative surgery will find something to transplant into the gap; already a case of transplantation of muscle into the gap left by excision of a scar from the muscles of the forearm has been reported as successful. Open wounds of muscle are much commoner than subcutaneous ruptures. If they become septic, suppuration is often troublesome, and may lead to sloughing, diffuse myositis, and rapid scar contraction, resulting in deformity which is most difficult to remedy. Treat by fixation of part in the best posi- tion, and antiseptic dressings; in clean-cut wounds numerous buried catgut sutures would hold together the ends of muscles intersected by tendon. Tendons are frequently wounded. When not completely divided, the chief danger is that of suppurative teno-synovitis, which often spreads widely and rapidly up the limb. If this is avoided, wounds of the sheath and tendon yield a good result, unless skin is also lost and the whole gap must heal by granulation ; everything is then adherent. When the tendon is completely divided, it should be sutured with catgut. If the central end is drawn into its sheath and cannot be brought down by forceps and relaxation of the muscle, an incision must be made into the sheath higher up and the tendon pushed down (Madelung). Quite recently, Gluck has obtained union of widely separated ends (from loss of substance), by uniting them with stout catgut; the latter became "organized" and formed the bond of union. Atrophy of muscle results from many causes, and not infrequently comes under the surgeon's notice. One of the commonest causes is simple disuse, well seen in the muscles of the thigh above a chronically inflamed knee or in those of a limb which has been some weeks in splints. In these cases, fatty infiltration may prevent loss of size of the limb. Next it may rarely occur from simple contusion or subcutaneous laceration (p. 219), or from vio- lent stretching, as of the deltoid and scapular muscles after dislocation of the shoulder; in these cases the influence of injury to nerves is not excluded. OSSIFICATION OF MUSCLES AND TENDONS. 221 Next we come to the results of injury and disease of the nervous system. The cases of cerebral paralysis which fall under the surgeon's care are those due to lesions of the motor area of the cortex ; when these are permanent, they cause only slow atrophy from disuse, the paralyzed muscles do not show the " reaction of degeneration," but they are frequently the seat of tremors, rigidity, and contraction—signs of descending sclerosis in the lateral columns. Much more frequently the surgeon sees cases of spinal or peripheral paralysis, due either to destruction of the great ganglion cells of the anterior cornua (infan- tile and acute adult spinal paralysis, progressive muscular atrophy), or to wound, contusion, or neuritis of motor nerves, practically severing the muscles from these cells. These cases contrast with those due to cerebral lesions; atrophy is very rapid—a matter of a few days—there is no tendency to active con- traction (though adaptive shortening is frequent), and the "reaction of de- generation " is marked—i. e., the muscles soon cease to react to the faradic current, but exhibit increased excitability to the constant; then this, too, gradually ceases to cause them to contract. All these signs are best seen in infantile paralysis, in which one or more limbs are paralyzed either wholly or as regards certain groups of muscles. The affected parts are helpless, wasted, pale or purplish, and cold, and they do not grow in proportion with the other parts of the body. Treatment.—When possible we must treat the cause of the atrophy, by curing the arthritis or fracture which prevents exercise, by combating myo- stitis or neuritis, by chiselling a nerve out of callus, or finding its separated ends and suturing them. Treatment of the muscles themselves is always most important, especially in infantile paralysis. The paralyzed part should be kept warmly covered, and cold douching, followed by friction with a rough towel till the surface reddens, massage, and the constant current em- ployed ; passive exercise, and active of all the muscles over which the patient has any control, should be used regularly, every day, for several months, before the case is despaired of. Permanent contraction or shortening of muscles may occur from constant irritation anywhere along the motor tract; hence its frequency in descend- ing sclerosis secondary to cortical lesions. It occurs also when a limb is kept constantly in such a position that a muscle is never stretched; this is the pathology of the so-called " contractions" in infantile paralysis—e.g., the foot is constantly extended, the calf muscles are at their shortest and adapt themselves to the position. It is the connective tissue in them which offers such stubborn resistance to flexion. In the latter class of cases tenotomy is often required: as also in the class due to interstitial myositis. Ossification of Muscles and Tendons.—Sometimes, without obvious cause, ossification extends into tendons from their insertion; usually this happens near joints affected by rheumatoid arthritis or where periostitis has been going on. Sometimes long pieces of bone (rider's bone) are found in the adductors of horsemen. There is a rare disease (myositis ossificans), oc- curring in young people, in which bony masses form first in the muscles of the back and neck, then in those of other parts, greatly impeding movement and causing much pain. Inflammation of Muscle.—Some think that muscular rheumatism is really a serous inflammation ; it often appears suddenly after an effort which might rupture many fibres. Putting aside these vague, rheumatic cases, myositis, except from wound, is rare. It is an interstitial process, and may be suppurative or productive (fibrous) ; the muscle-cells suffer secondarily. Suppurative myositis is usually due to wound or to infective irritation in pyae- mia, farcy, and other septic diseases; but abscesses form in the tongue and within the sheaths of muscles, especially the rectus abdominis, often without 222 INJURIES AND DISEASES OF LYMPHATIC VESSELS. obvious cause. There is nothing noteworthy about the symptoms. Chronic interstitial or fibrous myositis, when not due to injury, is probably of syphilitic nature; the muscle is converted into a rigid cord. Gummata occur, especially in the tongue. Tubercle is very rare. The treatment must be conducted on ordinary principles. New Growths of Muscle and Fasciae.—Of" simple tumors of muscle, fibroma (soft or hard), lipoma, enchondroma, and myxoma are the most usual, though all are very rare. Sarcomata—especially round and spindle- celled and alveolar—are commoner. Primary cancer does not occur, but secondary nodules, due mostly to direct extension from primary foci, are common. A tumor growing from the deep fasciae is in all probability a sar- coma, often of the variety known as recurrent fibroid, which recurs again and again locally, perhaps taking years to destroy the patient. These tumors, growing from superficial muscles and fasciae, may at first sight closely re- semble fatty tumors; but by putting the muscle into action or endeavoring to move the growth along the line of greatest tension of a fascia it will be found fixed deeply, whilst a fatty tumor moves freely over the deep parts. The treatment is early and free removal. CHAPTER XXIV. INJURIES AND DISEASES OF LYMPHATIC VESSELS AND GLANDS. Subcutaneous rupture of lymphatics is of course very common, but the for- mation of a persistent lymph-swelling is very rare. It is probable that much of the early discharge from wounds comes from divided lymphatics, especially in regions like the groin and axilla, but they soon close by clotting. There are several cases on record of wounds of the thoracic duct, either by stabs in the neck or wounds traversing the thorax. Constant free escape of lymph is the diagnostic point, and this loss rapidly exhausts the patient. Wilms has reported a case in which the wound (in the neck) healed under a plug. Inflammation and suppuration of lymphatic glands—e. g., inguinal—do some- times appear to be connected with a violent strain, though it is not at all clear how this acts. Acute Lymphangitis is almost invariably due to the absorption from some breach of surface—which may possibly have healed when the case comes under observation—of some infective irritant; chemical irritants may have some share in the process. Almost always an unhealthy sore is found or an infective inflammation, as erysipelas. The attacks of lymphangitis which precede the development of true elephantiasis will be noticed shortly. It is probable that the infective irritants produce lymphangitis only when they are arrested in the vessels by clotting; in the great majority of cases the products of septic absorption pass into the glands and may excite inflamma- tion there. Symptoms.—Aching pain and tenderness along the line of the vessels leading from a source of irritation are the first signs of lymphangitis. Then a firm tender red stripe, an inch or more wide, somewhat irregular in out- line, and slightly raised above the skin, appears; often it is made up of ACUTE AND CHRONIC LYMPHANGITIS. 223 several narrower streaks. It is due to lymph-thrombosis and to inflamma- tory peri-lymphatic hyperaemia and exudation. The glands to which the vessels lead are swollen and tender. The general symptoms of moderate fever are usually present; sometimes the onset is marked by a rigor and all the signs of severe fever. The fever may be prolonged, but usually subsides in two or three days. Usually lymphangitis subsides without complication ; sometimes suppura- tion occurs at some point, or at several points one after the other, the course being very protracted. It must be remembered that the deep or subfascial lymphatics are liable to inflammation like the superficial, but pain, tenderness, and fever are the only signs. There is a chronic lymphangitis, evidenced by the formation of a cord by thickening and matting of the vessels. The dorsal lymphatics of the penis in cases of hard chancre often furnish an example. The treatment of acute lymphangitis is—antiseptic treatment of the source of absorption; rest, and the free application of glycerine and belladonna along the inflamed vessels, and the use of hot fomentations. Cold fomenta- tions of lotio plumbi or of 1 in 20 carbolic lotion have also been recom- mended. Abscesses must be opened early. Thickening along the lymphatics, or chronic oedema of the part after prolonged or frequent attacks, will require cold douching, friction, shampooing, and careful bandaging. Elephantiasis Arabum consists in a slow hypertrophy of the skin, areolar tissue, and bones. The epidermis is thickened and the papillae enlarged; the true skin is immensely thickened ; its fibrous structure dense and almost rigid; the areolar tissue thickened, its areolae expanded, and filled with gelati- nous-looking stuff. The microscopical appearances are those of hypertrophy of the tissues involved. The bones also of the affected limb become enlarged and heavy, and the nearest lymphatic glands are enlarged. Its favorite seats are the leg, which it converts into a huge pachydermatous resemblance of an ele- phant's leg (Barbadoes leg, Bucnemia, etc.) ; and the male genitals, which it converts into a huge tumor, reaching down to the knees, and weighing perhaps more than 100 lbs. (Fig. 62). It is particularly a disease of warm climates, and is endemic in many tropical places ; dark races are more liable than the fair; men suffer more often than women. It is rare under puberty. The onset of elephantiasis is often marked by high fever, great pain in the parts affected, and rapid inflammatory swelling of them. When the scrotum is affected acute hydroceles form, and the swollen cords may dilate the abdominal rings so much that herniae descend when the swelling subsides (Fayrer). The surface of the skin may be- come eczematous and discharge a chyle-like or offensive serous fluid. These febrile and inflammatory paroxysms tend to recur; they may be very frequent, and the increase in size of the part rapid, or few and far between a slow increase in size goes on. Fig. 62 Dr. Wiblin's patient. The curled promi- nence in the front of the tumor is the hypertrophied prepuce. Without them, however, In some cases clear bead-like vesicles form on the skin, and when pricked 224 INJURIES AND DISEASES OF LYMPHATIC VESSELS. discharge a coagulable white or pinkish fluid : they are varicose lymphatics (Figs. 63, 64). Attacks of chyluria may occur, and these are believed to be due to rupture of lymphatics into the urinary tract. (W. Roberts.) Often there is no lymphorrhagia, no superficial varix. Fig. 63. Lymphatic varix of scrotum; enlarged gland is shown. From a drawing in the Medical College Museum, Madras. Pathology.—Obstruction of the lymphatics preventing return of lymph from the part, and irritation starting from the lymphatics giving rise to the inflammatory attacks, are believed to be the keys Fig. 64. to the disease. The endemic form of the disease is probably due to the presence in the lymphatics of the scrotum or lower limb of adult nematode worms three to four inches long—the filarias of Bancroft. These by their irritation cause the in- flammatory attacks and obstruction to the lymph- flow through the inflamed glands, whence may follow varicosity and rupture of superficial lym- phatics. Abscesses and buboes also may occur. A portion of the above, natural The adult WOrmS which Te*]lJ CaUSe the. ^chief size. are rarely found ; but at night (i. e., during rest) myriads of larval forms -fa inch long may be found in the blood. Manson believes that these are taken in by mosquitoes when they bite; that they pass through a developmental stage in these in- sects, then enter water, and finally find their way again to the alimentary canal of man. He says the distribution of elephantiasis is that of the mos- quito. Obstruction of lymphatics occasionally occurs from other causes and pro- duces similar pathological results. Thus we get sporadic cases. Prognosis.—The tendency is always to increase, though often very slowly. The bulk of the part, large loss of lymph, foul ulcers, and frequent ACUTE LYMPHADENITIS. 225 febrile attacks may exhaust the patient; frequently the general health is good. Treatment.—In early stages removal from the endemic area may lead to arrest of the disease, especially in Europeans. A Martin's bandage worn constantly may be of use. The general health must be looked to. For Barbadoes leg, ligature of the femoral or external iliac artery has been done with a good deal of success. This failing, as it often does, ampu- tation only remains, and this is at present the only treatment for elephan- tiasis scroti. Amputation of Scrotum.—First examine for hernia; if one is present, its neighborhood must be carefully avoided. If the tumor is large, the patient should lie on his back for an hour before the operation with the scrotum elevated by cords and a pulley attached to the ceiling. Then a very strong Esmarch's band is applied and secured by tapes from slipping forward, or a clamp of two wooden bars approximated by screws and nuts may be used (Turner). Small flaps are now fashioned round the base, where the skin is healthy and simply dragged from surrounding parts, to cover the penis, testes, and raw surface. Then the penis is found by thrust- ing a finger into the hole whence urine issues, and slitting up the prepuce; it must be quickly dissected out—care being taken not to divide the suspen- sory ligament—and held up against the pubes. Next a bold cut is made obliquely along the direction of one or other testis; these glands generally lie in large hydroceles, and are easily found, freed, and held up. Then by a clean sweep the mass is detached. Any loose-lying portions of blubber are cleaned away; the vessels (of which there may be few or a large number) tied as the tourniquet or clamp is loosened, the flaps sewn round the penis, testes, and wound, and the whole dressed with a wool dressing. Lymphadenitis, or inflammation of lymphatic glands, may be acute or chronic. Acute lymphadenitis is almost always secondary to some inflammation in the area whence its supply of lymph comes. Sometimes it is referred to strain or over-walking (p. 198). Lymphangitis is much more commonly absent than present, probably because the glands arrest infective particles which pass harmless along the vessels. Organisms believed to be the cause of the primary inflammation are often demonstrable in inflamed glands. Acutely inflamed glands are swollen, injected, much softer than natural, and of medullary aspect; sometimes strewn with fine hemorrhages, sometimes of deep purple color throughout. The whole process consists in dense infiltra- tion of the gland with round cells, which block the lymph-sinuses completely, and in the more intense cases red corpuscles escape in large numbers. In slight cases resolution may occur rapidly, but in more advanced ones the pro- cess is slower and takes place by fatty degeneration of the products; the acute process then commonly becomes chronic. When suppuration is about to occur yellow foci appear at different spots of the cortex, and enlarge and blend more or less rapidly. Sooner or later the periglandular tissue is in- fected—sometimes when the gland itself shows little change—and a peri- glandular abscess develops; this may cut off the blood-supply of the gland and cause it to necrose. In other cases the interglandular abscess bursts into the subcutaneous tissue; or the gland becomes adherent to the skin or to a serous or mucous membrane, and pus bursts through it. The form of inflammation depends largely on the character of the primary disease—i. e., upon the nature of the irritant, which naturally tends to excite in a gland a process similar to that which it had set up at the source. Thus the poisons of erysipelas and diphtheria rarely cause suppuration, that of soft chancre and cadaveric poisons frequently do. 22() INJURIES AND DISEASES OF LYMPHATIC VESSELS. Chronic Lymphadenitis.—Now and again an acute lymphadenitis passes into a chronic state; the glands remain swollen and indurated, and may never return to the normal. Glands above some chronic inflammation may become similarly swollen, and upon section such glands are grayer and more opaque than normal, firm, and more or less plainly fibroid ; encapsuled ab- scesses, undergoing absorption, may be found, the periglandular tissue being much thickened; or there may be yellow patches of fatty degeneration. Syphilis in all its stages causes enlargement of glands; but they rarely be- come very prominent. The pathological process is the same as in other syphilitic lesions; but gummatous lymphadenitis is rare, affects chiefly in- ternal glands, and usually gummata exist in the organs whence the lymph comes. But by far the most common cases of chronic lymphadenitis are the scrofulous glands which we have shown to be tubercular. The histology of these is that of tubercle in general (p. 93). In early stages, typical miliary tubercle—the giant cell surrounded by epithelioid cells—may be found with few or no signs of diffuse inflammation; but soon general round-celled infil- tration of the gland occurs, followed by caseation, and either softening into puriform cheesy fluid, or inspissation and frequently calcification. The former result is the more usual in superficial glands, the latter in the mesen- teric and bronchial. These cheesy glands, especially bronchial, are regarded by Koch as the storehouses whence by some accident bacilli in small or large numbers may be sent all over the body (p. 97). To the naked eye the glands are at first moderately swollen, pinkish or pale gray, and softer than normal; the swelling increases, the gland becomes firmer, and small cheesy foci ap- pear, especially towards the centre; these enlarge and coalesce till perhaps the gland becomes wholly cheesy, or calcification or softening into cavities occurs. The periglandular tissue forms a dense capsule as a rule, but some- times a periglandular abscess forms and the tubercular gland may be bodily eliminated. The symptoms of acute lymphadenitis are rapid painful enlargement of one or more glands, accompanied by a good deal of oedema of surrounding tissues and redness of skin, the latter varying with the distance from the gland. If a perilymphatic abscess forms early, its diagnosis is generally easy; but when pus forms slowly in the gland, it is often very difficult to determine its pres- ence. The symptoms seem to point to abscess, but an incision often evacuates no pus (see Morbid Anatomy). The glands most commonly affected by tubercular lymphadenitis are the cervical, bronchial, and mesenteric—all receiving lymph from mucous sur- faces, which, in the strumous, are subject to chronic catarrhs; but the cervi- cal and other superficial glands may probably become infected through slight breaches of the skin, or secondarily to other tuberculous lesions, either by the lymphatic or the blood vessels. With regard to the cervical glands, it has been already noted (p. 91) that strumous lesions of the skin are specially frequent about the head and face. One or more glands enlarge slowly and painlessly, the skin being unaffected and the swellings distinct from each other. They may remain permanently in this condition, or the enlargement may continue and the glands become matted together. After a very varying time—weeks or years—one or several glands soften, the skin reddens, thins, and bursts, cheesy pus, and perhaps calcareous granules, escape, and a sinus, discharging more or less, remains, often for many months. Burrowing may occur far and wide, and the skin frequently becomes extensively undermined, thin, and purplish. Treatment.—Acute lymphadenitis requires rest, belladonna, and fomenta- tion, together with attention to the source of absorption. If an abscess forms it should be opened, and it is always well to give ether that this may be done INJURIES AND DISEASES OF BONE. 227 thoroughly ; for an imperfect opening leads to burrowing. Should a gland be found in the cavity it should be removed, either bodily or with the sharp spoon. If sinuses form, rest, drainage, well-applied pressure, and stimulant injections may bring about healing; but usually the quickest way is to slit them up, entirely or in part, and to sharp spoon them. Chronic enlargement is reduced by friction with some ointment, douching, and constant pressure. It is often very troublesome. Tubercular Glands.—In all cases pay attention to the general condi- tion. In the early stage frequent friction with ung. pot. iod. is sometimes followed by disappearance of the swelling; ung. plumbi iod., or ung. iod. is used by some. If a gland has softened at once, and before the skin is affected, make a small incision into it, and remove as much of it as possible with a sharp spoon ; introduce some iodoform into the cavity, and dress with a deep dress- ing and salicylic wool. If the abscess is pointing, treat similarly. If it has burst, enlarge the opening and slit up sinuses, if necessary, for draining; use the sharp spoon freely, endeavoring to remove all gland and tubercular granulation tissue; cut away all blue skin and dress as above. Sometimes a gland, which is steadily enlarging and softening in spite of treatment, may be removed entire before the skin is involved, and rapid union obtained with little scarring. Occasionally, too, one may have to remove a mass of matted glands pierced by sinuses from the neck, axilla, or groin ; but the mass should be the only one or a source of much trouble to justify this. Tumors.—Under the heading of Lymphadenoma or Hodgkin's Disease we have described a progressive hyperplasia of lymphatic glands and other lymphoid structures, which it is impossible at first to diagnose from inflam- matory cases; progressive involvement of glands and anaemia, or leucocy- thaemia, and the rarity of softening in the former are the points to rely upon. Myxoma is the only simple tumor known to develop primarily in lym- phatic glands. All forms of sarcomata occur primarily, even the melanotic, and the alveolar which so closely resembles cancer. They may run a slow local course, involving only a group of glands; or may prove intensely malignant. They differ from malignant lymphoma in having no tendency to spread to other groups of lymphatic glands. True cancers occur only as secondary growths. CHAPTER XXV. INJURIES AND DISEASES OF BONE. Contusion of bone is frequent. When subcutaneous, simple periostitis, rarely running on to suppuration, results. But when compound and due to considerable violence, especially gunshot, it may be followed by septic trau- matic osteomyelitis, and lead to abscess, necrosis, or death from embolic pyaemia. Fractures. Definition.—A fracture is a solution of continuity of a bone. Exciting Causes. — These are two: Mechanical violence and muscular action. Mechanical violence may be direct or indirect. It is direct when it 228 INJURIES AND DISEASES OF BONE. causes fracture at the part to which it is actually applied, as in fracture of the clavicle from a violent blow. It is indirect when force is applied to the ends of a bone (or chain of bones), and this gives way at the weakest point, as in fracture of the clavicle from falls on the shoulder or hand. The acromial end is rigidly fixed by the object against which the shoulder or hand rests, the sternal end is driven toward it by the momentum of the body, and the bone gives way usually about the middle. Muscular action most often breaks the patella or olecranon ; much more rarely a long bone—usually the humerus, then the femur, leg bones, or fore- arm bones. The sternum and pelvis may thus be broken. Stretched liga- ments may drag off the bone into which they are inserted. Predisposing Causes.—1. Original conformation, the bones of some people being unusually brittle without obvious causes ; rarely, this liability to fracture runs through three or four generations. 2. Atrophy from old age; prolonged disuse (accounting for the frequency of fracture during attempts to reduce old dislocations); in general paralysis of the insane, and at the ends of the shafts of long bones in locomotor ataxy. Cases of frac- ture from atrophy during cancerous cachexia are described, no local growth having been found. 3. Rickets and mollities ossium. 4. The presence of syphilitic, tubercular, or other form of caries. 5. The presence of some new growth, especially sarcoma or cancer in the bone. Varieties of Fracture.—The. following are the chief: Simple, in which there is no wound affording either direct or indirect communication with the air; compound, in which such communication exists from the first, or appears later from sloughing of the soft parts; complicated, in which dislocation of the fractured bone, rupture of a large nerve or artery, or extensive injury to soft parts coexists. Fractures are incomplete or complete. Examples of incomplete are—a splinter or apophysis is broken from a long bone ; the willow or green-stick fracture (occurring in young bones, often rickety, or in those softened by osteomalacia), in which the bone is not broken through, but torn open on one side only like an over-bent green stick (Fig. 65) ; a Fig. 65. Green-stick or willow fracture of the ulna in a young person. From the Museum of the Medical College, Madras. fissure running through more or less of a bone, generally a flat one, but sometimes a straight or spiral fissure is found in a long bone, especially the humerus or femur. When many fissures radiate from one point the fracture is starred or stellate. Complete fractures may be transverse, longitudinal, or oblique, according to the relation of their line to the axis of a long bone; the first two are rare, every degree of obliquity is common ; the line of frac- ture is often toothed or V-shaped; in cases from gunshot or other great vio- lence, fissures commonly extend into neighboring joints, or far toward them, or from similar causes the bone at the seat of fracture may be comminuted— i. e., broken into several fragments; if these are long and splinter-like, the fracture may be called splintered. As the size of the fragments increases, the comminuted fracture passes into the multiple, in which a bone is broken at two or more places, the intervening portions being unbroken. A fracture is impacted when the smaller fragment is driven into and fixed in the larger —e. g., the neck of the femur into the head or into the trochanter, with or SIGNS OF FRACTURE. 229 without splintering of the latter. A hole punched through a bone such as may be made in a flat bone by a bullet is called a perforated fracture, and a puncture made by a pointed instrument, & punctured fracture. Separation of an epiphysis may occur, is most common between ten and twenty years ; all are usually united by twenty-five; any epiphysis may suffer, but the lower of the femur and radius, the upper of the humerus and tibia, do so most frequently. Such fractures may occur through the epiphysial carti- lage, or this may carry away with it a thin layer of the shaft; in the former case soft crepitus only will be obtainable. After such injuries the epiphysis may ossify early, and growth of the bone be seriously curtailed. Fractures into or in the immediate neighborhood of joints are very likely to leave im- paired movement from exuberant callus or slight displacement of the frag- ments. An examination for fracture should be made once for all and thoroughly; an anaesthetic is often necessary. If so much swelling is present that it is impossible to feel the bones, fix the part in the best possible position for re- covery, and use ice if swelling is increasing; if not, fomentations to promote absorption. It is always well to feel the pulse beyond the injury to see that the main vessels are sound. Signs of Fracture.—(1) Abnormal mobility; (2 j Deformity; (3) Crepitus, are the chief; localized pain, tenderness, and swelling, and helplessness of the injured part are sometimes of value. Abnormal mobility is detected by simply pressing on a bone (sternum, rib, or skull), by rotating the distal portion of the bone (radius, femur) with the thumb placed on the upper to see whether it moves with the lower, or by grasping the bone with both hands at various spots and trying to obtain movement, either angular or transversely to the axis of the bone, between the portions held. If found, this is proof positive of fracture, such a condi- tion as an old ununited fracture being eliminated. But it may be impossible to seize or press upon the bone, or the fracture may be incomplete or im- pacted, and mobility consequently absent, and in some cases with slight dis- placement spasm of the muscles may keep the fragments securely locked. Deformity is due to displacement of the fragments, and this may be angular, lateral, longitudinal, or rotatory—terms which explain themselves. Dis- placement is due to the direction of the fracturing force and of the line of fracture, to the action of muscles and of the weight of the part, and to man- ipulation. Angular deformity, swelling from overlapping or projection of fragments, shortening or eversion or inversion of the limb below the fracture, may be obvious at a glance, or careful measurement may be required; but deformity is absent in simple fissures of flat bones, and even in some complete fractures of limb bones, especially in children; and it is undiscoverable clinically in many fractures of thickly covered bones and in cases of slight impaction. It is, however, the most important sign of impacted fractures. Habitual deformity must not be confounded with fracture or dislocation. When a person, after a fall or other accident, is found to have a limb short- ened or misshapen, the surgeon should always ask whether or not there was any deformity before the accident, else he may fall into the ridiculous error of treating an old deformity as if it were a recent injury. Crepitus is the sensation communicated to the ear or hands when the fractured bones are grated against each other, by proceedings similar to those employed for de- tecting abnormal mobility. It is absent when the fragments are separated by displacement, or by the intervention of muscle; also when they are firmly impacted or even locked by muscular spasm in cases where the bone cannot be fairly grasped above and below the fracture. Crepitus is simulated by the crepitation of blood coagulated in the subcutaneous tissue, and still more 230 INJURIES AND DISEASES OF BONE. closely by the grating in joints affected by rheumatoid arthritis, which is often conducted along a limb for some distance. Localized pain, tenderness, irregularity of bone, or swelling, are often of much value in cases due to indirect violence or to muscular action, and espe- cially where only one of two bones is broken. The pain may be detected by direct pressure and by gentle rotation; where there are two bones, by squeez- ing them towards each other, grasping them as far as possible from the painful spot. Helplessness of the part is characteristic of fracture, but complete loss of power is not uncommon in painful contusions. Also, considerable power is retained in incomplete or impacted fractures, and even in rare cases of com- plete unimpacted fractures, the patient being perhaps able to walk after fracture of the neck of the femur. Ordinarily movement of a broken limb is freer than normal; but it may be characteristically limited in impacted fractures—e. g., complete rotation in of the leg is impossible in impacted fracture of the neck of the femur. Repair.—For a few days the broken ends, sharp and more or less denuded of periosteum, lie in partially coagulated blood among bruised and torn tis- sues. The vessels of all parts irritated by the injury and subsequent move- ments of the fragments allow fluid and corpuscles to pass freely out, granu- lation tissue develops, and the blood disappears before it. By the tenth day this soft, pink tissue is present in quantity, infiltrating the soft parts, sur- rounding the bones, and forming a plug in the medullary cavity. By the fourteenth this tissue is a good deal firmer, and a membrane continuous with the periosteum appears on the surface of the spindle-shaped swelling, into which the ends of the bone are stuck as into soft sealing-wax (Billroth) The new tissue is called provisional or temporary callus, the ring outside being the external or periosteal, the plug inside the internal or myeloid (Fig. 66). The amount of this provisional callus varies directly with the Fig. 66. amount of movement permitted to the fragments—i. e., the amount of irritation of tissue; it is greatest in fractured ribs, least or absent in fissures of the skull, and always in larger quantity where a bone is thickly than where it is thinly covered—e. g., on back and outer rather than on inner side of tibia. In man the periosteal callus does not usually form a complete ring; it fills up angles and gaps caused by displacement. Ordinarily this granulation tissue begins in the third week to ossify directly or after conversion into fibrous tis- sue ; if, however, there is much movement of the fragments, islets of cartilage appear—they are common round broken ribs, and conversion into cartilage is usual in animals. OssiBcation begins in the periosteal callus and appears later in the myeloid, it starts round the vessels passing from the callus to the bone, at points most distant from them ; tubes of bone form and become lined by angular osteoblasts, which lay down layers of bone and establish Haversian systems. The periosteal bone thus becomes dense and adheres more and more firmly to the broken ends, and holds them strongly together. Ossification of the provisional callus is complete from the fourth to the eighth week, according to the size of the bone; and then the part is again fit for work. Slowly a round-celled exudation from the vessels has been enlarging the Haversian spaces of the broken ends, and the granulation tissue in one frag- ment, either directly or mediately through the provisional callus, joins that TREATMENT OF FRACTURES. 231 in the opposing fragment. By this melting together of the broken ends and subsequent ossification of the uniting material, permanent or definitive callus, the bone is rendered continuous. Ossification of the permanent callus begins after that of the provisional is complete, and ends usually about the fourth month. Absorption of all unnecessary temporary callus is the end of the process. In accurately set fractures, after a year or two, the medullary canal may be opened up and possibly all trace of fracture removed; as a rule, some evidence of displacement remains. When compound fractures are septic, the granulation tissue is exposed to constant irritation, and suppurates freely: some necrosis generally occurs, and thus it may be many months before healing, if it occur at all. Even if they do not suppurate, compound fractures heal more slowly than simple. Though other tissues help in producing the material which ossifies, prob- ably none of it would ossify in the absence of periosteum. If the shaft of a bone be removed subperiosteally, the granulation tissue produced frequently ossifies and a new bone forms. The vital processes in bone are not very active; hence we find that com- pletely detached fragments, protected from all .septic irritation, derive suffi- cient nourishment from the surrounding fluids to maintain life until they contract fresh adhesions; by transplanting bits of bone under aseptic condi- tions, Macewen has built up part of an ulna. The effect of sepsis is shown by the necrosis so common in compound fractures. Treatment.—When a person has received an injury which may have caused fracture, especially of a lower extremity, it is very important to pre- vent him from endeavoring to rise; for the bone is thus frequently thrust through the skin, and displacement and injury of tissue much increased. He should not be lifted until either the absence of such an injury is ascer- tained or the part is properly taken care of. If the leg is broken, one person should hold it alone, whilst others lift or carry. Further injury having been guarded against by tying the legs securely together at knee and ankle, or by the application of some temporary splint (e. g., sticks, umbrella frame, bundles of straw), the patient may be carried home on a litter made of two poles and a sack or horsecloth. A broken arm may be safely held by the other hand or placed in a handkerchief sling. The patient's bed must be made as firm and level as possible; in fractures of the thigh a door or planks should be placed beneath the mattress. The patient may then be placed upon it and examined, clothes which are at all difficult to remove being cut up along the seams. Whilst splints are being prepared, have the part washed as thoroughly as possible with soap and water and a flannel. When it is necessary to fetch apparatus, place the limb in the most com- fortable position (thus it is usually best to place the leg on the outer side, with hip and knee pretty fully bent) and steady it with sand-bags, bricks wrapped up, or handkerchiefs passing from the knee and ankle to the bed frame. The general indications for treatment are: (1) to place the fragments in their natural position; (2) to keep them together at perfect rest until they are firmly united. The first indication is fulfilled by the reduction or setting of the fracture. This must be done as soon as possible and with the smallest amount of force, all opposing muscles being relaxed by position. Thus, in fractures of the leg, the patient should lie ou his back and the hip and knee be bent to a right angle to relax the calf muscles, all apparatus being ready. One assistant now takes the foot and makes extension—i. e., steadily pulls upon it—whilst another, grasping the thigh with both hands just above the knee, holds it immovable or makes counter-extension. The surgeon watches and manipulates the fragments, directing the assistant to pull in this or that 232 INJURIES AND DISEASES OF BONE. line or to rotate, and when they are drawn into place the assistants main- tain extension until he has applied some retentive apparatus. The correc- tion of rotatory displacement is often forgotten, especially in the lower limb. Considerable force is sometimes required to overcome the interlocking of fragments, and anaesthesia is often necessary. It is a rule in treating frac- tures to fix the joint above and below the injury, but the upper may be left free when it is far above the fracture. Retentive Apparatus. Splints.—Some fractures are treated without any apparatus; usually some means are adopted to fulfil the second indica- tion—i. e., to keep the part at rest and prevent displacement; perhaps merely a bandage or strapping, more often a splint. A splint may be required simply to immobilize a joint; usually it is employed to prevent lateral, angular, and rotatory displacement, and often to maintain extension. Splints are divided into the movable, movable immovable, and immovable. The movable are made chiefly of wood, tin, perforated zinc,poroplasiic, leather, or gutta-percha; they are applied with ordinary bandages which become loose every few days, require reapplication, and necessitate more or less dis- turbance of the fracture. Many wood and metal splints are constructed for special fractures; but a deal plank, four inches wide and one and one-half inch thick, will enable a surgeon to treat a large number of fractures success- fully. The three last named materials are cut out, softened, and moulded to limbs as the cases present themselves. Flat wooden splints should be wider than the limb to which they are applied, and this is of especial importance in fractures of the forearm, where the bones may be pressed toward each other by the bandage. They require padding with a folded soft towel, strips of old blanket, or pads made of tow or cotton-wool sewn in soft muslin. In the emergencies of military and railway surgery, strong splints can be improvised with the smaller gauges of telegraph wire, which can be bent into the required shape by the fingers or dressing forceps, and easily cut with a strong pair of scissors. (Brit. Med. Journ., June 19 and 26, 1876.) It is a rule never to apply a bandage to a limb beneath a movable splint, as it may cause strangulation if the limb swell. Splints should generally be applied • to the limb in that position in which it is afterward to remain. When splints are used to prevent longitudinal displacement, and therefore bandaged tightly to the limb, the parts below must be equally supported by bandages or they will swell greatly. Prominent bony points must be care- fully protected by " ring " pads, or the soft parts will slough over them. In all cases the tips of the fingers or toes must be left bare in order that the state of the circulation in the part may be tested by pressing upon them. Strips of stout webbing with buckles are most useful for fixing splints be- fore applying a bandage. The movable-immovable and immovable appliances are made of plaster of Paris, tripolith, gum and chalk, starch, paraffin, egg and flour, silicate of soda. Splints of these materials become loose only by shrinking of the con- tained part; ordinarily they are applied once for all and are therefore called immovable. They afford uniform support to the injured tissues, and the fracture, once set, is not disturbed until it is united. But should cir- cumstances necessitate its occasional examination, many of the above materials may be used to form splints, which are removable at pleasure, and still retain the qualities above mentioned. Plaster of Paris is most generally employed. To apply it, the limb should be thoroughly washed, carbolized, and dried; then wrapped in one or more layers of boracic lint smoothly laid on. Loose muslin ("crinoline") band- ages, into the meshes of which plaster has been freely rubbed, are thoroughly INTERRUPTED PLASTER SPLINTS. 233 soaked in water, squeezed moderately dry, and rolled round the part without any pulling. When the lint is covered with one layer of bandage, long strips of tin, three-quarters of an inch wide, are placed at intervals all round the fracture, secured by two layers of bandages, and the limb held in posi- tion until the plaster has set----i. e., about ten to fifteen minutes. This answers admirably for simple fractures of the leg, and may be applied imme- diately except when, from direct violence or pressure of the fragments, sloughing of skin is probable, or when there is much and increasing swelling from extravasation, or a large artery has been torn ; or when any acute in- flammatory condition is present (Gurlt). Should the existence of small wounds or doubtful contusions render it desirable to examine a fracture from time to time, the Bavarian or book-back splint may be used. Suppose the leg is to be put up; cut two pieces of coarse flannel, each like two Cline's splints joined together behind and large enough to surround the leg and foot, with two inches to spare. Fasten them together by two rows of stitching, half an inch apart, along the mid line behind. Place them beneath the leg and bring together the inner by stitches along the front of the leg, dorsum, and sole of the foot. Thick plaster-cream is now rubbed in and spread smoothly over it to the depth of half an inch ; then the outer pieces are brought together firmly, pressed down on the plaster, and cut off close to the mid-line. When necessary, the stitches in front may be cut and the splint opened, the seam along the back acting as a hinge; it is reapplied with a bandage. Much less brittle splints are made by mould- ing to the limb several layers of muslin, or fewer of flannel or sacking, wrung out of water and then thoroughly steeped in plaster-cream. A plain bandage should be used to bind them to the limb whilst setting; it adheres to them, and when cut down in front acts as a hinge behind. Splints of almost any shape may thus be made; anterior, posterior, or lateral; when a considerable bend must be made, cut the layers partly through on each side, and interlace the flaps; the splint will be stronger if the cuts in successive layers do not correspond exactly. When the cuts in the bandage gape, interleave short bits of soaked bandage. Such splints may be rendered waterproof by frequent painting with shellac varnish or hot paraffin, and the absorption of urine or discharges prevented. But when a wound is to be left uncovered from which much discharge is expected, or which is to be treated antiseptically, a window cut in the splint will usually be insufficient; a break must usually be made. This is bridged over by two or more pieces of hoop iron or stout telegraph wire, held between the layers of bandage above and below the wound, and bent out into brackets opposite the gap, so that the dressing and bandages may pass easily beneath them. Projecting loops made in the anterior wire are often used for slinging the limb. If the part is heavy, plaster must be used for the splint; but if light, bandages steeped in paraffin, setting a little above the body-tempera- ture, will answer well. In either case the angle between the skin and splint should be caulked with a little wool, painted freely with hot paraffin. After the early application of immovable splints, it is well to raise the limb for twenty-four hours, to aid the splint in arresting swelling. The fingers or toes should be carefully watched; if they become bluish, cold, numb, and swollen, and blood driven from matrix of nail returns slowly, the splint should be at once cut up; pain may be slight or absent though gan- grene is commencing. The surgeon should always see the patient in six hours. When there is a tendency to longitudinal displacement plaster cannot be relied upon to prevent it in the thigh or arm, as there is no bony point above 234 INJURIES AND DISEASES OF BONE. upon which it can hold. Such cases should be otherwise treated till the ten- dency to displacement is over, when the permanent splint may be applied. A patient with a bad fracture is best kept in bed until pain and swelling have subsided. Many fractures of the upper limb may, however, be treated without such confinement. Fractures of the lower limb must be kept at rest (unless due to very slight violence) for three or four days, until it is certain that serious swelling is not going to occur beneath the splint; and fractures of the femur are best kept in bed until the tendency to displacement and shortening is over—i. e., three to four weeks. They may then get about on crutches with the leg slung from the neck. At the expiration of four to six weeks in the upper, and five to ten in the lower, the bone is carefully examined for abnormal mobility, and tested as to its power of bearing weight or strain. The examination proving satis- factory, splints are replaced by a flannel bandage, and the patient is allowed to begin to use his limb, crutches being given up, in the case of the lower extremity, as the patient gains confidence in his limb. A few general points require mention. Thus shock may require treatment (p. 166); retention is common after injuries of the lower limb and requires the catheter; constipation due to confinement may require attention. If pain and starting are troublesome during the first few days, opium in grain doses, once to thrice daily, is the best remedy. Course of a Simple Fracture.—When a recent fracture has been well put up, pain soon subsides; some swelling forms at the seat of injury, and perhaps a few bullae rise. In a week or ten days these subside, the skin be- coming discolored by blood-coloring matter soaking into it, and swelling due to callus round the bones is revealed. After most severe fractures there is slight fever, beginning within six hours of the accident, reaching its maxi- mum in twenty-four to forty-eight hours, and lasting three to ten days (Horsley). This is the purest traumatic fever; it is more marked in the young than in the old, rarely rises much above 100°, and appears to be due to irritation of sensory nerves, and to absorption of blood-ferment and of pyro- genous bodies resulting from simple inflammation, the more prolonged forms being associated with a good deal of swelling. Similar fever results from severe contusions without fracture. It does not disturb the general state. In all cases some fat-embolism probably occurs ; the droplets of fat, liberated from the crushed marrow and subcutaneous tissue, enter lymphatics and veins, and are carried by the blood current to the lung arterioles and capil- laries first, then to those of organs beyond. Many of the little masses reach the kidneys, and Riedel states that he found fat free in the urine about the third or fourth day in forty-two per cent, of the cases he examined, and it may be found again at the tenth to fourteenth day; in the first few days a little albumen and casts, especially a peculiar brown granular cast, were often present (D. Zeitschr. f. Chir., vol. x. p. 539); but in a considerable number of simple fractures examined at University College Hospital, I failed to detect fat, and albumen and casts were rarely met with. Horsley speaks similarly. Complications of Simple Fracture.— Comminution, multiple fracture, fracture higher up in the same limb, increase greatly the difficulties of treat- ment, but require no special notice; dislocation of a fractured bone will be noticed later. The extension of fissures into joints leads to effusion of blood and inflammatory fluid, which are generally absorbed without trouble, but the patient should be warned that impaired movement may remain ; sometimes strumous arthritis starts after such an injury. The soft parts may be much injured by direct violence, or by the sharp fragments in cases due to indirect force. So long as the skin and great vessels remain sound, such laceration, COMPLICATIONS OF SIMPLE FRACTURE. 235 and the swelling which results, are not very serious ; but if the skin is killed, or abraded or wounded over an extravasation which extends with little inter- ruption to the fracture, the probability is that the latter will become second- arily compound. The later this occurs the less serious is it, as formation of granulation tissue will be more advanced and will diminish septic absorption. But sepsis should be prevented by putting up aseptically all cases in which the skin is injured. The results of extensive subcutaneous laceration are swelling, ecchymosis of the skin, and formation of bullae; they are best pre- vented by elevation and uniform gentle compression with wool, outside which splints may be applied. Bullae should be pricked, dusted with iodoform, and covered with salicylic wool. Wound of a main artery and formation of an arterial haematoma is a rare and serious complication, most common in fractures of the femur low down (popliteal) and of the tibia high up (post. tibial), the vessels at these spots lying close to the bones. The vessel may be wounded at the time of the accident or later. An artery may be simply bruised, and thrombosis result; or it may be torn across and not bleed ; or it may be torn completely or incompletely across and bleed into the tissues. A deep diffuse swelling then forms, and at first increases rapidly, and the signs of superficial extravasation may also be present; the limb below becomes cold, pale, swollen, and numb, and pulsation is absent in the distal portion of the main artery. When extension becomes limited by coagulation and resistance of the tissues, a cavity remains round the torn ends of the vessel, and here some thrill or pulsation often develops (arterial haematoma, trau- matic " aneurism "). The chief danger of this complication is that it may lead to gangrene of the limb, by interruption of the arterial supply and by pressure on the veins; and laceration of numerous small vessels, most likely to occur from direct violence, will much increase the difficulty of maintain- ing the circulation. As to treatment, in early cases, elevation and compres- sion of the main artery for half to one hour may be tried with a view to limiting the extravasation, the part being wrapped in wool. If a localized haematoma result, the fracture must be treated as usual, and the complication may disappear under the necessary rest and compression. Should it not do so, digital compression of the main trunk has succeeded in several cases. Failing this, wait until the fracture is united; then the most certain treat- ment is the laying open of the sac and ligature of the artery above and below ; but ligature of the main trunk has been successfully done when cir- culation in the limb has been reestablished. If, however, swelling increase so that gangrene is imminent, the modes of treatment are two: (1) laying open the extravasation freely (see "Traumatic Aneurism"), turning out the clot and tying all bleeding vessels ; or (2) amputating. Amputation is a last resource, and should be done when the artery and vein are both injured, or when extensive injury of soft parts is also present. Some surgeons say that amputation must be done in rupture of the popliteal, whilst an attempt may be made to save the limb when the post, tibial is injured ; but collateral circulation should be established after relief of pressure and ligature of the popliteal, unless the soft parts are much injured. Operations for ligature of deep arteries under such circumstances are extremely difficult, so the sur- geon must be prepared to amputate in case of failure, and make his incisions accordingly. Gangrene of the limb after simple fracture may result from the original injury to the soft parts, everything beneath the skin being crushed; from diffuse inflammation starting from a wound ; or from pressure of extravasa- tion, especially when the main artery is ruptured; or from occlusion of an artery by pressure of an irreducible fragment. In these cases the surgeon will probably not be to blame ; but it may go hard with him before a jury 236 INJURIES AND DISEASES OF BONE. if it appear that gangrene has been caused by too tight application of appa- ratus, by strangulation by a bandage put on beneath splints—the limb having swollen subsequently—or by flexion of a limb after the application of a bandage. Amputation is the remedy. Contusion or laceration of large nerves is rare (Weir Mitchell, Injuries of Nerves, p. 104) in simple fractures; there is most danger of it in fractures of the middle of the humerus (musculo-spiral), and of its inner condyle (ulnar). Unless division is complete or pressure permanent recovery is perfect. Exer- cise the muscles daily with the constant current. Considerable edema from thrombosis of large veins sometimes appears; and, rarely, the phenomena of slight or fatal pulmonary embolism arise, from detachment of clot3 and their carriage into the right heart. The clots may be small or several inches long, with impressions due to the valves of the vein in which they arose; in the latter case they block the main trunk or primary branches of the pulmonary artery. In fatal cases the symptoms are: sudden praecordial distress and sense of great alarm, pallor or cyanosis whilst air is entering the lungs freely, rapid feeble pulse, and a cold sweat breaks out before death ; sometimes the patient feels the clot pass from its site of origin up to the chest. In milder cases the above symptoms may be less marked, and followed by deeply blood-stained expectoration; rarely the dulness of a large hemorrhagic infarct is detected. Fat-embolism has been regarded as a cause of early death—a rare event— after simple fractures, the symptoms being dyspnoea with rales, more or less shock, low or depressed temperature, and death resulting from coma; post- mortem small ecchymoses are numerous, and there is great oedema of the lungs. Cohnheim and others doubt that fat-embolism ever produces the above symptoms, for large quantities of fat may be injected into the circula- tion in animals without any serious symptoms ensuing. Traumatic delirium or delirium tremens is common; the patient does not sleep during the first night or two, and then the characteristic symptoms set in (p. 166). The fracture must be securely put up, if possible, in apparatus which will move easily with the limb, for the patient turns and twists this about in all directions, and often would stand on it if allowed. The limb may be swung, but should not be tied down. Suppuration and necrosis of fragments are extremely rare, unless the skin is severely injured. It has occurred, however, without obvious reason ; more often a septic wound or foul ulcer has existed elsewhere, or the patient is suffering from pyaemia or other acute infective fever, or delirium tremens. The diagnosis of suppuration is usually easy. Early antiseptic incision and thorough drainage would usually be the treatment, but amputation may be required. Results of Simple Fracture.—In the vast majority of cases sound bony union takes place, and the patient recovers with a limb able to perform its functions. The time required for union varies from three to ten weeks, with the age of the patient, the size of the bone, and the seat of the fracture; being shorter in the young, in the smaller bones, in the face than in the upper limb, and in the upper than in the lower limb (Malgaigne). In cer- tain fractures, fibrous union is the rule—e. g., of the acromion, coracoid pro- cess, and transverse of the olecranon and patella, the cause being separation and mobility of the fragments; the bond of union may from the first be so long, or become so later by stretching, that, in the cases of the olecranon and patella, power of extension is lost. In other cases no union may occur; for causes, etc., see p. 241. On the other hand, the formation of callus may be excessive, especially when the fragments are much displaced. Lastly, callus may soften after apparently firm union has taken place, and re-fracture COMPOUND FRACTURES. 237 occurs; this is generally due to the onset of an acute fever or inflammation, or scurvy. For a time, especially after middle age, the limb often remains cedematous, wasted, dry and brawny, and much affected by cold, change of weather, etc. —symptoms which are best treated by cold douches, regular friction, mas- Bage, exercise, and careful bandaging. Wasting is usually slight; it affects all the structures, and may be permanent; its causation then is not under- stood. Shortening and more or less angular union are common. In the latter case it may still be possible under anaesthesia to bend the bone straight; if not, and the deformity requires remedy, subcutaneous osteotomy should be done. Stiffness of joints is common, especially in the old and rheumatic, and in fractures extending into joints or in their close neighborhood. It is due to adhesions from arthritis, to displacement of fragments, to growth of callus, and sometimes to matting of muscles and tendons around the fracture. Much may be done by warm douches, massage, and forcible or gentle passive movement. After separation of an epiphysis, ossification of the growing cartilage may occur and increasing shortening of the limb result. Paralysis of motion and sense of great and persistent pain may result from the involvement of a nerve in callus. The musculo-spiral as it winds round the humerus is the nerve most likely to be thus involved. The sheath of callus has been opened with a chisel and the nerve freed, with disappear- ance of the symptoms as a result. COMPOUND FRACTURES. Definition.—Fractures in which a wound of the skin and soft parts communicates with the broken bone. CAUSES.-'-Fractures may be rendered compound (1) by the same violence which breaks the bone; (2) by the thrusting of a fragment through the skin; (3) by subsequent ulceration or sloughing of the soft parts—second- arily compound. Varieties.—These are obviously the same as in simple fracture; the most important are the compound complicated, characterized by much lacera- tion of soft parts, with extensive subcutaneous hemorrhage; laceration of large vessels; comminution of bones, or Assuring into joints. Diagnosis.—The signs of fracture are usual; and in addition, the frag- ments may project from the wound, or a finger may be introduced and the bone carefully examined; the nail is most useful in detecting a fissure. Slight oozing from the vessels of the bone often goes on for hours without any large vessel being torn. Sometimes air is sucked into the connective tissue of limbs, producing emphysema, recognized by swelling and soft crepi- tation ; more often, air in the tissues indicates a communication with the respiratory or alimentary tract; it deposits any germs it may contain close to where it enters. Dangers.—The immediate are due to shock from the frequently great violence of the cause and the amount of injury done to the soft parts; also to the possibility of serious hemorrhage from large vessels. But the exces- sive mortality after compound fractures is due chiefly to the occurrence of wound diseases, especially cellulitis, diffuse suppuration, erysipelas, acute osteomyelitis, spreading traumatic gangrene, septicaemia, and pyaemia; and to the results of chronic suppuration, hectic, exhaustion, and albuminoid degeneration. The wound may be a mere puncture or a very extensive cut or tear. 238 injuries and diseases of bone. Healing may occur under a scab, when the fracture is immediately con- verted into a simple one, or it may occur more slowly, but aseptically, under appropriate treatment, the course being almost as uneventful as that of a simple fracture; or the wound may become more or less aseptic, and then the door is open to the above-mentioned diseases. In the latter case there are more or less septic inflammation and septic traumatic fever, the latter usually subsiding as suppuration is established; but hectic fever may follow when pus burrows or bags in the limb. A frequent result of this inflamma- tion is the necrosis of fragments which would certainly have lived in simple fractures, and the separation and elimination of these may occupy months or years; operations are frequently required for their removal. Rarely dead fragments heal in, and suppuration occurs round about them after years of quiescence. It will be seen, therefore, that the course of a septic fracture is full of anxieties, and a very large number of such cases formerly died. Treatment.—The first point to decide is whether amputation is or is not necessary. The question is often a difficult one; but the operation must be performed in cases in which, (1) from damage to vessels and soft parts, cir- culation in the part beyond cannot be maintained ; or (2) in which destruc- tion of tissue is so great that healing either could not take place or would leave a useless limb. In other apparently less grave cases—viz., those of (3) extensive comminution and Assuring of bone, especially if (4) involving a large joint, everything will depend upon whether the parts can be rendered and kept aseptic, or fairly sweet, and most completely drained. As a rule, in hospital practice, it will scarcely be safe to trust to the latter chance. Amputate, unless it is probable that antiseptics will succeed ; but in private and in the country more liberty may be allowed. In civil practice, when- ever there is any doubt about the propriety of amputating, give the patient the benefit of it by rendering the part aseptic, and waiting; in military sur- gery the contrary seems to be the best rule—amputate when in doubt. In all cases the health, strength, and age of the patient, and the resources of the surgeon as to time, nursing, nourishment, etc., must be carefully con- sidered ; in the field, also the necessity for moving the patient long dis- tances. Lastly, injuries of the upper limb may often be treated conserva- tively when similar damage to the lower would imperatively demand amputation. Primary amputation should be done as close to the seat of fracture as pos- sible. It is often difficult to decide whether skin near the injury will, or will not live, and consequently it is no uncommon thing for bits of the flaps to slough. The surgeon must use his judgment in each case. If the soft parts above are extensively infiltrated with blood, the strictest antiseptic precautions and fullest drainage will be required to prevent suppuration and sloughing. If there be a simple fracture close above a compound about which suppuration occurs, it is likely to become secondarily compound. In determining where to amputate in these cases, the surgeon must consider the state of the parts between the compound and simple fracture, the antiseptic precautions which he can take; the less perfect the latter, the slighter the injury which will cause him to amputate at the higher rather than at the lower fracture. Conservative Treatment.—If it is decided to make an attempt to save the limb, the wound must be treated according to the general principles laid down at p. 173. The necessity of keeping the wound aseptic often renders difficult the treatment of the fracture. The clothes having been removed, the wound should be covered with a guard whilst the limb is carefully cleaned with soap and water. Meanwhile, whatever apparatus is required ANTISEPTIC TREATMENT OF COMPOUND FRACTURES. 239 must be prepared, and the spray got ready if it is to be used—we ourselves should employ it. Then the limb is thoroughly disinfected for at least eight inches above and below the wound. The latter may now be examined with the finger, and a decision come to as to the treatment of fragments in cases of comminution: those which are quite loose should be removed, but those which are still attached by soft parts may be left. -If the wound becomes septic, however, those from which the periosteum is widely separated will probably die, and may therefore be removed at once where antiseptics cannot be employed. Fragments of bone may be carried far from the seat of frac- ture, especially in gunshot injuries. Of course, bullets and all foreign bodies must be carefully removed. Hemorrhage from the bone is often troublesome, oozing sometimes continuing even for days; vessels in soft parts may also bleed. Elevation acts well in slight cases ; but if the bleeding is at all free, enlarge the wound, and examine it carefully, turning out the ends of the bone so far as this can be done without stripping the periosteum from them ; tie any vessel which can be seized, use some hot antiseptic for general oozing, and for a vessel in the bone it may be possible to plug its canal with septic gauze or wool; the cautery should not be used if it can be avoided. If pressure be applied, see that good drainage be provided, lest blood be forced widely into the tissues. Wounds of large vessels, especially a main artery, will be evidenced by the escape of blood from the wound; or, if this is small, by the formation of a haematoma, with weakening or cessation of pulsation in arteries below. The vessel or vessels must be tied (perhaps through a counter-opening); failing this, amputate. This operation must be done when both femoral artery and vein are torn. Now disinfect the wound, using 1 in 20 carbolic, or 1 in 1000 sublimate lotion if the case is seen within an hour or two and has not been subjected to septic examinations. One of these fluids must be squirted into every recess of the wound by means of a syringe to which a piece of gum elastic catheter is attached by rubber tubing. To insure its reaching all parts of the surface, the wound may be closed round the catheter ; but little distend- ing force must then be employed lest the fluid be driven into the areolar planes, and, being retained, excite inflammation there. In case of prolonged exposure the wound must be treated with a 1 in 5 solution of carbolic in alcohol, chloride of zinc, gr. xx-xl ad gj, or sublimate lotion 1 in 500. If thoroughly septic and inflamed even these remedies will probably fail. Then the freest drainage and immediate drying or disinfection of all discharge must be chiefly relied on. Thus, in a case of compound fracture of the lower third of the femur, with a fissure running into the joint between the condyles, antiseptics failed, and on the second day the temperature was rising fast and the limb swelling. I made a free incision down to the fracture on each side of the limb, passed a large tube across, and laid open the knee-joint, the result being recovery, with little fever and no necrosis. Drainage must be free in proportion as sepsis is intense, and in all cases it is well to err on the side of too free drainage; the case may become septic in spite of our best endeavors. The wound being now aseptic, the fracture must be reduced. To this end, it may be necessary to enlarge the wound, or to cut off a projecting piece of bone bare of periosteum. In all cases in which there is any difficulty in pre- venting displacement, the fragments should be wired, the wire being cut short and hammered down in aseptic cases. The wound, if large, should now be carefully sutured, ample provision for drainage being made. A reliable form of antiseptic dressing must now be applied—gauze, wool, jute, moss, etc.; in bad cases, the difficulty is to obtain room for a dressing 240 INJURIES AND DISEASES OF BONE. of size sufficient to deal with the discharge, and at the same time to obtain such a hold upon the limb as will fix the fragments. A large gauze dressing is the best in bad cases for the first two or three days, splints being applied outside this; whenever necessary, the bandage is cut, the dressing opened, the limb raised by the surgeon, who maintains extension with a hand on each side of the fracture, the old dressing is removed, the fresh one slipped in, and the limb lowered on to it. Thus the disturbance is reduced to a minimum. The splints used in these early days are those employed in similar simple fractures. When the free discharge which results from the injury and treat- ment is over, it may be possible to use some immovable interrupted or fenes- trated splint (p. 233), and to combine it with some form of lasting dressing. In France, A. Guerin's " pansement ouate" has been largely used. The part, having been thoroughly disinfected, is wrapped in a large quantity of cotton-wool, and bandaged at first loosely, then more and more tightly until as much force as a man's arm will bring to bear is used. By this time the wool should have been compressed to a layer not less than two inches thick. The limb may now be shaken without causing pain, and the advantage of such perfect fixation when a patient must be carried long distances, as with a retreating army, is very great. But an ordinary cotton-wool dressing is not a guarantee against septic disease; to render it so, the dressing must be impregnated with an antiseptic; and wool may with advantage be replaced by some more absorbent substance, as dry moss or peat. Such a dressing is intended to be a permanent one. Its disadvantages are, the difficulty in maintaining the proper relation of the fragments during all the bandaging, and the great bulk of the necessary materials. It was formerly a frequent practice, in cases of compound fracture, with only a small wound caused by protrusion of a fragment, to close it with lint and collodion or tincture of benzoin, or steeped in blood and allowed to dry on. Most of the cases were at first converted into simple fractures by this artificial scab; but a few had already become seriously infected, and inflam- mation resulted. Consequently these small wounds should always be disin- fected and covered with a small antiseptic dressing of some kind, which need not be changed if it does not come through. Serious cases may be success- fully treated by occlusion (p. 199). In septic cases the temperature must be closely watched for the indications which it gives of imperfect drainage and formation of fresh abscesses. Open- ings must be enlarged and counter-openings made; but should the patient fall into a hectic state, a secondary amputation should be done and the limb removed. This operation should not be too long postponed. Experience has shown that amputation (intermediate) during the period of high septic traumatic fever is very fatal; having missed the period for primary ampu- tation, many think it best to temporize until suppuration is established. But this is doubtful, for it is scarcely fair to compare the relative mortality after intermediate and secondary amputations in the treatment of compound frac- ture, so many cases die before reaching the period of suppuration. At all events, in cases in which the patient seems in imminent danger of death from acute septicaemia, especially accompanied by spreading suppuration or gan- grene, amputation must be done without delay. In these cases supporting treatment must be given from the first. The patient may be allowed to get up and about as soon as there is no danger of displacement or of disturbance of the dressings. Sequestra come away now and then, but often remain embedded in callus, keeping sinuses open for many months after the patient has begun to use the limb. When sufficient time for the separation of the sequestra has elapsed, an operation should be undertaken for their removal; they are sometimes extremely difficult to find. NON-UNION, FIBROUS UNION, FALSE UNION. 241 Delayed Union, Non-union, and Pseudarthrosis.—In some cases union of the shafts of long bones is delayed for several weeks; in others even after months there is no attempt at union; in others again the bones are bound together by fibrous tissue, which may form a shorter or longer, loose or dense band, perhaps partly ossified (fibrous union, Fig. 67), or it may be arranged as a capsule uniting the fragments which are smooth, covered by dense fibrous tissue or by true cartilage (false joint). In the latter case one end is generally hollowed out and enlarged, the other convex, so that the joint is of the ball-and-socket variety (Fig. 68). The capsule secretes a lubricating fluid, and may become studded with papillary growths, and these may become loose bodies in the joint. In cases of delayed union, at the usual time for removal of the splint the bones are found still loose and incapable of bearing strain ; but in the course of a few weeks, if the fracture is put up again firmly, union takes place as usual. This delay is not uncommon after compound fractures of leg in which Fig. 67. Fig. K/0& Fibrous union, partly ossified, of lower end'of femur. False joint of tibia and fibula, showing ends of frag- ments and capsule. the wound has healed early. The same state of matters may continue for months or years, but there is no pain or tenderness. In close fibrous union the patient may retain considerable power over the limb, but in false joint and non-union the limb is flail-like. On the whole, the condition is un- common. Agnew has collected 630 cases, of which 219 (34 per cent.) were of the humerus, 180 (28 per cent.) of the leg bones, 155 (24 per cent.) of the femur, 76 (12 per cent.) of the forearm bones. It is very rare in childhood, most common in the prime of life, old age having no special influence. As general causes, may be enumerated debility from starvation, hemorrhage, lac- tation, or disease, especially an acute fever; severe syphilis; pregnancy, the influence of which is very doubtful. Local causes are wide separation of the fragments; actual interposition of a piece of muscle, tendon, or other substance, which is probably frequent; imperfect fixation. Defective blood supply, owing to fracture through the course of the nutrient artery and consequent impaired nutrition of the fragment towards which it ran, has been mentioned as a cause, though a priori it does not seem a likely one. Curling thought he had found this fragment atrophied; G'urlt, however, was unable to detect any difference in Curling's specimens. Defective innervation is said to have an influence, when the fracture is cut oft from connection with the spinal 16 242 INJURIES AND DISEASES OF BONE. centres whence its nerves spring, by injury to either the centres or the nerves; Bognaud (" Sur l'influence de quelques lesions du systeme nerveux sur la for- mation du cal." These de Paris, No. 370,1878) gives six cases of fracture of both bones of the leg or of the fibula only, accompanied by complete para- plegia from fracture of the spine at or below the twelfth dorsal, in which no union occurred; but when the spinal lesion was higher up, more or less com- plete union occurred. The existence of disease of bone, due to new growth, syphilis, osteomalacia, fragilitas ossium, may delay or prevent union ; in many of these cases it occurs soundly and quickly. In compound fractures the retention of necrosed fragments, over which the skin may heal, is a not uncommon cause. Treatment.—Combat any unfavorable general condition; try change of air. In cases of delayed union pay special attention to the fixation of the limb; sometimes, when the leg is firmly put up, union is hastened by allow- ing the patient to use it a little whilst walking with crutches, and thus to irritate the fragments somewhat, or he may walk without crutches if the fragments are fixed by a good apparatus. The constant current has been recommended. When the case has passed into the class of ununited fracture, the patient may be anaesthetized, the fibrous tissue snapped by bending the limb to a right angle in various directions, and the ends then rubbed freely together. Or, H. Thomas's operation of percussing the bone ends with a copper mallet for five to ten minutes, whilst the skin is protected by a thick piece of felt, may be tried; the limb is then put up firmly for four to six weeks. Repeat the operation if callus does not seem to be forming. Subcutaneous section of the fibrous tissue, or passage of a seton or needles through it, is not to be recommended; so, as further treatment necessitates the production of a compound fracture, it must be considered whether the inconvenience justifies the risk, which varies with the surgeon's ability to maintain asepsis. Should an operation be determined upon, the best is to cut down upon the fracture from that side which permits easiest access, the muscles being spared as much as possible. The fibrous tissue between the fragments must be divided or removed; it must be remembered that large, even main, vessels are sometimes adherent to this fibrous tissue. Each end is then turned out of the wound, and its surface freshened by forceps or saw —the two surfaces being so cut as to fit closely together. The ends must Fig. 69. Volkmann's operation. then be drilled and secured to each other by one or two sutures of the stoutest silver wire drawn very tight, secured as in Fig. 44, the ends cut short and hammered down. Ivory, or (better, because more easily absorbed) compact bone pegs may be driven through both fragments when they tend to over- ride (Fig. 69). These operations must be done antiseptically, the wounds thoroughly drained, and the limbs fixed by some interrupted immovable apparatus if possible. In united fractures of the forearm bones it is sometimes found that the lower fragments have fallen together, and no efforts can draw them apart PARTICULAR FRACTURES. 243 to meet the upper; the ulna, as the more important bone, should then be united. Cases of angular union may be re-fractured, if they yield to force which will not seriously injure the soft parts. When the union is too stout for this, antiseptic osteotomy with a chisel may generally be done, and the new fracture must be properly treated. Amputation may be required to remove a useless limb. PARTICULAR FRACTURES. Where nothing is said concerning the symptoms and diagnosis of special fractures, it is implied that there is nothing to add to the preceding general remarks. 1. Fractures of the Ossa Nasi are frequent on account of their exposed position ; usually compound and comminuted, rarely involving one bone only. Deformity is often great, but masked at first by swelling; hemorrhage from the nose may be free or absent; emphysema may result from blowing the nose. These fractures may extend into the nasal processes of the superior maxillaries, and rarely to the cribriform plate, opening the door to septic meningitis; the septum is frequently broken, and its support lost. Treatment.—Whenever suspected, a careful examination of the inner surfaces should be made for the detection and reduction of irregularity; an anaesthetic or cocaine may be necessary. The reduction is best effected by Fig. 70. Fracture of lower jaw at eye-tooth. Madras Med. Col. Museum. the pressure of a steel director or similar slender strong instrument; it may be very difficult to keep the fragments in position, but plugs are said to be of little service; they are best made of antiseptic wool, and changed daily. Union occurs in two or three weeks; it is sometimes complicated by ab- scesses and necrosis of fragments. Should deformity remain, it may be re- lieved by operation. Emphysema requires no treatment; epistaxis nothing special. 2. Fractures of the Malar, rare; dislocation of it from its sutures very rare. Resulting from direct violence, the bone is usually driven in on the upper jaw and may interfere with the movements of the lower. It may be raised by a finger from the mouth; when firmly fixed, it is advised to make a 244 INJURIES AND DISEASES OF BONE. small opening in the skin, pass a hook beneath the bone or screw an elevator into it, and then raise it; it might be wired in place. 3. Fractures of the Superior Maxilla involving the body are rare, and result only from great direct violence. The bone may be separated from its fellow, or driven bodily backward toward the spine; any of the processes may be broken or the antral wall depressed. Diagnosis is generally easy, union rapid, and necrosis rare in compound cases. It may be difficult to prevent recurrence of displacement: wiring teeth, or fragments of alveolar processes, is often of great use; so also is fixing the lower against the upper jaw, especially after the teeth of the latter have been fixed in a gutta-percha trough. Use chlorate or permanganate of potash washes for offensive dis- charges into the mouth. 4. Fractures of the Lower Jaw are caused by direct violence and may occur at any point. Of 143 published cases, 80 were single, 49 were double, and in 14 there were more than two lines of fracture. Of 80 single ones, 5 affected the alveolar processes, in 25 the fracture affected the symphysis, in 22 the incisor region, in 15 it ran among the back teeth, in 8 behind the teeth, and in 5 through the neck (Gurlt). But published cases of so common a fracture are likely to be selected; and it would seem that the above figures place fractures through the symphysis and neck too high. Double fractures are often symmetrically placed on each side of the mid- line. Symptoms.—Pain, swelling, crepitus, inability to use the jaw, mobility of fragments, and usually bleeding from the gums, loosening and irregularity of the teeth. In cases of double and multiple fracture, the displacement may be very great; in single fractures of the body Fig. 71. it is slight, also of the ramus, because of the attach- ment of the masseter and pterygoid to both frag- ments ; in fracture through the neck, the external pterygoid may drag it forward. It is rare for the inferior dental nerve to be torn, and still more rare for permanent anaesthesia of the skin to result. Treatment.—See that no tooth has slipped down between the fragments; replace loose or dislocated teeth and fix them to secure neighbors. When dis- placement is absent or slight, cut a piece of paste- a, shape of pasteboard splint; board, gutta-percha, or poroplastic wide enough to b, side-view of the splint as ap- reach from the hyoid almost to the red border of the plied; the longer piece to the lip^ to the shape here given (Fig. 71, a), soften it in base of the jaw, the shorter one ^yj watef an(j fifc j ^ • , ; fc doubled back under the chin, *iv n . i • if 1 i 1 and its ends brought up on mental slips flat on the jaw before the submental eithei side. are doubled up along the rami. Fix the splint with a bandage of equal width, one and one-half yards long, and torn into four tails except about eight inches in the middle ; tie the two anterior tails over a pad of lint just below the occiput, the two lower tails in front of the sagittal suture, and lastly knot the four ends together near the vertex. The lower is thus firmly fixed against the upper jaw, and uniform pressure is kept up along the bone; when there is a large gap from loss of teeth, insert a piece of moulded gutta-percha of proper thickness. In all cases where there is the least difficulty in preventing displacement, or in which it is desirable to avoid the above uncomfortable apparatus, the frag- ments may be wired, as specially recommended by H. Thomas (" Fractures of the Lower Jaw "). Wire fa of an inch thick is used. It may be suffi- cient simply to pass it between firmly fixed teeth on either side, forcing them apart if necessary; or a loop may be thrown over a tooth in one fragment FRACTURES OF THE JAW. 245 and its ends passed through a hole drilled between teeth in the alveolar pro- cess of the other (Fig. 74); or the alveolus of each fragment may be drilled. Thomas tightens the wire by screwing up each end with a twister (Fig. 73, a), and the tightening must be repeated by re-introducing the twister when- Fig. 72. Four-tailed bandage for dressing wounds on chin and fractured jaw. ever mobility appears. In the second method (Fig. 74) one end of the wire is passed twice from without in through the same hole, but in the third, one has to be passed from within out. This is effected by sticking it into Thomas's hollow needle (Fig. 73, b), introduced from without through the hole and then withdrawn with the wire. For drilling the bones, Thomas uses a watchmaker's bow-drill, and does not find anaesthesia necessary. The cure is complete in five or six weeks; pseudarthrosis is rare. Fig. 73 a, twister; b, hollow needle. After Thomas. Fracture of jaw, wired after second method. After Thomas. The discharge into the mouth from compound fracture is often very un- pleasant, and the breath offensive. Frequent washing with dilute Condy's fluid or chlorate of potash, or alum lotion, gives relief; and iodoform may be applied with a brush. 246 INJURIES AND DISEASES OF BONE. Abscesses not unfr/quently form at or near the fractured points, often with necrosis. They should be opened early to prevent burrowing under the fascia and down the neck. Loose portions of bone should be removed when they are quite detached. The patient for the first fortnight must be fed entirely with broth, gruel, bread-pap, etc. Fracture of the Clavicle is generally oblique, and caused by indirect violence, falls on the hand and shoulder; but sometimes it results from direct violence, especially toward the acromial end, and is then usually transverse; muscular action is a rare cause. In children it is frequently incomplete. It may be situated at any point; but is most common toward the outer end of the middle third, next toward the acromial end, rarely in the sternal third. Symptoms.—The clavicle holds the scapula out from the trunk, and the upper limb is slung to its outer end by the coraco-acromial ligaments. When the bone breaks about its middle, the whole shoulder falls somewhat, and the point of the shoulder (acromial end of outer fragment) turns forward and inward, so that the distance from the sternum to the acromion is less than on the sound side. The patient cannot lift the arm, but supports it at the elbow with the other hand. The outer end of the inner fragment re- mains fixed by the sterno-mastoid and rhomboid ligaments; it may project beneath the skin owing to marked falling of the outer fragment. The ordinary signs of fracture are present. When the fracture is between the coraco-acromial ligaments, there may be but little deformity, and often little or no crepitus; but when external to the ligaments, deformity is usually marked, the outer end of the acromial frag- ment turning till it points directly forwards. The fracture is rarely comminuted, double, compound, or complicated, except from gunshot injury. The complications include a few cases of injury to the subclavian artery, resulting, after a few weeks, in the formation of an aneurism; compression or wound of the subclavian, internal jugular or other large vein by a displaced fragment, in either case perhaps leading to gan- grene, and in the latter characterized by great extravasation into the con- nective tissue of the neck; laceration of, or pressure on, the brachial plexus, causing paralysis (p. 44), usually partial and temporary , and emphysema, perhaps with haemoptysis from wound of the lung. It is difficult during life to exclude the coexistence of a fractured first rib and wound of the lung by it. These complications are almost always due to direct violence, and often to gunshot injury. Treatment of Simple Fracture.—The object is to keep the shoulder drawn outwards, backwards, and upwards; correction is sometimes needed chiefly in one of these directions. The clavicle is so superficial that very slight displacement or a small amount of callus constitutes a deformity. When it is very important to avoid this, the patient should be kept for one month lying flat on her back on a firm mattress, with the elbow fixed to the side and the head slightly raised by a pillow which must not extend down to the shoulders; she may be turned slightly towards the sound side. Union being tolerably firm, the patient may be allowed to get up, wearing some apparatus for one to two weeks. Union is complete in three to six weeks, and is almost always bony. Ordinarily, the best method is by Sayre's strapping. Cut two strips of stout strapping, each 3J inches wide or less, and long enough for the follow- ing purposes. Wrap the upper arm on the injured side in boracic lint wider than the strapping. Stitch or pin one end of the first strap round the arm, just below the axilla; now heat the strapping, and seizing both shoul- ders strongly draw back their points, whilst an assistant carries the strapping FRACTURES OF THE CLAVICLE. 247 across the back towards the sound side, then across the front of the chest and between the elbow and the side round again to the back, where the end is fastened by a stitch to the first part of the strap. By this strap the elbow should be drawn back somewhat behind the shoulder. The second strap starts from the front of the sound shoulder, crosses its point, and runs obli- quely down across the back to the point of the elbow; it then ascends in front of the forearm and hand laid flat upon the chest, to the point of the shoulder, and ends behind it; by traction on this strap after it has passed the elbow the latter is first raised and then drawn forwards, the loop of the first strap acting as a fulcrum and the shoulder passing back as the elbow comes towards the front. A third wide strap is sometimes applied round the forearm, elbow, and trunk; it keeps the hand from working out, and is therefore useful in children, but must not be drawn tight, as it tends to drive the shoulder towards the mid-line. The strapping may not need reapplying for one to three weeks. It sometimes irritates and brings out a crop of boils; Fig. 75. Fig. 76. "Three-handkerchief" treatoent of fractured clavicle. intertrigo in the fold of the elbow may be prevented by the free use of boracic ointment. When strapping is not to be had, several turns of bandage may be made to represent each strap. Treatment by figure-8 bandage and a thick wedge-shaped pad in the axilla is shown in Fig. 75. Place the pad with its thick end upwards in the axilla; draw back the shoulders by the figure-8 bandage; lever out the shoulder by a few horizontal turns round the elbow, and raise the shoulder well by a sling taking the elbow and forearm. Objections to it are that the pad if effectively used causes dangerous pressure on the axillary vein ; and that the figure-8 bandage presses directly on the fractured bone. The latter objec- tion applies also to the three-handkerchief plan (Fig. 76); two are looped round the shoulders and tied behind, leaving one end of the knot longer than the other. The long ends are then passed across the back and under Bandage for fractured clavicle. 248 INJURIES AND DISEASES OF BONE. the opposite loop, and finally tied together, forcibly drawing the shoulders backwards toward each other. The third forms a sling to support the elbow and forearm and bind them to the side. Many kinds of apparatus have been devised for fractured clavicle ; but no matter which is used, the patient should be told that slight irregularity will probably remain; it is often great in complicated fractures. Cases of willow fracture should be put up in Sayre's strapping; the trac- tion of this will considerably reduce deformity when this is present, and the fracture not seen till a week or so has elapsed. Fractures of the Scapula.—The body of this bone may be broken across, comminuted, or starred, by great direct violence; one case is known due to muscular action (Ranking's Abstract, vol. ii. p. 194). The symptoms are great pain in moving the shoulder ; crepitus detected by placing one hand flat on the surface, and moving the arm up and down pump-handle-wise; abnormal mobility upon grasping the lower angle and the upper part of the bone; and often some irregularity from displacement can be felt in compari- son with the sound bone. Compound fractures are generally from bullets, etc. Bony union occurs in four to six weeks, sometimes with much displace- ment ; movements good. Treatment.—Immobilize the scapula by a large pad and broad flannel bandage, fixing also the arm to the side; or strapping may be used to fix the scapula. Treat compound fractures as directed on p. 238. Fracture of the Neck of the Scapula, detaching the coracoid process and glenoid cavity, or the latter alone, from the rest of the bone, is so rare that its existence has been doubted ;x it is due to falls or blows on the shoulder. The symptoms are the following: The shoulder sunk, arm lengthened, acromion usually prominent, deltoid flattened ; the head of the humerus with the fragment may be felt in the axilla; the deformity is easily removed by pushing up the arm, when crepitus will probably be detected. Crepitus may be felt also on pressing the coracoid process, situate deeply below the clavicle, beneath the margin of the deltoid; but the line of fracture may run external to this process. Crepitus, easy reduction of deformity (although with great pain), and the ready occurrence of redisplacement, are the chief points of diagnosis between this accident and dislocation; whilst the fact that the head can be felt to accompany the shaft in all its movements nega- tives fracture of the neck. Bony union should occur in four to seven weeks, with good movement. Treatment.—Sayre's strapping, as for the clavicle. Sir A. Cooper rec- ommended the bandage shown at Fig. 73 with a smaller pad. To obtain elevation, the starched figure-8 bandage, mentioned under " Fracture of the Acromion," is useful. Fracture of the Acromion is common, and generally occurs through its tip in front of the acromio-clavicular joint; less often through its base ; up to twenty-five the epiphysis generally separates. Some cases of supposed fracture at the base are really cases of non-ossification of the epiphysis. This fracture may be due to direct or indirect violence; rarely to muscular action. Symptoms.—Flattening of the shoulder and more or less inability to abduct the arm, both most marked when the fracture is through the base; irregularity in the line of the spine ; abnormal mobility, easy removal of deformity, and perhaps crepitus on pushing up the arm. Treatment.—The object is to keep the head of the humerus pushed up against the acromion ; this is done by means of a figure-8 bandage, the upper 1 See a case by Mr. May, of Beading, Med. G-az., Oct. 8, 1842. Mr. Wormald possessed a specimen, now in the Museum of St. Bartholomew's Hospital. FRACTURES OF THE HUMERUS. 249 loop of which passes under the opposite axilla, crossing over a pad placed at the root of the neck on the injured side, while the lower loop passes down the back and under the elbow, bent at a right angle across the chest. Three or four of the concluding turns of the bandage are to be taken round the body, arm, and hand horizontally; it is well to use fixed dressings. Union is usually ligamentous, owing to the difficulty of keeping the parts in strict apposition. Fracture of the Coracoid Process is rare; caused by blows on the front of the shoulder, usually inflicting much other damage; sometimes by muscular action. Symptoms.—The patient is unable without great pain to execute the motions performed by the biceps and coraco-brachialis—that is, to bring the arm upward, inward, and forward; and motion and crepitus of the detached process may be felt by seizing and moving the tip or pressing upon it whilst the patient moves his shoulder. Thickness of fat or muscle, or swelling, renders the diagnosis very difficult. Union is fibrous, and may stretch considerably. Treatment.—The humerus may be brought forward and inward, to relax the biceps and coraco-brachialis, and confined to the trunk, with the forearm bent over the chest; but simple fixation of the arm to the side gives almost as good a result. Fractures of the Upper Extremity of the Humerus may run (1) through the anatomical neck, (2) through the line of junction of the epi- physis, (3) through the surgical neck, (4) the great tuberosity may be detached, (5) one and three may be complicated by dislocation of the head. (1) Fracture through the Anatomical Neck—i. e., within the cap- sule—is very rare, known to occur only in advanced life, due to direct violence, and difficult of diagnosis as there is little displacement. But, more often, the line of fracture leaves the anatomical neck, and runs through the tuberosities (one or both). There may be comminution from driving of the head into the cancellous tissue of the upper end of the shaft, one or both tubercles being split off; the head may be impacted in this position. Signs.—Impairment of motion and crepitus are the most reliable signs (R. W. Smith); shortening is slight, not exceeding half an inch, and there may be hard swelling anteriorly due to the upper end of the lower fragment displaced (1) by force applied to the outer aspect of the shoulder, and (2) drawn up and in by muscles. When the fracture is impacted, we rely chiefly on deformity. The arm is slightly shortened, the acromion projects more than usual, the shoulder has lost to a certain extent its roundness. In consequence of splitting off of the tuberosity crepitus may often be obtained when the shoulder is grasped with moderate firmness and the arm rotated. The head cannot be felt in the axilla, nor can the finger be pressed in beneath the acromion toward the glenoid fossa; passive movements are usually free, but painful. If the impaction is not firm, the deltoid may draw the shaft upward and considerably increase the shortening during the first weeks of treatment (Hutchinson, Med. Times and Gaz., 1866, vol. i. p. 247). (2) Fracture at the Line of Junction of the Epiphysis.—The epi- physis includes the head and both tuberosities, and usually unites at twenty. This fracture is fairly common. Many cases have resulted from fracture by the finger in the axilla during labor, others from falls or violent pulls up and out upon the arms of children ; later it is usually due to great and direct violence. Signs.—The head of the bone can be felt in the glenoid cavity (by which sign this accident is distinguished from dislocation); it remains motionless 250 INJURIES AND DISEASES OF BONE. Fig. 77. when the elbow is rotated, and is sometimes so displaced by the scapular muscles that its lower surface looks forward and outward; the fingers cannot be pressed in toward the glenoid fossa, immediately beneath the acromion, but they enter a depression about 1 i inches lower down; there is a striking and abrupt projection beneath the coracoid process, caused by the upper extremity of the shaft of the bone drawn in by the muscles constituting the folds of the axilla. It is rounded, smooth, and slightly convex, not with the sharp irregular margin of ordinary fracture. Slight extension from the elbow draws the lower fragment into its natural place and crepitus may be obtained ; but the bone immediately projects again when extension is discon- tinued ; the axis of the arm is directed downward, outward, and backward, the elbow being a little from the side ; shortening is considerable. (3) Fracture of the Surgical Neck—i. e., of the bone between the epiphysial line and the insertions of the pectoralis, teres major, and latis- simus (Fig. 77)—is by far the commonest fracture of this part of the bone; it occurs at all ages, and may be caused either by direct or indirect violence. The signs are those of the preceding variety, but crepitus is rougher; the lower fragment often lies more deeply in the axilla, and causes more pain by pressure of its sharp end upon the brachial plexus; much swelling from extravasation is common. The lower fragment may be impacted into the can- cellous tissue of the upper, rendering the diagnosis much more difficult. The signs are slight shortening, (half an inch or so), some deformity, and perhaps crepitus if the head be grasped firmly whilst the arm is rotated, pain at a part not directly injured, and loss of power. Seri- ous injury of the large vessels and nerves from this fracture is almost unknown. It is rarely compound, unless due to gunshot. (4) Fracture of, the Greater Tuberosity is caused by blows or falls on the shoulder, by violent action of the scapular muscles, or the process is left behind in dislocation of the head. Signs.—Increased breadth of the injured joint; the head and neck of the bone are drawn forward and inward by the axillary muscles, whilst the separated tuberosity is drawn outward by the supra- and infra-spinatus and teres minor; a groove may be felt between the tuberosity and the head of the bone, the latter moves with the shaft, and crepitus is obtained if the fragments are pressed together; the whole limb can be moved in any direc- tion by the surgeon, but active rotation out is quite lost. Mode of Union.—All the preceding fractures usually unite firmly by bone, even fracture of the anatomical neck; for, though this fracture would seem likely to deprive the head of the bone of vascular connection, some ligamentous bands, sufficient to prevent this, usually remain untorn; in cases of impaction there is no difficulty. The patient should be informed that some deformity and loss of motion are likely to remain, though time and use will go far to restore the latter; also that growth may be impaired after separation of the epiphysis. Repair occurs chiefly from the lower fragment, and callus is often excessive. Even should the head remain loose, there is no ground for the belief that it will necessarily necrose and cause suppuration. The time required for union varies from four to eight weeks. Fractures of the Cervix Humeri with Dislocation of the Head. —All the above fractures must be diagnosed from dislocation; especially Fracture of the surgi cal neck of the humerus united. FRACTURES OF SHAFT OF HUMERUS. 251 fracture through the surgical neck, in which we find shortening, an abnormal bony mass moving with the shaft lying in the axilla, and the elbow thrown out from the side. The diagnosis rests first upon the demonstration of the presence of the head in the glenoid fossa, and secondly upon the discovery of abnormal mobility in the length of the bone. In some rare cases, how- ever, it is found that the shoulder is flattened, the deltoid tense, the acromion sharply felt, and the fingers sink in immediately beneath it, showing that the head is absent from its normal place. It is felt in the axilla, but does not move with the shaft, and crepitus is obtained here; the signs indicate that dislocation and fracture coexist. Treatment.—In intracapsular and impacted fractures there is little to be done beyond fixing the arm to the side and treating extravasation ; until this has almost or quite subsided, the patient should remain in bed. In fractures of the surgical neck, swelling often prevents the attainment of knowledge as to the position of the upper fragment. Till swelling has subsided the limb may be comfortably arranged upon a pillow and fixed by sand-bags or weight extension to prevent shortening. Then the limb may be put up in splints. If extension has to be maintained the fingers and hand must be well bandaged; an inside angular splint reaching to the level of the fracture must be fixed to the forearm and arm, and a nicely moulded shoulder-cap of sole-leather, stout gutta-percha, or plaster of Paris reaching down to the outer condyle must be well fastened upon the shoulder by a spica. The arm is to be secured to the side, and a small sling, supporting only the hand, worn. Later on, the shoulder-cap alone, fixed by a starched or plaster bandage, will suffice. When the upper fragment is abducted, Moore recommends abduction of the arm, with extension, until the fragments interlock; then bring the limb carefully to the side. Sometimes it is necessary to keep the arm abducted, the patient remaining in bed; this may be done by weight extension or by a splint like an L turned upside down (Tyrrell). This is the method for treatment of fracture of the great tuberosity. Marked displacement inward of the lower fragment is met by a pad in the axilla. Erichsen recommends for some cases a very simple splint consisting of a strip of leather six inches wide and two feet long, half of which is bandaged to the trunk and half to the arm, whilst the rounded bend fits closely into the axilla. After five or six weeks the patient may swing the arm gently to and fro, gradually bringing it into use. In Fractures with Dislocation an attempt should be made at once, under complete anesthesia, to push the head back into the socket, by placing the fingers upon it and the thumbs upon the acromion. Failing this, some have permitted union to take place, and then six or twelve weeks later have tried to reduce, often without success. The best results seem to have followed the pushing of the lower fragment up into the glenoid fossa, the head being left alone. Fractures of the Shaft of the Humerus are often at once recogniza- ble by deformity, shortening, helplessness, and crepitus ; but in more or less transverse fractures from slight violence, especially in children, some care in examination is necessary. When the fracture is between the pectoralis major and the deltoid, the upper fragment is drawn in, and the lower up- ward outside it; when below the deltoid, the muscle drags the upper frag- ment out and the long arm muscles pull the inner fragment up inside the outer. Complications are bruising, with consequent thrombosis, or rupture of the 252 INJURIES AND DISEASES OF BONE. brachial vessels, and pressure upon or laceration of a nerve. Involvement of the musculo-spiral in callus occasionally occurs. Treatment.—Two to four short splints of Gooch's material placed round the limb and buckled on above and below the fracture. If extension is re- quired, replace one of these splints by an external angular. Firm pressure above will, of course, necessitate bandaging all distal parts. A sling support- ing only the hand must be worn (Fig. 78). After a few days an immovable splint (plaster) may be applied. Fractures above the middle are best treated like those of the surgical neck. In the absence of pulse at the wrist, apply no bandage lest gangrene occur and be attributed to it; raise the limb slightly on pillows. Fracture of the Lower Extremity of the Humerus presents many varieties. 1. A transverse or oblique fracture above the condyles (supracon- dyloid). The radius, ulna, and lower fragment are drawn up and back (Fig. 79), the triceps is tense, and the olecranon projects as in dislocation backwards of both forearm bones. The deformity is, as a rule, easily reduced with crepitus, but returns immediately. The relation of the two epicondyles to the ole- cranon is normal, measurements from the acromion to the outer epicondyle Fig. 78. Fig. 79. Treatment of fracture of shaft of Oblique transverse fracture above the condyles, lower .humerus. fragment displaced backwards. are a little short, but those from the epicondyles to the styloid processes are normal. The fingers cannot be pressed into the great sigmoid notch of the ulna, nor can the pit on the head of the radius be felt. 2. Detachment of the lower epiphysial cartilage, including the radio-ulnar surface and both epicon- dyles (though the internal ossifies and unites separately at eighteen), presents the same symptoms. Either this or the above fracture is very common in children; opportunities of direct examination of the bones are very rare. 3. There is a T-fracture: in addition to the above a fissure runs down through the articular end, separating it into outer and inner pieces, between which crepitus may be obtained. 4. The capitellum (Fig. 80) or the trochlea may be broken off with an epicondyle; the latter involves displacement back- ward of the ulna and often of the radius also. 5. Either epicondyle may be detached ; pain and crepitus during pronation or supination are localized to their vicinity, and a bit of bone may sometimes be grasped and moved ; the joint is not implicated. Treatment.—Swelling is often too great to permit of an accurate diag- nosis. The limb may then be placed upon an inside L splint, with the joint FRACTURES OF THE FOREARM. 253 exposed for treatment. Usually one or two lateral L splints are used later, the joint being fixed at or a little over a right angle; sometimes a posterior gutter-splint of plaster or poroplastic acts best; again an anterior L splint. Fixed apparatus is not suitable for the immediate treatment, especially in children. It is often very difficult to keep the fragments in position by means of splints, and the patient should be warned that impaired movement is likely to result. After the third week, when the splints are changed, it is well very carefully to perform the movements of the elbow and radio-ulnar joints three or four times, and, so far as is possible, without causing pain. After the fifth week splints can generally be removed, and passive and active movement must be freely used. J. Hutchinson recommends extreme flexion as the position most likely to prevent displacement in supracondyloid frac- tures. Fractures of the epicondyles give but little trouble. It has been recommended to treat fractures separating the trochlea only in the straight position, putting up the limb in a moulded posterior splint, and Fig. 80. Fig. 81. Lines of fracture in the humerus, of the surgical neck, of the middle of the shaft, and of the internal condyle, passing into the joint. Fracture of olecranon, with liga- mentous union. St. Mary's Hospital Museum. paying particular attention to the preservation of the obtuse angle which the limb naturally forms outward ; when this is the same as on the sound side, it is held that the fragment must be in position. Fractures of the Forearm.—Fracture of the olecranon is usually due to direct force, rarely to violent action of the triceps; in the former case there may be much bruising and swelling. Signs.—Flexion of the elbow is easy or possible, but active extension is impossible, and attempts at it are to be discouraged. The fracture is usually transverse, passing into the joint through the narrowest part of the process (Fig. 81). A transverse gap is felt in the bone here, just perceptible or wide enough to let the thumb sink in. Greater separation than this is usually prevented by untorn aponeuroses and ligaments. Sometimes the fracture is " starred," and there is no displacement. The distal fragment is occasionally forced through the skin, or this is perforated by the original violence. 254 INJURIES AND DISEASES OF BONE. Treatment.—If great swelling is present subdue it whilst the limb lies comfortably upon a pillow ; if there is any possibility of the skin sloughing, put up the part antiseptically. French surgeons treat this injury with the elbow bent to prevent anky- losis, a possible but very rare occurrence. In a perfectly straight position the lower fragment is apt to push the olecranon out of its fossa on the humerus. The best way of treating it is to use a straight anterior splint padded thickly opposite the joint, to give a slight bend, and secured by plaster bandages, in which a window over the elbow may be cut on the third day to see how the fragments are lying. The splint should reach from the level of the axilla to the wrist. When necessary an attempt may be made to bring down the upper fragment by long strips of strapping applied ob- liquely round the splint and arm, beginning half-way up the triceps and reaching down to the fragment; this may be renewed from time to time. Passive movement may be employed in three to four weeks, the finger press- ing the olecranon toward the shaft as the elbow is bent. Malgaigne's hooks have been used in this fracture, but antiseptic wire is certainly preferable, and in cases of compound fracture use should be made of the wound to unite the bones by suture. Passive movement may then be employed after a week. Usually short fibrous union is obtained (Fig. 81), bony union being rare. The arm is strong and movements of the joint good or perfect. This may be the case even with a longish bond of union, but generally weakness or uselessness of the limb goes with this. It is right then to open the joint, re- move the fibrous tissue between the fragments, and wire them together, allowing the suture to remain in. Fracture of the coronoid process has very rarely been demonstrated, but may be more frequent than is generally believed. Experiments show that it is often broken by blows on the palm with the elbow bent and fixed, less often with the elbow straight. Malgaigne found the fracture frequently in backward dislocations which he had produced. Muscular action may be a cause, as when the pro- cess was torn off in a boy of eight who was hanging by one hand from the top of a wall (Liston). Signs.—These are said to be dislocation of the ulna or both bones backward, easy reduction and easy reproduction, crepitus, and the presence of a small hard movable body in the fold of the elbow. Treatment.—An angular splint and sling. Union will probably be ligamentous. Fracture of the Shafts of the Radius and Ulna.—Both these bones may be broken or only one. In the former case all the signs of fracture, especially deformity and abnormal mobility, are strongly marked. When the radius is broken below the tubercle, the hand is almost always pro- nated, because it is cut off from the supinator brevis and biceps, but passive supination is easy; also the pronator quadratus always tends to approximate the lower ends of the bones, especially if both are broken and low down. When only one bone is cracked through with but little displacement, it may be impossible to make a positive diagnosis: slight swelling and irregularity, pain and tenderness at a point not struck, the pain being elicited not only by direct pressure but by movement of the part and by pressing the bones together at a distance, and perhaps crepitus, are chiefly to be relied on. Fig. 82. Sling for fractured forearm. Supports the whole arm from elbow to fingers. COLLES'S FRACTURE: MECHANISM. 255 Treatment.—Prepare two splints of wood one inch wider than the widest part of the forearm, one to reach from the outer epicondyle to the knuckles, the other from the inner epicondyle to the wrist. Reduce any deformity by extension between the wrist and elbow, and then, the elbow being bent, apply the splints to the forearm held midway between pronation and supination (with the thumb uppermost), and fasten them firmly on with straps or buckles; next bandage the hand to the back splint and the two splints to each other, and place the forearm in a sling (Fig. 82). The fingers may be moved daily to prevent matting of their tendons. Union is generally com- plete in four to six weeks. Non-union is not very rare. Sometimes formation of callus is excessive; it spreads across the inter-osseous space and unites one bone to the other, thus destroying the all-important movements of pronation and supination. When this has happened in cases of simple uncomplicated fractures, courts have regarded it as due to malpractice, and have given damages against the surgeon. To prevent it, some surgeons pad the splints thickly along the middle; but if they are firmly applied with ordinary padding the muscles will be pressed in between the bones. Wide splints are important to pre- vent pressure of the bones toward each other by the bandage in crossing from one splint to the other. In cases of comminuted or multiple fracture, the difficulties of treatment are much increased, and no action would lie on the ground of imperfect success. The fingers must be carefully watched; in no other part has gangrene occurred so frequently, either from swelling beneath a bandage directly ap- plied, from immovable splints, or from inflammation usually resulting from injured soft parts. Calles' fracture is a fracture of the lower end of the radius half to one inch above the wrist, either transverse or rather oblique upward and backward; the lower fragment is sometimes displaced bodily backward to a greater or less extent, less often it turns on its anterior margin as upon a hinge, the posterior margin of the upper fragment penetrating the cancellous tissue of the lower for perhaps half an inch ; the upper fragment may remain firmly impacted in the lower, and the latter may be split into several pieces. Usually the styloid process is carried outward as well as backward. The styloid process or lower end of the ulna is sometimes broken also (Fig. 83). The fracture may occur at any age, but is exceedingly common among Fig. 83. Fracture of the lower end of radius and ulna, from Dr. Smith on "Fractures." old women, being due in them to falls and slight violence. Up to twenty the epiphysis may separate. It will be seen, upon consideration of the posi- tion of the radius (running downward, forward, and inward) in ordinary falls upon the hands, that if the force running along it be resolved into ver- tical and horizontal components, the former will tend to tear off the lower end of the radius to displace it backward and forward and somewhat out- ward in most cases, the lower end of the fragment being chiefly acted upon. The radial extensors and extensors of the thumb maintain the deformity. 256 INJURIES AND DISEASES OF BONE. That this is the mechanism of the displacement seems to be shown by the fact that a few cases are recorded of falls on the back of the hand resulting in a similar fracture, but with displacement forward of the lower fragment and reversal of the clinical signs. Signs.—The appearance is very characteristic. When the part is exam- ined from the radial side (Fig. 83), it has much the appearance of a silver fork (Velpeau). Opposite the radio-carpal joint, behind, is a rounded prominence formed by the lower end of the radius and the carpus, and a little higher up (one inch or so) there is a marked angular depression. Opposite the latter, or rather a little lower down on the palmar aspect, is a sharpish prominence, the lower end of the upper fragment, covered by mus- cles. The hand is usually a little abducted, the extensors of the thumb tense, and the styloid process of the ulna prominent on the inner side; the latter may be dislocated from the carpus or even forced through the skin. The deformity inayjbe easily reduced with marked crepitus, or reduction may be quite impossible; when effected, it may be permanent, or the deformity may return at once. The styloid process of the radius moves with the carpus, and, unless broken, constantly preserves its normal relations to it; in dislo- cation it does not do so. The backward dislocation of the carpus may be accompanied by chipping of the posterior border of the lower end of the radius. Treatment.—Impaction, when present, should be undone, if possible, by strong traction on the hand and direct pressure forward on the fragment. In the absence of better means, cases may be treated with the splints men- tioned in the last section—the back splint being thickly padded up to the fracture to press the lower fragment and hand forward, the anterior splint being thickly padded below and reaching only down to the fracture. With strapping, the hand may be fixed in a position of adduction to the back splint. When all tendency to swelling has subsided, a plaster gauntlet, leaving fingers and thumb free, and running well up the forearm, will give Fig. 84. Application of Gordon's splints to Colles's fracture. a good result. Gordon, of Belfast, recommends the addition of a rounded, tapering, projecting margin to the outside of the front splint, to be applied against the everted fragment of the radius. In the splints which go by his name, the posterior or ulnar splint is wider at the hand, and provided with a flange piece on which the inner border of the hand rests (Fig. 84). The great difficulty in all cases, especially in the old and rheumatic, is to prevent stiffness of the fingers and wrist; the fingers should be liberated as soon as possible, and the wrist may be cautiously moved after three to five weeks, according to age, etc. The patient should be informed that stiffness will last some months, and that recovery may not be perfect. The use of Carr's splint (Fig. 85) reduces these evils to a minimum, and the simple act of grasping the bar reduces the deformity in unimpacted cases, its direction being more oblique than the line of the heads of the meta- FRACTURES OF THE HAND AND RIBS. 257 carpals to which it corresponds. A small dorsal splint is also used, and for the first four days the fingers may require to be fixed over the bar by the bandage. -After a week they and the thumb are left free. Fractures of the Hand.—The carpal bones are rarely fractured with- out a severe smash, and excision, or, in some cases, even amputation, entire or partial, may be necessary, though this should be avoided, if possible. Fracture of the metacarpal bones, or of the phalanges, will be readily recog- nized. The former usually form a prominence posteriorly when broken, owing to the preponderating action of the anterior muscles. With respect to compound fracture of these parts, no part of the hand should be ampu- tated unless positively necessary, and even one finger, and especially the thumb and forefinger, should be saved, if it can be done. Treatment.—For fracture of the carpus simply immobilize the wrist. For those of the middle metacarpal bones, make the patient grasp a ball of tow or some other soft substance, and bind his hand over it with a stump Fig. 85. Carr's splints for a left Colles's fracture. bandage; but for fracture of the lateral metacarpal bones, support the hand on a firm wooden splint, cut into the shape of the thumb and fingers. If only one finger be fractured, fix it by a thin wooden splint long enough to reach from the wrist to the end of the finger, with the upper or palmar part broader than the lower. It must be remembered that the palmar surfaces of the metacarpals and phalanges are concave, so the splints will require suitable padding. Plaster of Paris and gutta-percha are very useful in these fractures. Fracture of the Ribs is very common after twenty, under puberty extremely rare. In two cases, eighteen and twenty-four years old, 60-100 Kgr. pressed the sternum back to the spine without causing fracture. It is generally due to direct violence, when the tendency is to displacement inward of the fragments, and the depression may remain ; not uncommonly it is caused by indirect force, as when the thorax is violently squeezed from before back, the fracture being often bilateral, and usually situate an inch or two from the sternal end. Sometimes, and usually in the aged, one or more ribs are broken by violent coughing. (Malgaigne, quoted in Brit, and For. Med. Rev., vol. vii. p. 554.) The middle ribs break most often, the first rarely, the twelfth very rarely. These fractures may be incomplete or complete, simple or compound (through the skin or lungs), single or multiple, complicated in many ways, but comminution is generally due to gunshot injury. Several ribs, perhaps the majority on each side, may be broken. Signs.—Fixed, lancinating pain, aggravated by inspiration, coughing, and all movements of the chest, and induced by pressure on the rib at a distance from the painful point; this is especially valuable when the point has not been directly injured. Crepitus is often felt during inspiration by the hand placed flat on the painful spot, or heard here with a stethoscope, but care must be taken not to 17 258 INJURIES AND DISEASES OF BONE. mistake pleuritic friction for crepitus. The patient often describes the " click;" pressure on the anterior end of the rib may elicit it, or alternate pressure on either side of the fracture; much fat or muscle (e. g., near the spine) necessarily obscures the sign. The latter manipulations may reveal abnormal mobility, but often this cannot be detected, and actual falling in of the side is rare, even when several ribs are broken in two places. There may be great dyspnea in this case. Exact diagnosis is not of much consequence, for in all cases of pain on inspiration after a blow on the chest the treatment is the same. Emphysema, or presence of air in the cellular tissue, is a not infrequent complication of this fracture. The air forms a soft, diffuse swelling that crepitates characteristically, disperses on pressure, but does not pit; it may be limited to the region of the wound, or extend over the whole body, render- ing the patient absolutely unrecognizable from swelling, though such extreme emphysema is very rare. It is thus produced : the broken bone pierces both layers of the pleura and wounds the lung. In cases of large wound in the lung, air now enters the pleura at each inspiration, but in expiration the soft lung tissue falls together and prevents it from reentering the lung. A pneumothorax therefore forms, the lung becomes more or less rapidly com- pressed, and at each expiration some of the air is forced from the pleura through the wound in its parietal layer into the superficial cellular tissue. But little force is required to drive it on. In these cases, in addition to the subcutaneous swelling which may conceal the physical signs of pneumo- thorax, dyspnoea increases until asphyxia may ensue. Much more commonly the emphysema is limited to the vicinity of the fracture, and there is no pneumothorax; this has generally been explained by supposing that the pleura was not really opened by the wound, the lung being here adherent to the chest wall; but it is certain that in many cases no adhesion exists, yet the lung does not separate from the chest wall. Slight hemoptysis, lasting perhaps two or three days, is common, the blood coming from bruised or torn lung. Slight hemothorax also is frequent, the blood being mixed with serous effusion, and forming six or eight ounces of purple fluid containing no clot; it comes from small vessels of the lung and pleura. Very rarely main intercostal vessels are torn, the hemorrhage being large or even fatal. Cases are recorded in which a broken rib has wounded not only the lung, but the heart, or even the diaphragm and some abdominal viscera ; they are very rare. In simple fractures a pleuritic rub may be heard a few days after the injury in its neighborhood, but serious inflammation of pleura, or lung, or suppuration of the fracture is rare. After fractures of several ribs, and espe- cially in the old and feeble, there is a great tendency to hypostatic conges- tion and pneumonia; in them, too, bronchitis often appears, or becomes much worse after this accident. Union takes three to four weeks; is almost always bony, the callus forming in large amount sometimes uniting adjacent ribs; and cartilage is usually found in the callus before ossification. Treatment.—Much relief is usually given by bandaging the thorax firmly, during expiration, with a broad flannel roller, kept up by shoulder straps. A piece of stout strapping passing once and a half round the body also answers well. A less perfect mode of fixing the fragments is to strap the injured side with three-inch strapping, passing well beyond the mid-line in front and behind, and fixed during expiration. Some patients find all bandages intolerable, especially those in whom the fragments have been driven inwards by direct force; they do well when simply kept in bed. If FRACTURES OF THE COSTAL CARTILAGES. 259 a fragment is markedly depressed, and apparently the cause of pain or of hemorrhage, Malgaigne's suggestion—to pass a sharp hook cautiously round its upper border and elevate it—might be acted on. Ordinarily emphysema and hemothorax require no treatment. Air deposits all solid particles before it reaches the finer bronchi; its presence iu the tissues or over an effusion in the pleura therefore causes no decompo- sition. But should the lung be so compressed by air as to threaten asphyxia, a free opening must be made into the pleura; compression by fluid, on the other hand, may be relieved by aspiration. Some surgeons still treat early severe pain and dyspnoea in the strong and healthy by bleeding to six to eight ounces. In the bronchitic or emphyse- matous apply no bandage; use turpentine and simple stupes early, and give the mist, ammon. carb. F. 141. Severe cases are almost always most com- fortable when well raised on a bed-rest; a bed-pull, or something high up to hold, often affords relief. Fractures of Costal Cartilages are not uncommon ; the eighth is that most often broken, near the bony rib, and almost always the outer is dis- placed in front of the inner fragment. Complications are rare. Fractures of the Sternum are rare, and due to direct violence or in- direct, as when the body is strongly bent backward or forward. It has oc- curred during straining in parturition. Frequently it accompanies other and severe injuries. Compound fracture, except from gunshot, is almost unknown. The line of fracture may take any direction, but is usually roughly trans- verse ; if there is any displacement, the lower fragment overlaps the upper. Treatment as for fractured ribs. Fractures of the Pelvis are generally due to very great violence, either direct or indirect; very rarely to muscular action. They are best divided into two classes, according as they do or do not break the pelvic ring. The former are by far the more serious. Sometimes the articulations are torn open ; especially the symphysis from direct violence, forcible abduc- tion of the thighs, or the wedge action of the foetal head, chiefly in primiparse. These injuries may be combined with fractures, which are more common. The horizontal pubic ramus and the pubic arch may be broken through on one (Fig. 86) or both sides; or this anterior fracture is accompanied by another line passing behind the acetabulum, through the sacroiliac joint or through the lateral mass of the sacrum (double vertical fracture). In another well- marked variety the head of the femur is driven against, fissures, and perhaps forces in the ace- tabulum, being itself driven into the pelvis. The hip bone may be separated into its original three component parts. In the second class we find transverse fractures of the broad part of the ilium, of the crest, of the anterior spine, of the ischium (very rare), and transverse fractures of the sacrum or coccyx. Premature ossifica- tion of the coccyx to the sacrum predisposes it to fracture during labor, and also from falls, kicks, etc. Signs.—Fissures, neither breaking the continuity of the ring nor separat- ing a fragment, cannot be diagnosed. Fractures of the second class are usually accompanied by displacement and all the ordinary signs of fracture, Fig. 86. Fractured hip bone. St. Mary'.- Museura. 260 INJURIES AND DISEASES OF BONE. but are sometimes detected only by careful examination of the outline of the bone traced through the skin, the rectum, or the vagina. When one hip bone is detached as a whole, it is usually drawn up, so that the lower limb seems shortened, but the relation of the trochanter to the anterior spine is normal. In the double vertical fracture, displacement of the fragment often causes widening of the distance between the crests, diminution of that between the tubera ischii. Whenever the ring of the pelvis is broken, there is ina- bility to stand, owing partly to pain, partly to sense of great lack of support. When the head of the femur is driven into the pelvis, the injury may easily be mistaken for fracture of the cervix femoris. For the cause is similar, the limb is helpless and usually everted, deep crepitus is obtained, and the trochanter rotates in a small arc; but shortening is slight or absent, though the violence has been great enough to cause an extracapsular fracture; the hip is markedly flattened, and a finger in the rectum or vagina feels the pro- jection into the pelvic wall. It very rarely happens that both acetabulum and cervix femoris are fractured. Complications.—It is these which render pelvic fractures so dangerous; even severe uncomplicated fractures are usually recovered from, though the shock is often marked. The complications are: 1, rupture of the urethra, generally in the membranous, but sometimes in the bulbous portion by a dis- placed pubic fragment, or by the fracturing force; 2, rupture of the bladder usually by the original violence; 3, laceration of the rectum in fractures of the sacrum and coccyx; 4, laceration of the iliac arteries or veins, chiefly in double vertical fractures; 5, suppuration in the pelvic areolar tissue occa- sionally occurs. Treatment.—First, in all injuries to the lower part of the abdomen, or which may have caused fracture of the pelvis, pass a scrupulously clean catheter to ascertain the state of the urethra and bladder. If blood or bloody urine has escaped from the urethra, attention will of course be drawn to the part. In this case, a soft catheter should be tied in, and the bladder kept constantly drained; but if no instrument can be passed on account of rupture of the urethra, anticipate extravasation of urine by opening the perineum freely upon the end of the catheter, and endeavor to find the proximal end of the urethra and to pass a catheter along it into the bladder Treat them as after external urethrotomy. When the urethra is sound, but the bladder ruptured, the catheter enters easily. A fragment generally pierces the bladder on its non-peritoneal sur- face, but a blow over the distended organ causes it to burst where it is cov- ered by peritoneum. Gunshot may of course wound it anywhere. The object of treatment is to prevent escape of urine into the peritoneum or con- nective tissue. Some rely upon constant drainage through a large catheter. Gouley and Mason recommend a free lateral cystotomy, a tube being intro- duced through the wound into the bladder, or even into the peritoneum for a short time. Willett and C. Heath have opened the abdomen and sewn up rents in the peritoneal surface, the patients dying. The operation is difficult, the space obtainable between the recti of a strong man being small. The simple catheter usually fails; more experience is required to decide between the alternative operations. The next care is to immobilize the fragments with a firm bandage or broad belt round the pelvis, the knees being tied together; or, better, with a double spica of plaster strengthened by strips of wood or tin. The patient should lie on a thin mattress placed on planks. The following means of raising the patient to change clothes, attend to back, use bed-pan, etc., will be very useful. Have a stout rectangular wooden frame made, three feet wide and a little longer than the patient, with numerous hooks along the outer surfaces of its ANATOMY OF THE NECK OF FEMUR. 261 side ; on to these are fastened by eyelets or cords bands of broad webbing or of stout calico. The ends of two ropes, each nine feet long, are fastened to the corners. The patient is placed upon the bands, and when it is desired to raise him, the ropes are hooked on to one of two pulleys, the mate of which is fastened to the ceiling or to a special frame over the centre of the frame. Any one band may be removed at will. Much difficulty has been experienced in preventing displacement forward of the fragment in fractures of the sacrum and coccyx. This has been done °y Pluggiug tne rectum with a tampon through which a tube is passed for the escape of flatus; it is removed for defecation, and replaced until dis- placement ceases to recur. The bowels should act easily. In fractures breaking the pelvic ring, at least eight weeks should elapse before the patient stands. Fractures of the Femur.—These are very important, frequently laming the patient, and not uncommonly bringing disgrace upon the surgeon. The primary varieties are: (1) fractures of the neck; (2) oblique fracture through the great trochanter; (3) separation of the great trochanter; (4) fractures of the shaft; (5) intercondyloid fractures. Fig. 87. Section through head, neck, and tr of femur (Bigelow). The dotted lines: to show the movement of the trochanl the anterior intertrochanteric line in of the base of the neck. Anatomy of the Neck.—If a horizontal section be made through the head, neck, and trochanter (Fig. 87), it will be seen that near the head the anterior and posterior layers of cervical compact tissue are about equally strong; further out the posterior gets thin and is continued beneath the cancellous ridge of the posterior intertrochanteric line, but does not reach the outer wall of the trochanter, whilst the anterior becomes thicker until the anterior intertrochanteric line, which is entirely compact tissue, is Fig. 88. ochanter Impacted fracture of the neck of femur into the head ; ire added from Bigelow's " The Hip." er round fracture 262 INJURIES AND DISEASES OF BONE. reached. In blows upon the trochanter, tending to drive it in towards the head, this strong anterior layer resists impaction ; it usually cracks more or less vertically, and acts as a hinge round which the shaft rotates as the poste- rior part of the neck is driven into the hinder part of the great trochanter (Fig. 87); or, if the fracture occurs nearer the head, as the hinder part of the neck is driven into the head (Fig. 88), the foot being everted in either case. Impaction of the base of the neck into the cancellous tissue frequently results in fissuring or comminution of the whole trochanteric region; the fragments may hold together, the trochanter being split and widened, or they may all be loose and detached. This action of blows received at right angles to the hip or in front of the mid-line is aided by the oblique position of the neck running outward and backward from the head. After mid-life all bones undergo atrophy, not diminishing in size, but becoming lighter from enlargement of cancellous and Haversian spaces and formation of fat in them. The neck of the femur is especially affected, in women more severely than men, which explains the great frequency of fracture of the neck of the femur in women over fifty. It is usually said that, as a result of this change, the angle between the shaft and neck diminishes in the aged until it becomes even acute. But Rodit found the average angle in the child and adult to be 131°, in the aged 128°—a difference too trifling to have much effect. The extremes met with were 121° and 144° (Tillaux, Anat. Topograph'que, 1882, p. 957), and there can be no doubt that a horizontal position of the neck renders fractures from indirect violence more easy, whilst unusual obliquity renders it more difficult. It must be noted that anteriorly the ileo-femoral ligament is attached to the anterior intertrochanteric line, and that consequently the whole neck on this aspect is intracapsular; the synovial membrane is reflected from the capsule on to the neck considerably higher up, so only half to three-quarters of an inch of the neck is really in the cavity of the joint; and lastly, many cap- sular fibres are reflected along the neck toward the head, forming retinacula of very considerable strength. (1) Fractures of the Neck of the Femur were divided by Sir A. Cooper into intracapsular and extracapsular; but this division is of little value, for it is scarcely possible for a cervical fracture to be wholly extra- capsular, and many of them take an oblique course, beginning well within the joint and ending outside it. Moreover, it is often impossible during life to be certain as to the exact seat of a fracture, though good guesses may fre- quently be made; for treatment an exact diagnosis is unimportant. By intracapsular fracture is really meant a fracture of the narrow part of the neck ; by extracapsular, one of the base of the neck, with more or less impac- tion into the trochanter. Fractures of the neck may be caused by direct blows upon the hip, or by indirect violence along the femur; they may occur at any age and in either sex. After fifty, and especially in women, atrophy of the neck may be so marked that slight and indirect violence—such as missing a step, slipping off a curb, stumbling, or even turning in bed—may be sufficient to break it; it then yields usually at its narrowest part (intracapsular) near the head. Fractures about the base of the neck (extracapsular) are generally due to great and direct violence, and are consequently most often met with among laboring men, from falls in the hunting field, etc.; but they occur also in the aged when exposed to proportionately great violence. Sometimes direct vio- lence causes an intracapsular fracture in people under middle age. In the rare fractures of the neck of the femur which occur before twenty, it becomes a question whether the case is not one of separation of the epiphysis of the SIGNS OF FRACTURE OF NECK OF FEMUR. 263 Fig head. Some twenty cases in which this diagnosis was made are on record, and one was proved by autopsy. Signs.—The patient complains of more or less pain about the hip, in- creased by motion. In cases due to direct violence there are often great swelling and bruising about the hip, with more or less shock; but in those from indirect force, there is no immediate bruising and little swelling; in the latter, after three or four days a patch of bruising sometimes ap- pears in Scarpa's space. Unless swollen by hemorrhage, the hip is usually flattened from driving in of the trochanter. When the base of the neck is driven into the trochanter, the latter is generally split and widened or com- minuted, and this may be felt before swelling comes on or after it has subsided. In the great majority of cases the limb is more or less completely everted (Fig. 89), and it is always shortened, the amount of shortening varying greatly. Crepitus is often obtainable upon reducing the shortening by extension and rotating the limb; it is most easily ob- tained in fractures wholly within the joint, but in some cases (firm impaction) it is im- possible, by justifiable force, either to reduce the shortening or to obtain any crepitus, or more than a click or two; much manipula- tion is worse than inexact diagnosis. In cases of impaction it will be found also that the toes on the injured side cannot be inverted like those on the sound side. The arc of rota- tion of the trochanter lessens as its radius is shortened by fracture or impaction of the neck; but the sign is difficult to make out except in unimpacted fractures of the base, in which rotation occurs round the axis of the shaft of the femur. The limb is perfectly help- less, as a rule, and the heel cannot be raised from the bed; sometimes the knee can be raised and the heel drawn up, and in not a few cases the pa- tients have walked considerable distances, the fractures having been intra- capsular or firmly impacted. The amount of shortening varies from a fraction of an inch to two or three inches; it is least when the fracture consists of a slight impaction of the neck into the head or the great trochanter, greatest when the trochanteric region is comminuted by impaction of the neck, the capsular insertion torn, and the shaft left free to be acted upon by all the muscles passing from the pelvis to the lower limb; the fracturing force also may have driven it upward. In fractures of the narrow part of the neck, the periosteum and retinacula may remain in great part untorn, and the displacement is proportionately slight; so long as the capsule is attached to the outer fragment the displacement can hardly exceed one and a quarter inches, and interlocking of the surfaces may keep it under half an inch. In these cases, however, it is not uncommon for the shortening to increase considerably during the first week or so, owing to undoing of impaction or interlocking, or to rupture by muscular action, manipulation, or an attempt to walk, of bands softened by inflamma- tion ; whilst in fractures toward the base of the neck, the shortening usually reaches its maximum at once. It is said that gradual shortening of one to Fracture of the neck of the thigh bone within the capsule, showing shortening and eversion of the leg and foot. After Sir A. Cooper. 264 INJURIES AND DISEASES OF BONE. two inches during the six months following the injury may result from interstitial absorption of the neck. There are several methods of ascertaining the amount of shortening. In all the patient should be lying with the limbs symmetrically placed. The easiest plan is to bring the limbs together in the mid-line, and see if the internal malleoli are on the same level, making sure also that there is no tilting of the pelvis—i.e., that the anterior iliac spines are in the same horizontal plane. Greater accuracy is attained by measuring from the anterior spines to the internal or external malleoli. To prove that the neck is broken, it is neces- sary to show that the trochanter has risen toward the iliac crest. Simple vertical measurement from the crest to the trochanter will not do, as the latter has been driven back toward a higher part of the crest as well as up- ward. Nelaton's line, from the anterior spine to the most prominent point (vague) of the tuber ischii, normally touches the top of the trochanter when the thigh is neither ad- nor abducted. But the most accurate method is by means of Bryant's triangle: a vertical is dropped from the anterior spine, and from this the distance to the trochanter is measured upon each side; rotation in or out is measured by the base line from the spine to the trochanter. Eversion has been explained above; when the fragments are loose, the foot naturally rotates out. Inversion sometimes occurs instead of eversion. In unimpacted fractures it may be accidental, and the foot is easily made to roll out; but when it is fixed it is probably due to an unusual direction of the fracturing force—e. g., to a fall on the hinder part of the hip with the foot inverted. In some cases it has been impossible to undo this deformity by such force as could be safely used. Diagnosis.—The possibility of shortening from previous injury or from rheumatoid arthritis, upon which an injury to the hip has been superadded, must be remembered. A simple severe contusion sometimes causes complete eversion and helplessness of the limb, with a good deal of bruising and pain about the hip. Fracture will be eliminated by the absence of shortening and crepitus, and the possibility of effecting completely passive inversion. It is said that gradual absorption of the neck of the femur may result from such injuries and give rise to actions for malpractice. The defence must rest upon the absence of signs of fracture, and reference to cases in which ab- sorption is said to have occurred.1 From dislocation on to the pubes cervical fractures with eversion are distinguished by the absence of swelling due to the displaced head, and by signs of fracture—crepitus, abnormal mobility; fractures with inversion differ similarly from dorsal dislocations. The diag- nosis from fracture of the acetabulum with entry of the femoral head into the pelvis is best made by absence of all irregularity of the inner surface of the pelvis upon examination by rectum. As to the diagnosis between intracapsular (narrow part of neck) and extra- capsular (base of neck) fractures, a positive diagnosis of an extracapsular injury is possible only in cases in which great immediate shortening, com- minution of the great trochanter, rotation of the trochanter upon the axis of the shaft, or the presence of a distinct bony mass in the outer part of Scarpa's space (the angle formed by bending of the neck), is present. When the swelling has subsided, the trochanter will be found thickened by external 1 Smith, op. cit.; Canton, On Interstitial Absorption of the Neck of the Femur from Bruise, etc., Med. Gaz., Aug. 11, 1848; Norris, Boston Med. and Surg. Journ., 1838, p. 368, mentions complete absorption of the humerus in a lad of eighteen, who broke the bone near the middle five weeks after a previous fracture at same spot; Agnew, Surgery, vol. i. p. 746, saw half the humerus disappear in eight years after a fracture. FRACTURE THROUGH GREAT TROCHANTER. 265 callus and matting of soft parts in extracapsular fractures. Guesses as to the state of matters may be made on the following grounds: Extracapsular fracture is probable: from great, direct violence, indicated by bruising, swelling, and shock ; in persons under fifty, and in strong and healthy men above that age; whenever the immediate shortening is over one inch. Intracapsular fracture, on the other hand, generally results from slight and indirect violence, with slight local and general symptoms; in persons, especially women, over fifty ; and the immediate shortening is usually about half an inch. There is no late or early thickening about the trochanter. Firmly Impacted Fractures are indicated by shortening under one inch, retention of more or less power over the limb, and inability to invert completely; they generally result from direct violence. Enlargement of the trochanter shows the injury to have occurred at the base. Prognosis.—In the young, strong, and healthy, even severe injuries of this kind are generally recovered from ; but in the aged, it is no uncommon thing for a fracture, due to slight violence only, to prove fatal, and usually by hypostatic pneumonia or bedsores, whilst more severe injuries kill by shock. As to the limb, it may be said that extracapsular fractures almost always unite by bone, and that the tendency to union of any kind diminishes as the head is approached, owing to the difficulty in obtaining and main- taining contact of the comparatively small broken surfaces, and to the very imperfect nourishment of the upper fragment. As a rule, intracapsular fractures do not unite at all, or there is loose fibrous union ; sometimes it is Fig. 90. Oblique fracture through the trochanter major. firm, very rarely bony. Impaction favors the latter. The head preserves its vitality perfectly, and when no union occurs, may become hollowed out and eburnated as a socket for the stump of a neck, which progressively atrophies. Lameness practically always results from these injuries, some- times it is very great; the foot may be much everted, and the hip often remains sensitive and painful; in many cases the patient gets about well with a stick and a high sole. Bigelow figures a specimen of cervical fracture showing that the weight of the body may be borne in walking by the ileo- femoral ligament and the obturator internus, each hypertrophied. (2) Oblique Fracture through the Great Trochanter (Fig. 90) may occur at any period of life, but is rare. The following signs have been described ; eversion, about one and one-half inch shortening, and the shaft of the bone felt separated from and posterior to the trochanter, which is attached to the neck. This fracture unites readily by bone. Treatment, that for fracture of the neck. 266 INJURIES AND DISEASES OF BONE. (3) Fracture of the Great Trochanter results from direct violence, and may occur before or after eighteen, at which age the epiphysis unites to the shaft. At first standing or walking may be little interfered with, but they soon become painful; there is no shortening, no crepitus, may be ever- sion, and the fragment has been felt loose. Union will be fibrous, and would probably occur best with the limb well abducted and rotated out. (4) Fractures of the Shaft, (a) upper end, just below the Small Trochanter.—There is usually much deformity from tilting forward and outward of the upper fragment, the ilio-psoas causing its forward displace- ment, whilst the lower fragment is drawn up and back by the hamstrings and gluteus maximus. (b) Middle Portion.—As the upper end is departed from, the tendency to displacement of it becomes less, but the action of the hamstrings and other long muscles is unimpaired; if the fragments are interlocked, an angle for- ward and outward usually forms; if longitudinal displacement is possible, shortening is marked. (c) Lower End, Supracondyloid ; and Separation of the Epi- physis, which unites at twenty-five. Sometimes there is little or no displace- ment ; but shortening may arise in oblique fractures, or from impaction of the upper into the lower fragment. Rarely the lower fragment is flexed by the gastrocnemius upon the tibia. The latter displacement may be over- looked unless examined for, the results being non-union, great lack of steadi- ness, and annihilation of the movements of the knee, or sloughing of the skin over the point of the displaced bone. Ordinarily the fragments remain parallel, but the lower, together with the tibia, drops back and is drawn upward. (5) Fractures of the Condyles.—There are T-fractures, like those of the lower end of the humerus. They may be due to direct violence or to driving of the shaft of the femur between the condyles; either condyle may be displaced backward, the tibia rotating with it; the upper fragment may penetrate the skin, or the popliteal vessels may be injured by the lower. Sometimes only one condyle is broken off and is but little displaced. Much effusion into the joint follows, rarely suppuration ; stiffness is always likely to result. Treatment.—There is a very large number of methods by which frac- tures of the femur may be treated ; some are applicable to fractures of one kind, others to fractures of a different sort. In the treatment of Fractures of the Neck we must be careful not to do more harm than good by efforts to reduce shortening and eversion; in unimpacted fractures endeavors may be made in this direction. The object of treatment is to immobilize the fragments, and keep them in the closest possible contact until the strongest attainable union has occurred ; but the occurrence of bedsores or of hypostatic pneumonia may, in the aged and feeble, render it necessary to get the patient up in some fixed apparatus one to two weeks after the accident—the preservation of life comes before the preservation of the function of a limb. In all cases of fracture of the femur the patient should lie on a thin mattress placed upon boards, that the pelvis may not sink into a hollow. A fracture bed (p. 260) is always useful. The simplest and best plan of treatment for the aged is to place both limbs on a double inclined plane, made of pillows if the real thing is not at hand, and to tie them together at knee and ankle. If there is much ten- dency to shortening, extension may be made by fixing the limb upon a double inclined plane, so that the weight of the pelvis shall make more or less constant traction ; or weight-extension from above the knee may be used, and long heavy sand-bags placed on each side of the limb. They must be FRACTURES OF THE SHAFT. 267 frequently looked to, that eversion may not arise from their displacement. Syme placed a sheet over both limbs, not including the feet, and fastened it to the bedsides; over this he placed sand-bags as above. Some surgeons make extension by Liston's long splint (see below); it is most uncomfort- able, the perineal band often causes sores, and elevation of the trunk is im- possible. Where the latter is not desired, Desault's long splint and weight extension may be used. Lastly, extension may be made by oblique traction from a Smith's anterior splint or a Hodgen's splint fixed to the thigh ; these are excellent. Fractures of the Shaft are commonly treated by Liston's long splint (Fig. 91). It is a half-inch deal board four inches wide for an adult, nar- rower and lighter for a young person. It should reach from just below the axilla to five inches below the foot. At its upper end it has two holes, and at its lower end two deep notches. It must be well padded, and the perineal band is then put in place, its tapes being passed through the hole at the upper end of the splint. The dorsum of the foot being well padded, con- veniently by having the splint pad long enough to turn in over it, the foot Fig. 91. Liston's long splint. is fixed to the splint by a firm figure-8 bandage, the lower loops of which pass alternately through the anterior and posterior notches, the upper round the ankle and splint. The bandage being fixed, extension is made upon the foot and splint, till the length of the limb is satisfactory, and the perineal band is then tightened ; thus counter-extension is maintained. The band- age is now carried up to the seat of fracture. A broad body bandage is next fixed to the splint above the hip, and carried behind the back and round the body firmly two or three times; this, and proper width of the splint, counteract its tendency to ride forward. Lastly, eversion is prevented by slipping the lower end of the splint into an interval between two rectan- gular brackets fixed to a narrow plank eighteen inches long, tied to the bed by a hole at each end. The whole apparatus is very uncomfortable; the perineal band galls, and tends to cause displacement of the upper fragment; the thigh bandage tends to draw the fragments out towards the splint; and it is difficult to keep the splint in place. Sir W. Fergusson improved matters considerably by making counter- extension from a strong jean belt fitted accurately to the upper third of the opposite thigh; from this a band extends back and front to the upper end of the splint. This also draws the splint towards the body; but unfortu- nately the opposite thigh is not a fixed point. Desault's original long splint is much better than Liston's modification. It is a plank of the above measurements used simply to prevent movement of the hip and knee and eversion of the limb. The fragments are kept in place by four short splints placed round the thigh and buckled to the limb above and below the fracture; weight extension is used if any is required 268 INJURIES AND DISEASES OF BONE. and the limb is best fixed to the splint by means of a small sheet, fastened to the splint, carried beneath the limb and round again to the splint, drawn tight everywhere, and fixed with drawing-pins. In many cases short side splints, weight extension, and sand-bags, give an excellent result. When the fracture is high up, and the upper fragment tilted forward, the lower fragment must be raised to its level by some kind of double inclined plane with extension. The ordinary double-inclined plane may be used, but is cumbersome and in the way. Nathan Smith's anterior splint (Fig. 92) is much better; it is made of bent telegraph wire, with cross-pieces opposite the leg and thigh, by means of which the limb is slung at the proper height, and extension is made by having the point of suspension beyond the foot, the bed being raised. The splint is fixed to the limb by a roller or by strips Fig. 92. Smith's anterior splint, from Hamilton's " Military Surgery," New York, 1865. of bandage passing beneath it from bar to bar. Hodgen's splint is similar in principle, but the parallel bars run alongside the limb instead of in front of it. The foot is tied to the lower end of the splint by means of a stirrup, and the limb rests upon strips of bandage passed beneath it from bar to bar. Extension is made as with Smith's splint. Either of these splints permits the exposure of a posterior wound with the least possible disturbance. When this is not required, the ordinary Maclntyre splint bent to a suitable angle may be applied and slung. When a Thomas's knee splint which fits moderately well is at hand, it is the most comfortable plan of treating fractures of the shaft of the femur in all but the youngest patients. Short splints are buckled round the thigh, and stout papers, like the Field, folded in four, make very good ones, requir- ing no padding. Extension, elastic or fixed, is easily made from the foot- piece, and the limb is supported by strips of bandage. The foot can be slung at any height to meet tilting of the upper fragment. A fracture of the shaft in young children is very difficult to treat, on ac- count of their small size and restlessness. In very young children no plan can compare with that used at Guy's, which may be called vertical extension. It is best made by means of a weight and stirrup running well on to the thigh; the block through which the cord runs is vertically above the hips, and the weight must be sufficient to maintain the length of the limb thoroughly. The child can then be lifted for purposes of cleanliness without any fear of displacement; or both legs may be rigidly tied to a crossbar, so that the pelvis is very slightly raised from the bed. For children of four or five, Hamilton's double long splint, with a cross- FRACTURES OF THE PATELLA. 269 bar at the lower end, acts well. Both limbs are secured, short side splints, and weight extension if necessary, being used. The child can be lifted and turned at pleasure. In supracondyloid fractures, in which the lower fragment is drawn strongly back into the ham by the gastrocnemius, the ordinary practice is to treat the fracture by some form of double inclined plane. The objection to this is that these fractures often implicate the joint, and, if ankylosis occurs, a flexed position of the knee will be most unfavorable. It is probably better to divide the tendo Achillis, and to use the long splint with weight extension, which treatment yielded good results in three cases (Treves, British Medical Journal, 1883, vol. i/p. 306). Fractures of the femur aie best kept in bed until there is no longer any tendency to displacement—i. e., six, eight, or ten weeks. Even then it may be necessary to apply some supporting hip-splint of starch, plaster, or leather, and to sling the limb by a bandage passing round the neck and under the foot, whilst the patient gets about on crutches. Until there is no danger of shortening this sling should not be used. In old people and others whom it may be desirable to get out of bed before union has occurred, a Thomas's hip splint applied with plaster bandages will give the best result; the patient walks on a patten with crutches. If this cannot be obtained, the whole limb may be put up in starch or water-glass, finishing above with a hip spica; the splint must be strengthened round the hip with strips of mill-board, tin, etc. Fracture of the Patella is of two kinds, according as it is caused : (1) by muscular action ; (2) by direct violence. Fig. 93. An old fracture of the patella, with wide separation of the fragments. The patient fractured the bone twice. The first time he was treated with bandages, etc., to bring the broken parts together, and they united well. The second time the limb was laid in an easy position without bandages. The result is here Bhown; the upper fragment high up in front of the femur; the lower one down in front of the tibia; the power of extending the joint lost. When the knee is bent, as in the above cut, the condyles of the femur are seen with the skin tightly stretched over them. Fracture of the Patella by Muscular Action generally occurs thus: A person perhaps misses a step in going downstairs, or misses his footing after a leap, and makes a strong effort to save himself from falling ; the knee 270 INJURIES AND DISEASES OF BONE. Fig. 94. is bent, and the patella lies on the convex surface of the condyles ; the sudden contraction of the rectus snaps it across. Signs.—The patient feels and often hears a sudden snap, falls to the ground, and has much difficulty in rising, being unable to straighten the knee. Once up and resting on the limb, the patient may discover that he can walk backward, dragging the injured limb back after the sound one, The surgeon finds the joint swelling from effusion of fluid, and it may become very tense; there is a transverse interval usually at or below the middle of the patella, varying in width from a just perceptible chink to a gap two or three inches wide, and increased by bending the knee. Mode of Union.—After ordinary treatment by splints, bandages, etc., bony union is very rare; close fibrous—under half an inch—is perhaps the rule, but it may be long and weak from the first; in other cases, again, when, after six or eight months of treatment, the patient is allowed to bend his knee, an originally short fibrous bond stretches, the fragments separate more or less widely, power of straightening the knee, and of keeping it straight is, as a rule (to which there are few striking exceptions), propor- tionately lost, and the patient is lame and in constant danger of falling and of refracturing the patella, or of breaking the opposite one. In cases of refracture, the fibrous bond does not usually yield, but it tears off a fresh bit of bone, usually from the lower fragment. Fig. 94, A, shows the fragments united by short fibrous union. In B the fragments are close together and equally everted; in C they are widely separate, and the lower only is everted. Mr. W. Adams has shown that in the cases in which patients recover with wide separation of the fragments (in some cases as much as four or five inches), there is no ligamentous union at all, the fragments being held together by the subcutaneous fascia in a thickened condition ; so that what is commonly called union by a long ligament is in reality no union at all. Mr. Adams supposes that the fascia adheres to the sur- face of an everted fragment as in C, or to both, as in B, and thus prevents further union. There are also cases of short fibrous union which subsequently stretch, The causes of non-union appear to be separation of the fragments by muscular action, by effusion into the joint, and by their resting upon the convex surface of the femur, which tilts forward the broken surface of the lower frag- ment more especially, and by the intervention of clot and torn tissue between the fragments. Some surgeons deny the effect of muscular action, attributing the separation to effusion (Hutchinson, Heath). It seems fairly certain that both are causes of separation. Treatment.—The simplest plan is, first, by position, to relax the muscles which tend to separate the fragments. With this view, raise the patient's body on a bed-rest to an angle of 45° with the bed, and the injured limb, straightened upon a well-padded back-splint, also to 45°; thus are relaxed the rectus, crureus, and vasti. Secondly, to bring the fractured surfaces into as close apposition as possible, it is necessary: first, to prevent effusion, or remove it if already present. It may be prevented by rolling elastic web- bing round the joint, or by the immediate application of a plaster splint over wool, from the foot to the groin (C. Heath), and these also prevent tilting ; it may be drawn off by aspiration, repeated if necessary, unless coagulation has occurred. In some cases separation is slight, and position and a simple See Mr. W. Adams's paper in Pathological Transactions, vol. ii. p. 254.. treatment of fracture of patella. 271 splint are sufficient; in others much ingenuity is expended in endeavoring to draw the fragments together. A figure-8 bandage or strapping is the commonest plan, and is used with Wood's splint (Fig. 95), which is typical of many, This is a straight light iron splint, provided with two movable hooks behind the knee. Over these the folds of a figure-8 bandage are passed, including Fig. 95. Wood's splint for fractured patella, applied. in each opposite loop one of the broken fragments and drawing them together. In emergencies the same mechanical effect may be obtained by a straight broad splint of wood, well-padded, and placed behind the limb. Notches may be made with a saw in the edge of the splint at the proper place for fixing the figure-8 folds of bandage, or two stout nails or screws may be placed behind in the places of the hooks in Wood's splint. Figure-8 straps and bandages applied only above and below the fragments tend to increase their eversion; pressure should therefore be made uniformly over the joint. It is doubtful whether figure-8 straps ever do much. Very good results are obtained by the use of an immovable splint from the first, the patient being allowed after a week to go about on crutches with the limb slung. The apparatus should be worn for two months, and should then be changed for a leather knee-cap, preventing flexion, which must be worn for four months more; then the patient may begin to bend the knee. Sometimes movement is quickly recovered; at others there seems almost complete ankylosis. To remedy this an India-rubber accumulator may be worn constantly behind the knee; then, perhaps, the bond of union will stretch. Thomas recommends the use of his knee-splint applied as usual, with extension ; a piece of elastic webbing is sewn to the bandage round the leg, and then moderately stretched and stuck on to the skin of the thigh by lead- plaster on its under surface. Constant traction on the skin is thus obtained, and slight pressure on the fragments to prevent eversion. The patient walks about after the first few days. It must be worn, at least, nine months, and it may be two years before movement is restored to the joint; but Thomas does not interfere with nature. Mechanically, the most effective instrument for treating fractured patella is Malgaigne's hooks (Fig 96). Two of these are fixed into the tendon at the upper edge of the bone, and two into the lower, and they can be brought and kept in apposition by the screw. If properly applied they cannot pene- trate the bone nor wound the joiut. They may be kept in six weeks to insure bony union. Malgaigne had treated (1853) about eleven patients, producing bony union, with no bad results. In several cases treated in the London hospitals, however, erysipelatous inflammation and burrowing of 272 INJURIES AND DISEASES OF BONE. matter from the wounds have endangered both the limb and life of the patient after the use of Malgaigne's apparatus. In view of the length of time occupied in the above treatment, and of the frequently unsatisfactory results, and of the dangers of Malgaigne's hooks as ordinarily used, Lister has proposed to treat recent fractures of the patella by opening the joint and wiring the fragments together (Bntish Medical Jour- nal, November 3, 1883), with the proviso that no one shall attempt the operation who does not feel certain that he will keep the wound aseptic. The operation is thus performed. A two-inch incision is made down the middle of the patella, having its centre opposite the frac- ture, and deepened till the joint is opened and the frag- ments bare in the line of the wound. All fluid is pressed from the joint, and clot, etc., scraped from the fractured surfaces. With an ordinary brad-awl oblique holes are now made from the superficial to the fractured surfaces at points as nearly as possible corresponding, and a piece of silver wire -fa inch thick, is pushed into each hole as the awl is withdrawn; a hollow needle like Thomas's (Fig. 73, b) would greatly facilitate its passage through the second fragment. A pair of dressing forceps is next pushed from the deepest part of the joint on the outer side through to the skin, cut down upon, opened so as to tear a free passage, and then a short drainage tube is pulled into the joint as they are removed. The frag- ments are now drawn strongly together by pulling on the wire with sequestrum forceps, and the wire is then twisted through more than half a circle (Fig. 44), its ends cut short, and the two kooks hammered down. The skin wound is sewn up closely. Passive movement should be begun on the third day, and the patient may be dis- charged walking in six weeks. The results of this operation will vary with the skill of the surgeon in the use of antiseptics. Of 20 completed cases collected by Turner (Clin. Soc. Proc, 1883), union seemed bony in all but 1; movement was perfect or good, most of the patients being able to kick strongly, in 16, although 2 of these suppurated; in 1 union was fibrous; and in 3, more or less complete ankylosis resulted. One of the latter was again broken, the teguments also yielding, and the compound fracture required resection of the knee. A similar case of refracture has occurred. It is probable that imperfect appo- sition of the fragments caused weak union, hence the necessity for great care in bringing the fragments accurately together. The dangers to life and limb, then, are at least as obvious as the advant- ages of the operation. Each surgeon must decide for himself whether and when he will undertake it, so much depends upon his general success in keeping wounds aseptic. We think that it should not be done in recent cases without strong special reasons; for even Lister cannot be certain of asepsis. But in the treatment of old fractures with long union or none, and dis- abled limbs, all are agreed that the above operation is the proper treatment. In these cases it is sometimes extremely difficult to bring the fragments into contact; in one case they were left one inch apart after division of all strong tendons and bands around (Jordan Lloyd). Of 28 completed cases (Turner, loc. cit), there were 2 deaths from pyaemia and acute septicaemia, the latter after amputation for acute suppuration in the joint; in 9 cases complete, and in 3 partial, ankylosis resulted, more or less suppuration occurring in all but Fig. 96. Malgaigne's hooks for fractured patella. FRACTURES OF THE LEG BONES. 273 1 of each kind; in 1 the operation was abandoned, as the fragments could not be drawn together; in 1 the union was obviously fibrous, 1 broke again during passive movement, but was ultimately improved, and in 11 the result was good. All except those that died were benefited, as their joints were previously useless, but many were evidently in considerable danger. Doubt- less the results will improve as surgeons become more experienced in anti- septic treatment. If acute inflammation or suppuration occur during simple treatment or after wiring, employ the treatment for suppurative arthritis. 2. Fracture by Direct Violence is generally comminuted, rarely longitudinal. There is usually much inflammation, but not much separation of fragments; so that immobilization of the joint in the straight position, and relaxation of muscles, suffice until inflammation has been subdued. Then, if desirable, an immovable splint may be applied. If there is any injury of the skin, render it aseptic, and wrap the joint in a large quantity of salicylic wool with uniform pressure. 3. Compound Fractures may be treated by wiring of the fragments, unless the other bones of the joint are comminuted, when excision will be necessary, or amputation if the soft parts are torn away or the popliteal vessels injured. If the facilities for antiseptic treatment are slight, and it is necessary that the patient should be transported any considerable distance, the surgeon will lean towards amputation rather than excision, where one or other is necessary. Fractures of the Leg.—Both bones may be broken, or either tibia or fibula alone; the sound bone in the latter case acting as a splint, tending to prevent displacement of the fragments and rendering the diagnosis otherwise difficult. These injuries usually result from indirect violence, such as falls upon the feet, from which an oblique fracture of the tibia from behind downward and forward at about the junction of the lower and middle thirds (thinnest point) usually results; the fibula may yield at the same level or near its neck. In this ordinary fracture of the tibia the upper fragment is sharp and pointed, lies immediately beneath the skin, and is easily forced through it by attempts to stand, by the weight of the unsupported foot if the patient is carelessly lifted, or by action of the calf muscles. Hence compound fractures of the tibia are more frequent than of any other bone. But fractures from direct violence are not uncommon, the bones breaking at the points affected, and the fracture of the tibia being more transverse and often comminuted; these injuries too are often compound, the skin being cut by the sharp crest of the tibia. When involving either end of the tibia they frequently extend into the joint. The more transverse a fracture is, the less the displacement. The long calf muscles always tend to cause shortening by drawing the lower fragments up and back; in fractures of the tibia high up, the quadriceps extensor often seems to pull the upper fragment forward. The diagnosis of fracture of both bones is usually easy; and the tibia, being subcutaneous, generally causes no difficulty—inability to stand, and some slight irregularity, localized pain, swelling, and tenderness being found at a point not directly injured even when the positive signs of fracture are slight. In the upper two-thirds of the fibula the diagnosis may be impos- sible ; pain constantly referred to one spot when the bones are pressed together at a distance from that spot is very significant. The fibula breaks most commonly about three inches above the malleolus. Treatment.—For mode of reducing displacement, if present, see p. 231. To guard against rotatory displacement, the rule is to keep the ball of the great toe in line with the inner edge of the patella. When a leg is extended, 18 274 INJURIES AND DISEASES OF BONE. these two points and the anterior superior iliac spine are practically in line. Considerable care is required to guard against rotatory deformity with certain splints (Arnold, Macintyre), which, whilst they fix the foot, allow the femur and upper fragments to rotate out; the patient then recovers with the toes turned in, a much commoner deformity than the converse one. The ideal spint should allow the fragments to move together, but not separately. There are many plans of treating these fractures, the most generally useful being the immovable splints, Cline's leg splints, Macintyre's and Arnold's splints. Whenever it is deemed safe to put a fracture of the leg up in plaster at once, there can be no better treatment; if swelling is at all feared, raise the foot well, or employ even vertical suspension for twenty-four to forty-eight hours. When this is not desirable, fractures below the middle of the leg are generally best treated by buckling two Cline's splints (each with a foot- piece) firmly to the limb, whilst it is held in good position, and then apply- ing a bandage which can be removed without disturbing the fracture. The limb may be slung in a Salter's cradle, or, if there is much difficulty in pre- venting upward and backward displacement of the lower fragment, it may be laid upon its outer side with the hip and knee fully bent, and the knee supported by a pillow if necessary. The patient soon gets used to the posi- tion, which relaxes the calf muscles. In fractures above the middle of the leg it is necessary to control the thigh, the upper fragment not giving sufficient hold for the splints. This is done by Macintyre's and Arnold's splints. The hip should be flexed and the knee straightened as much as possible to relax the quadriceps extensor. Macintyre's splint is very useful in cases where displacement is reduced by keeping the knee at a certain angle, for its angle can be varied at will. It is straight, and only part of the thigh-piece is shown in Fig. 97. One must Fig. 97. Macintyre's splint. be chosen in which the foot-piece is not driven by the leg to the end of the slots in which it runs. Then the foot should be sewn into a close-fitting flannel sock having tapes attached to the plantar surface of the heel; these are tied to a button on the under surface of the foot-piece, and suspend the foot to it at a proper height without making any special pressure on the heel. Next fix the foot firmly to the foot-piece by strapping. Now adjust the angle of the splint, see that there is no rotatory displacement, and bandage from above the fracture up to the top of the splint. Having thus obtained a fixed point, such extension as may be necessary is made by dragging the foot and foot-piece downward, and then fixing the latter by screwing up the screws upon which it runs in the slots. Lastly, a figure-8 bandage round the foot and ankle, reaching up to the fracture, is applied. The splint is intended treatment of fractures of the leg. 275 to be fixed to a block of wood ; but this should never be done. It should always be slung to allow the foot to rotate out with the femur. Macintyre's was formerly a favorite splint for the treatment of compound fractures; the wound was left exposed, and endeavors were made to prevent the pads from becoming soaked with putrid discharge. Arnold's splint consists of a flat iron foot-piece and back splint bent to about 160 degrees opposite the knee. The limb is fixed to this (properly padded), and then a padded wooden splint is buckled on each side of the leg. The apparatus is slung by two straps passing through slits in cross- pieces attached to the back splint, and through similar slits in the cradle. Friction prevents the splint from turning, the foot remains vertical, and the femur and upper fragment rotate out within the bandage. This splint should therefore be slung with the toes pointing a little outward, as in sleep. In the United States fractures of the leg are usually treated by Dr. Buck's method, the American stirrup (Fig. 98). This consists of a broad strip of Fig. 98. Weight extension by the American stirrup. strong adhesive plaster, attached by its ends to the sides of the leg below the fracture, leaving a long loop, a, below the heel. The ends of plaster are fastened to the leg by imbricated cross strips, c, and the sides of the loop are prevented from pinching the sole by a piece of wood, b, wider than the mal- leoli. To the centre of the piece of wood is fastened a cord, which passes over a pulley, d, fastened to the foot of the bed at the proper level. Exten- sion is made by a weight, e, sufficient to neutralize the action of the muscles. Counter-extension is provided for by raising the lower part of the bedstead, /, on wood-blocks. Coaptation splints (Cline's) are also used to the fractured part, when the fracture is oblique. Fractures of the fibula generally require six, of the tibia seven, and of both bones eight weeks to unite. When a joint is involved,passive movement should be begun in the fourth or fifth week, and the joint should always be treated in that position which will be most advantageous should ankylosis result. Fractures in the Vicinity of the Ankle are of several kinds. (1) Simple fracture of the fibula three inches or less up. (2) Ditto with frac- ture of the internal malleolus or rupture of the internal lateral ligament of the ankle. (3) Fracture of the lower ends of the leg-bones with fissure into 276 injuries and diseases of bone. the ankle-joint, and sometimes driving up of the astragalus between the mal- leoli, causing characteristic widening of the part. (4) Fracture of both malleoli with displacement of the foot backward. The second variety is that known as Pott's fracture; it results from violent twists outward of the foot. The foot is usually everted, sometimes extremely so, and sometimes it is also displaced backward. Cases have occurred in which these displacements, especially the latter, could not be overcome, even under chloroform and after section of the tendo Achillis. All these injuries are best treated by Cline's splints or plaster of Paris. In extreme eversion Dupuytren's splint (Fig. 99) is sometimes used. It is a Fig. 99. Dupuytren's splint applied. straight plank padded so thickly opposite the lower half of the leg—down to the internal malleolus—that the foot cannot be dragged in to touch the wood. It is fixed above first; then the foot is drawn in by a figure-8 bandage. Compound Fractures of the leg are treated on the principles laid down at p. 238. The best splints are Cline's, one or two, outside the dressings, where the discharge is likely to be free; Arnold's splint when the fracture is high up; and a fenestrated immovable splint (p. 233) as soon as possible in all cases, and from the first in cases neither due to great violence nor largely compound. Fractures of the Foot.—Simple fractures are rare, generally due to falls on the feet, and most commonly affect the calcaneura. If the tuberosity is torn off and drawn up by the calf muscles, the treatment is complete flexion of the knee and extension of the ankle as for ruptured tendo Achillis. A fragment of the astragalus may be thrown out of its place forward or back- ward and to either side; if irreducible, antiseptic excision will be necessary. Usually in these cases there is little displacement, and immovable splints fulfil all requirements. Metatarsal bones are sometimes broken by direct violence. Compound fractures are usually attended by so much damage to soft parts that amputation is necessary. When in any doubt put the part up antiseptically and wait: always save as much as is possible, especially the heel and ball of the great toe. diseases of bone. 277 CHAPTER XXYI. DISEASES OF BONE. Atrophy of the Bones is marked by diminution in weight, the size, as a rule, remaining unaltered. The bone may be reduced to a thin shell of compact tissue and the cancelli to fine threads, the meshes between which are filled with fat. The causes are: 1. Disuse, atrophy being extreme in the tarsus, for example, in old-standing cases of knee-joint disease; and this atrophy must be remembered when undertaking the reduction of old disloca- tions. 2. Old age ; the long bones suffer chiefly. 3. Pressure, seen in the effect of chronic hydrocephalus upon the skull bones and of aneurisms and tumors pressing upon but not invading the substance of bones. In all these cases Wagner states that absorption is effected, as in normal growth, by myeloplaques. 4. It occurs in some forms of mental disease and especially in general paralysis. Sometimes fragilitas ossium occurs in people otherwise apparently healthy, and it may run in families. Hypertrophy of Bones is occasionally met with as a congenital defect, or as the result of hyperemia of the part, from the existence of a large ulcer, of inflammatory disease near the epiphysis, etc. Most cases of enlarged bones are distinctly due to inflammation. Arrest of Growth must be distinguished from atrophy. It occurs especially in parts the seat of spinal paralysis before growth is complete, also in cases of disuse. Early ossification of the epiphyses after dislocation, epiphysitis, or rickets has a like effect. Neuralgia in Bone.—The bones, like other parts, are subject to that severe and continuous pain which is known by the name neuralgia. The patients are generally women; the part affected the condyles of the femur, or the head of the tibia or humerus. Deep-seated abscess, syphilitic or tubercular deposit, may be mistaken for neuralgia in bone. (See " Diseases of the Nerves.") Inflammatory Processes in Bone. General Pathology. A " bone" in the living body consists of compact and cancellous bony tissue, and is covered by the vascular periosteum, whilst its internal spaces are filled with yellow or red marrow, according to the particular bone and its age. Running through the bone are a number of fine channels, contain- ing vessels and a little connective tissue running between the periosteum and the medulla. Each of the soft parts of a bone—periosteum and medulla— may be primarily and chiefly inflamed; but it must be remembered that very frequently periostitis and osteomyelitis occur together. The inflamma- tion may be acute or chronic, and all degrees of the process are met with from the least to the most intense. The bony tissue takes no part in the process; it suffers only secondarily, and becomes either thickened, eroded, or dies. But it is the custom to speak of inflammation affecting the soft parts in Haversian canals or cancellous spaces as ostitis. Periostitis is characterized by cell-exudation into the deeper layer of the periosteum, raising up the superficial fibrous layers and stretching them tight; ait the same time the vessels entering the Haversian canals are more or less stretched and drawn out vertical to the bone surface. We now find 278 DISEASES OF BONE. upon the surface of the bone a low swelling usually called a node, dying away gradually at its edge, red or purple in color, and either soft and gelatinous or hard and fibrous in appearance, according as it consists largely of round cells or of spindle cells and fibrous tissue. The surface of the bone appears unchanged ; the microscope shows cells invading the Haversian canals, but as yet little or no erosion has taken place. This is simple periostitis. The cell infiltration may rapidly or slowly break down into pus (acute and chronic suppurative periostitis), stripping up the periosteum more or less widely, and finally bursting through it at one or more points. In the acute case hard unaltered bone may be seen and felt through these apertures; it is white, all superficial vessels have been destroyed, but not necessarily dead. It necroses if the irritant has been so intense as to cause death of the vessels in the Haversian canals, so that circulation cannot soon be reestablished. It is practically certain, however, that an intense irritant directly destroys the life of bone apart from its action through the circulation ; for, in simple fractures, perfectly loose fragments do not die, and under aseptic conditions bone may be transplanted. Total necrosis is sure to occur if suppurative osteomyelitis and periostitis occur together. From periostitis alone the bone often does not die in its whole thickness; circulation is maintained in the deeper parts, and the superficial layer is ultimately thrown off by ulceration of the living bone where it joins the dead (p. 61). The dead fragment is called a sequestrum. This process generally occurs upon the shafts of long bones; it sometimes follows an injury or exposure to cold, and usually runs the course of a simple acute abscess, but there is an extremely acute form which is generally infective (acute infective periostitis). In chronic suppurative periostitis, which usually occurs in connection with cancellous bone (vertebrae, tarsal or carpal bones, epiphyses of long bones), and secondarily to a focus of chronic suppurative osteomyelitis or chronic " ostitis," the bone bare at the bottom of the abscess is eroded and softened by the cell-growth of the primary inflammation. In long bones, however, erosion of the shaft, and in short bones of the surface, may start from be- neath the periosteum, the young cells extending thence into the Haversian canals and widening them by ulceration. This process of ulceration of bone is called caries. It is usually scrofulous—tubercles being found in the peri- osteum and also in the spongy granulation tissue which often springs up after the opening of the abscess—and occurs chiefly in the young. A syphi- litic caries is also well known. There is a chronic suppurative periostitis met with especially about the phalanges of strumous children, coupled, not with caries, but with superficial or total necrosis. It is much more common for a periostitis to end in ossification—osteoplastic periostitis—than in suppuration. Bone may form early and rapidly round the bloodvessels running between the elevated periosteum and the Haver- sian canals ; the little tubes of bone form continuations of the latter. To- gether they make up a mass of spongy bone, at first easily detached from the surface of the bone, and containing a highly vascular marrow in its, chiefly vertical, spaces; but as time goes on the line between new and old disappears, and very frequently the vascular spaces in both become abnorm- ally filled up by osseous layers, and the bone proportionally dense (sclerosed). These periosteal deposits are called osteophytes; there may be a layer of uniform or varying thickness over the whole bone, or a ring round, or a patch upon one part, or osteophytes may assume sharp-pointed and promi- nent, or low rounded forms. Whenever a bone is found pathologically thickened, we know that the periosteum has been laying down bone. Chronic irritation of slight intensity is required to cause this form, and VARIETIES OF OSTITIS. 279 syphilis frequently supplies it in cases of osteoplastic periostitis of single and of many bones; but often no cause can be discovered. Osteophytes are common around sequestra and carious foci, over abscesses in bone; and so- called "expansion" of bone, over cysts, tumors, and foci of chronic osteo- myelitis, is due to continuous deposit of bone by the periosteum whilst the deeper parts are removed by the morbid process. Bone sometimes forms in tendons inserted into the inflamed parts, and sometimes loose plates appear in adjacent connective tissue. Ostitis.—We have already said that the hard substance of bone takes no part in inflammation, but suffers only secondarily to the changes which occur in its soft parts; nevertheless the term is justified on the same grounds as myositis, neuritis. Acute Ostitis accompanies acute periostitis or osteomyelitis, but there is no time for naked-eye change in the bone. Consequently, ostitis may be looked upon as a chronic process having two chief results—removal of bone, such as occurs physiologically in the formation of the medullary canal (rarefying ostitis), and the laying down of bone, as in the formation of compact tissue (sclerosing ostitis). Rarefying Ostitis (inflammatory osteoporosis, caries) is due to erosion of bone by a round-celled exudation which replaces the marrow proper. A tarsal bone thus affected will have its spaces full of vascular, grayish, semi- translucent granulation tissue instead of the usual yellow marrow. Where erosion is proceeding, the bony laminae show numerous small semicircular notches (Howship's lacune), and in many of these lie giant cells (osteoclasts). The inflammation may subside and the removal of bone be replaced by its formation, generally in excess of the normal, the result being sclerosis of the diseased part. But very commonly the cell-growth degenerates, breaks down into pus, or caseates and perhaps subsequently softens. Thus a chronic ab- scess forms, suppurative periostitis is either coincident or secondary, and when the skin bursts a soft ulcerating carious surface of bone is left bare (p. 278). The abscess may not burst, but may remain locked in the bone, exciting sclerosing ostitis and periostitis (chronic abscess of bone). Not infre- quently the infiltrating cell-growth dies and caseates before the bony septa around which it lies are absorbed; their blood supply is cut off, and they too die and appear as sequestra in the pus of chronic abscesses. Sometimes a mass as large as a filbert may thus be killed (caries necrotica). The in- flammation, however, by no means always runs these courses. For years it may go on eating away bone without the formation of any pus (caries sicca, fungosa); and the bone, unable to bear the weight thrown upon it, yields and deformity results. Ultimately recovery may occur by the process above mentioned. This is most often seen in the spine and epiphyses of long bones. The causes of rarefying ostitis are many. This is the process by which the ends of broken bones are softened, melted together, as it were, and perma- nently united; it removes also exuberant callus; it is by a caries simplex that bone is removed under pressure from an aneurism ; tumor, etc., or that a sequestrum is loosened. Syphilis commonly produces gummatous infiltra- tion of the periosteum, and, starting thence, of the bone (ostitis), which assumes a worm-eaten appearance; after a time the vessels of the new growth become obliterated (p. 117), it caseates, suppuration follows, and a carious focus is left bare, often with sequestra adhering to it, as seen in syphilitic disease of the skull. Around it osteoplastic periostitis and sclerosing ostitis are generally marked. By far the greater number of cases of caries are those known as scrofulous; all those affections of the spine, carpus, tarsus, phalanges, and spongy ends of the long bones which are so common in chil- dren and young people. There is no longer any room for doubting that the 280 DISEASES OF BONE. great majority, if not all, of these cases are tubercular. Their microscopic anatomy (gray granulations being tolerably frequent), the frequent demon- stration of B. tuberculosis in the granulation tissue and the inoculability of pus from it, the pathological course of the cell-growth, the clinical course of the disease, and especially the frequency of general tuberculosis among the causes of death, unite to make the demonstration complete. Sclerosing or Condensing Ostitis corresponds to other " productive " inflammations; in bone the cell-growth ossifies. New bone is laid down by the medulla; Haversian, cancellous spaces, and medullary canal are more or less completely filled up, and the bone becomes solid, heavy, ivory-like, and frequently enlarged from coexisting osteoplastic periostitis (hyperostosis eburnea). Its cause, like that of osteoplastic periostitis, is a chronic irritant of the lowest intensity. We find it round about a sequestrum, an abscess in bone, or a carious focus (though least commonly when this is tubercular). Some cases are due to syphilis; but it is often impossible to discover the cause, especially in cases where many bones are affected. Osteomyelitis.—Having considered the chronic affections of the marrow under the varieties of ostitis, we have now to speak only of the acute inflam- mations, which may be spontaneous or traumatic. In spontaneous diffuse osteo- Fig. 100. Fig. 101. The result of osteoplastic periostitis and Necrosis of the humerus from acute infective sclerosing ostitis. osteomyelitis. myelitis the medulla becomes at first intensely hypersemic, then cedematous, swollen, and of purple color, often clotted with actual hemorrhages; on section the marrow projects above the level of the saw cut. Next yellow streaks and patches appear, so that the aspect is variegated—yellow, red, and pur- ple ; but distinct abscesses do not form, the suppuration being diffuse. The periosteum is always affected, and in many cases it appears to be the starting- point of the disease. The pus beneath it often contains globules of oil, forced SYMPTOMS AND TREATMENT OF PERIOSTITIS. 281 out from the medulla. When suppuration occurs on both sides of a bone, it dies of necessity in its whole thickness; and there is great danger that it will die either superficially or centrally when pus forms on one or other sur- face as the result of so intense and acute an inflammation. The inflamma- tion may remain fairly localized or may spread from end to end of the bone, causing separation of both its epiphyses and death of the whole shaft. Some- times one or other joint suppurates. Sometimes abscesses form in the soft parts around the bone. The veins leading from the bone are thrombosed, and in many cases contain clots un- dergoing puriform softening, having become infected from the abscess. It is thus that this disease is so frequently associated with secondary foci of suppuration in the viscera, serous cavities, etc.—complications which may appear before the skin is broken. The pus invariably contains micrococci, which have been cultivated, found to have a characteristic growth, and in- jected into animals without injurious effect until bones were broken or bruised, when suppurative osteomyelitis set in. In man a history of injury or cold is frequent. Some regard these cocci as not only the cause of the disease, but as organisms specific to the disease; others (Kocher, D. Zeitschr. f. Chir., xi.) as organisms which would excite suppuration wherever they lodged. The disease has occurred during many acute specific fevers, but whether or no from the action of the causes of these diseases is unknown. Diffuse traumatic osteomyelitis starts from septic amputation, wounds, and compound fractures, the medulla being invaded by organisms from the wound (Klebs). The morbid appearances are much the same as those above given; but the periosteum is only slightly affected, the marrow projects from the end of the bone like a fungus, and becomes gangrenous, putrid, and discolored, whilst it is quite sweet in the spontaneous form. Embolic pyaemia and acute septicaemia are frequent complications. Severe compound contusions of bone may be followed by this disease. It may affect flat and short bones, as well as those of the limbs. Traumatic osteomyelitis is not usually diffuse; it may be very limited, leading to the death of only a small portion of bone, such as the ring-shaped sequestrum which so often separates in septic stumps. Small sequestra, indeed, frequently form in aseptic stumps, the saw having, presumably, killed them directly. We must now turn to the clinical side of bone diseases. Acute Periostitis (p. 277).—There is usually a history of injury, expo- sure to cold, syphilis, or the patient is suffering from acute rheumatism or one of the acute specific fevers. It generally occurs on thinly covered bones, especially the tibia, ulna, clavicle. The symptoms are more or less acute pain and tenderness, swelling fixed to the bone and dying gradually away at the edge, and the skin over it being but little affected. The ending is usually resolution; but the case may run on to suppuration, when the skin reddens and swells, the fever rises, and all the symptoms become more severe. The process is circumscribed, and necrosis is superficial, or does not occur. Treatment.—Rest, elevation, belladonna, and fomentation in all acute cases ; early incision if pus forms; iodide of potassium, if there is any history of syphilis, and anodynes for pain. In prolonged cases, marked by constant pain worse at night, a subcutaneous cut through the node down to the bone often gives great relief. Chronic Osteoplastic Periostitis and Sclerosing Ostitis may result on the subsidence of an acute inflammation, or be due to syphilis, to the presence in the bone of a sequestrum, an abscess, or a carious focus, especially 282 DISEASES OF BONE. syphilitic. Sometimes many bones are affected, and without obvious cause; in children a suspicion of congenital syphilis will be justified. The symptoms are enlargement and weight of one or more long bones in whole or in part, with much aching pain, worse at night, and in damp, cold weather. Treatment.—Iodide of potassium internally, and constant warmth locally, will usually relieve the nocturnal pain ; in tolerably recent cases counter- irritation may do good. Of course, any local disease will be looked for and treated, especially abscess. A linear cut into the b6ne with a Hey's saw fre- quently relieves the pain of chronic subcutaneous nodes; trephining is still more efficacious. Acute Primary Infective Periostitis and Osteomyelitis (Liicke). (Acute Necrosis, Typhus des Membres, Acute Necrosial Fever).—This dis- ease affects long bones, usually those of the lower extremity and almost always occurs before the epiphyses are ossified. It often follows injury or exposure to cold, but these are only predisposing conditions; it is almost certainly due to the action of some generally infective organism—perhaps the micro- coccus which has been isolated (p. 281.) Symptoms.—The patient is taken ill, usually suddenly, with high fever and perhaps a rigor and delirium ; there are severe pain and tenderness at the affected part, so that the limb may be quite helpless; after two, three, or more days, according as the disease begins in the periosteum or medulla, the part becomes cedematous and more or less reddened, varying with the depth of the bones. After some days crepitus may be obtained at one or both ends of the inflamed bone, indicating separation of the epiphysis; and the symptoms of fluid in a joint may be added. The fever continues very high; and at any time the rigors and metastatic inflammation of embolic pyaemia may set in. The result may be death from septicaemia or pyaemia before or after the opening of the abscess; or, later, from hectic or some intercurrent disease. There is reason to believe from the early symptoms that some cases of this disease abort before suppuration occurs; and Beck says that those cases end in enormous thickening of the bone. In the great majority of cases abscess occurs and spreads rapidly until it is opened or bursts ; necrosis almost inva- riably results—total, superficial, or central; and, as a rule, great and general thickening of the bone follows. Early ossification of the epiphysis is likely to occur if the part is separated, or the sequestrum approaches it nearly. If the epiphysis is uninjured, growth may be abnormally rapid under the stim- ulus of increased blood-supply. Treatment.—At first, fever is the only symptom to treat. So soon as it is evident that deep-seated inflammation is its cause, foment assiduously. If the case gets worse, watch carefully for the earliest reddening or certain fluctuation, find the point of maximum tenderness and swelling, and make a free incision here under antiseptics right down to the bone. It is better to incise before pus is present than after it has bared the shaft from end to end. When the pus is evacuated, unless the patient is already suffering from pyaemia, the temperature falls considerably, but is usually some time in reaching normal. Separation of the sequestrum and thickening of the femur then proceed. If one epiphysis is loose it should be kept in position by apparatus. Look to drainage, and await the separation of the sequestrum and the formation of a shell of new bone. If both epiphyses are loose, some surgeons still allow the shaft to remain as a spanner to keep them apart; but most surgeons remove it in one piece or after division with the chain shaw. Extension is kept up and the periosteum forms new bone. NECROSIS. 283 The nature of fluid in a joint should be ascertained before anything is done ; if it is pus, amputation is indicated. Lastly, if symptoms of pyaemia set in, or if the patient is obviously losing ground, either after the opening 01 the abscess or later from suppuration, amputation should be done. Diffuse Traumatic Osteomyelitis, such as results from septic amputa- tions, resections of joints, contusions of bone, compound and especially gun- shot fractures, the general symptoms, pain, and swelling, are very similar, but the pus formed in the medullary canal escapes in quantity by the open- ing. The soft parts retract from bone which has necrosed, as is specially well seen in contused skull bones in which this process has arisen. Treatment.—There are three methods : (1) In slight cases drainage and antiseptics may be employed, and the separation of the sequestrum awaited. (2) In severe cases the choice lies between amputation or reamputation at the joint above, and (3) removal of the whole of the marrow with a sharp spoon, and applying iodoform freely to the interior of the bone. If it is probable in a compound fracture that amputation will ultimately be re- quired, and also that the patient will have a fair chance of recovery if amputation is done at once, this treatment had better be chosen. Under other circumstances scraping out of the medulla should be tried. Stoll has reported six and Petrowski eight successful cases occurring in stumps; and Keetley, in a recent fracture of a chronically inflamed femur, scraped out the marrow from end to end and then wired the fragments, union without necrosis occurring. Chronic Abscess is a rare consequence of ostitis, and is usually tuber- cular; there may be a history of injury. It occurs in cancellous bone, especially in the extremities of the tibia; much more rarely in the medulla. For mode of origin, see p. 279. A cavity lined with a vascular membrane, and filled with pus, is formed in the substance of the bone, which is usually very dense around it (Fig. 102). The whole bone may be much thickened. There may possibly be a small piece of necrosed bone confined in the cavity, or some caseous stuff. Symptoms.—Abscess may be suspected when, in addition to permanent inflammatory enlargement and long-continued tenderness, there is a fixed tensive pain at one particular spot, aggravated at night, and unre- lieved by any remedy, though it may have occasional remissions. Abscess is only one of the causes of osteoplastic peri- ostitis (p. 278); strictly localized pain and tenderness render it the probable one. There is always danger that abscess near an epiphysis will burst into the joint, causing destructive arthritis, or into the epiphysial line. Treatment.—Suspicion of abscess justifies the per- formance of linear osteotomy—i. e., a saw cut into the bone, with antiseptic precautions. The treatment will do good any way; and if pus wells up along the saw a small trephine will soon give sufficient drainage. Fig. 102. % mm Abscess in the tibia; cavity lined by smooth glistening membrane. Necrosis. Extensive necrosis occurs almost solely in compact tissue like the shafts of long bones, but necrosis of small fragments is frequent in cancellous bone, and a whole epiphysis may die. Its immediate causes may be enumerated thus : direct injury killing everything, or stripping off the periosteum and 284 DISEASES OF BONE. Fig. 103. bruising the medulla—e. g., in amputation ; acute or chronic suppurative periostitis or osteomyelitis, and especially both together; rarefying ostitis caseating before the bone is absorbed ; sclerosing ostitis, causing obliteration of the vascular canals over a considerable area, which dies as a consequence. Sir J. Paget has described this last variety as quiet necrosis; there is no suppuration, but the presence of the sequestrum helps to keep up the ostitis. The patient suffers from all the symptoms of chronic osteoplastic periostitis; ultimately spontaneous fracture may occur. Then the diagnosis made is likely to be " malignant growth," amputation is performed and the seques- trum found, probably only partly separated. If fracture does not occur, the trephine, used to relieve pain, may reveal the dead bone. That the seques- trum is not separate, even after many months, is owing to a continuous slow spread of the sclerosis and consequent necrosis. In many cases we do not know the remote causes; but syphilis, tubercle, the acute specific fevers, especially typhoid, and phosphorus in the special case of the jaws, are recognized as such. Separation of Sequestrum and Repair.—When a portion of the shaft of the tibia dies as the result of suppurative periostitis, the pus first of all raises up the periosteum from the bone and then bursts through it at one or several spots. The membrane now granulates and begins to form new bone, leaving apertures of varying size where it has itself been destroyed. We thus get formed a shell of new bone with holes in it (cloace), through which pus escapes and a probe passes down to touch the sequestrum. Meanwhile a rarefying ostitis has been excited all round the sequestrum, the groove of demarcation has formed, and in the course of months or even years, according to the size of the sequestrum and the bone affected, the femur and flat bones taking the longest time, the piece of dead bone is thrown off, or becomes loose in its case. Fig. 103 shows a certain amount of case, but either part has been removed, or the periosteum over the front of the tibia had sloughed and no new bone formed. Fig. 101 also shows a sequestrum in its case. In cases of necrosis from acute suppuration, the sequestrum presents superficially a normal surface ; it is irregular where living bone has been eaten away from it. But in syphilitic necrosis of the skull and cases of tubercular ostitis, the se- questrum is often rarefied from previous erosion, and in other cases it may be dense from previous sclerosis. When the sequestrum is removed from its bed of granula- tions, these grow, fill the cavity, and ossify or form fibrous tissue; the new bone is often sclerosed. The shape of the bone is frequently greatly altered, but improvement occurs with time. Diagnosis of Necrosis.—First there is the history; next, the presence of one or more sinuses through which an ab- scess discharges. These often have large pouting granula- tions at their mouths, and may have been present for months, a circumstance which at once gives rise to the suspicion that bone is at the bottom of it; examination by palpation may reveal thickening of the bone; and a probe passed along a sinus may strike bare bone. In the absence of the two latter signs, however, one would often slit up a sinus to examine more carefully for its cause. It must never be forgotten that bare bone does not mean dead bone. The longer it remains Necrosis of shaft of tibia, incomplete formation of a new shell; involvement of knee and caries of upper epiphysis of tibia. DIAGNOSIS OF CARIES. 285 bare, the greater the probability that it is necrosed ; but even after months no sequestrum may be found, only osteoplastic periostitis and ostitis compli- cated by abscess which left a surface of bone that does not heal. Treatment.—The indication is to remove the sequestrum. As it is im- possible to tell the limits of this until the groove of demarcation has formed well all round, we must wait for longer or shorter periods, as above said. Ultimately the probe conveys the information that the bone is loose, or it is likely that the process of erosion is far advanced, and that a little force will tear away the sequestrum. Then an attempt to remove may be made. A small nodule or a thin flake may be loose in three weeks, and lifted off with a pair of forceps. In larger cases, a free incision must be made near the Fig. 104. Sequestrum forceps. chief sinus, and deepened along a probe if necessary until the cloaca or the sequestrum is reached. If small it may be lifted out; if large, the part must be rendered bloodless, and the case opened sufficiently by chisel and mallet or cutting forceps, to permit the extraction of the sequestrum, after division if this is helpful. As little shell as possible should be removed. Un- less the case is aseptic it is well to sharp-spoon away all granulation tissue before applying sublimate lotion and iodoform to the cavity; this should be plugged with gauze to check oozing, which is often free. It is difficult to keep such long cases aseptic, but every effort Fig. 105. must be made to do so. Amputation is required in cases of fixed sequestrum in which the patient is losing ground; in certain cases of acute necrosis (p. 283); and in cases where a sharp se- questrum has wounded a main artery and in which the condition is so bad that conservation is hopeless. Caries. The nature of caries has already been explained under the heading of rarefying ostitis (p. 279). Speaking roundly, caries is erosion of bone by tubercular inflammation; syphilis is almost the only other cause which need be mentioned. It attacks spongy bones far more often than compact (Fig. 105), the vertebrae being by far the most commonly affected. Diagnosis.—If we take the tarsus, there is a history of pain followed by slow swelling, at first perhaps limited to the region of one bone, later becoming less circumscribed; the skin remains pale, unswollen and movable over the swelling for a long time; but ultimately, as all the signs increase, it assumes a dusky red color, fluid collects beneath it and a carious bone. finally escapes, leaving a ragged purplish opening through which pale granulations can be seen. Perhaps more than one opening forms. A probe strikes soft gritty bone, which breaks down easily, per- haps bleeds, and is tender, differing in all these points from necrosis. Thin 286 DISEASES OF BONE. pus escapes from the sinuses; and when these are connected with a larger focus, the discharge may be very profuse and exhausting. The dangers are chiefly hectic, albuminoid degeneration, exhaustion, and acute tuberculosis. Treatment.—First, attend to the general condition; it is not too much to say that everything depends upon the general health. The prognosis varies almost directly with the patient's ability to carry out expensive treatment, and to spend a long time over it. The diet should be carefully regulated and contain a good deal of milk; cod-liver oil should be taken, with any other remedy indicated ; and the patient should live at Margate, or some other suitable seaside place, changing from time to time. Under this treatment, and dressing with iodoform wool and rest, many cases get well without operation. Among the poor, however, want of time and means necessitate steps to expedite the cure. The tendency of surgery is more and more to treat tuber- cular disease like malignant disease—to extirpate it thoroughly and early, whenever this can. be done, to prevent it from acting as a focus whence bacilli may again be distributed. Accordingly, whenever a carious form Fig. 106. A gouge. is not getting well and it is possible to do so, the part is rendered bloodless, the sinuses are slit up, and the carious bone gouged away as completely as possible; or, if seen early, this may be done when the abscess is opened or the inflamed bone cut into. Sublimate lotion may now be used, then plenty of iodoform and a wool dressing. In more severe cases excision of joints or amputation of parts—as the foot —will be required. Osteitis Deformans. This disease was described by Sir J. Paget in 1876, in Trans. Med.-Chir. JSoc, from which paper this account is taken. The disease begins in middle age or later, is very slow in progress, may last many years without influence on the general health, and may give no trouble than that due to bone changes. Even when the skull is hugely thickened the mind remains un- affected. The disease affects most often the long bones of the lower limb and the skull, and is usually symmetrical. The bones enlarge, soften, and curve ab- normally under pressure. The spine may sink and seem to shorten, with greatly increased dorsal and lumbar curves; the pelvis may become wide, the necks of the femora nearly horizontal; but the limbs, however mis- shapen, remain strong and fit to support the trunk. At first, and sometimes throughout, pains may occur in the affected bones, varying much in severity and character; not nocturnal nor periodic. There is no fever; urine and feces normal; no syphilis; but three of five cases were associated with sarcoma. Post-mortem.—The bones are greatly thickened, the surfaces of some of the long bones slightly irregular. Their compact tissue is wider but less RICKETS. 287 dense than normal; whilst in most cancellous bones the structure is abnorm- ally dense. The skull may measure one inch in thickness. Microscopically the changes are those of ostitis and periostitis; a section through a sarco- matous growth infiltrating bone scarcely differs from one through a simply inflamed part. No treatment is known to be of value. Rickets. This is a general disease affecting especially the children of feeble parents, and probably excited by all debilitating conditions; the chief being bad feeding, bad air, want of light, want of exercise, and dirt. Of course, syphilis often occurs in rickety children and vice versa; but except that syphilis depresses the health there is no reason to regard it as a cause of rickets. The early symptoms are profuse sweating about the head when asleep, throwing off the bedclothes, general tenderness, and dislike of being danced and played with. Changes in the bones now appear. The lines of junction of the shafts and epiphyses of the long bones thicken and swell out; this is most noticeable at the lower ends of the tibia and radius; the junction of the bony and cartilaginous ribs becomes beaded; all the bones soften, the flat bones thicken—or thin under pressure. If able to walk, the child ceases to do so. He suffers from indigestion, and has diarrhoea with pasty, offensive stools; the belly becomes protuberant. If the disease continues, changes in the bones become marked. The stature is stunted; the dorsal and lumbar spine bowed markedly forward, from simple weakness, in an almost uniform curve, but sometimes the curve is lateral; the head is large, long from before back, the forehead high, square, prominent, craniotabes common at posterior angles of parietal, fontanelles slow in closing, dentition late; the face is small, triangular, with very peaky chin; the chest is beaded (rickety rosary), narrow from side to side, prominent in front, with a groove running down each side just external to the beads except where heart and liver support the chest; the pelvis is flattened from before back, if the child i? kept lying, but if walking about the acetabula are thrust in towards the sacrum, as in osteomalacia, and the inlet is triangular; the limbs are bowed in various directions—the humerus out at the insertion of the deltoid, fore- arm bones back above middle, femora forward, tibiae forward or forward and outward; the latter is the most frequent deformity of all. Genu valgum or varum often appears later. The brain, liver, spleen, kidneys, and lymphatic glands are sometimes large from increase of fibrous tissue, and to some extent of essential structure (Dickinson). The urine contains excess of phosphates— e. g., phosphate of lime. According to Sir W. Jenner, the youngest children in large families are most affected. The onset of the disease is generally from six to eighteen months; rarely it appears at six or eight years or even later (late rickets). As a rule the bones are quite strong by twelve, but they are bowed and stunted, the humerus and femur being one-fourth shorter than the average (Humphry), the epiphyses uniting early after subsidence of active disease. Pathology.—The blue line of multiplication of cartilage cells prepara- tory to ossification is much thickened and irregular both towards the bone and towards the epiphysis. Calcification of the walls of the primary areolae (spaces in which the cartilage cells lie) occurs irregularly, patches of bone or of calcification being found in the preparatory zone and patches of large cartilage cells in the formed bone. The primary areolae fuse into the secondary, but as deposit of bone on the walls of these is both slight and irregular, the bone remains weak. Beneath the periosteum there is also 288 DISEASES OF BONE, Fig. 107. excessive production of cells, but calcification is very backward. Absorp- tion of the healthy bone, formed before the onset of the disease, goes on to form the medullary canal; so ultimately the soft imperfect bone has to bear the weight alone. Bending, fracture, thickening at the epiphyses and at the margins of bones growing in membrane (skull) are thus easily explained. Nature usually throws out a buttress of bone on the concave side (Fig. 107) which gives a flat razor-like appearance to the femur or tibia. Treatment.—Diet: mother's milk only for seven to eight months (not longer), then cow's milk, with one- fourth to one-third water or lime-water, sweetened; this may be used instead of mother's milk if that is not forthcoming. The water may be omitted as the child gets used to cow's milk. At least a quart should be given daily; oatmeal, bread and milk, arrowroot, and other starchy foods may now be given, and after twelve months a little underdone meat finely minced, fresh fish, or egg. No sweets, cakes, tea, stimulants, or pre- served meats should be given. The child is not to " live as we do " so soon as it has cut a tooth. The child should sleep alone, in a long flannel night-dress tied below the feet; the window should be open, but the child not in a draught. It should be in the open air as much as possible during the day. A child just beginning to walk should be kept off its feet for a month or two; in older cases that will get about, splints should be applied—wooden ones nicely padded placed inside or outside the limb, extending to the hip, as in genu valgum, or only to the knee. Little straightening can be effected so long as a child walks about, but as the limb grows longer, the curve, if prevented from increasing, will be less noticed. When walking is pre- vented, elastic traction will do a good deal. A tepid bath of salt and water every morning, afterwards a good rubbing with a rough towel and massage of all the muscles of the limbs are very useful. The child should be out in the open air during the day as much as possi- ble in the sunniest and most open spot attainable, in a perambulator or playing on the ground when it is dry. Change of air, especially to the sea- side, is very beneficial. With regard to medicine—cod-liver oil and syrup of the iodide of iron or vin. ferri seem to do more than any others. Rickety deformities of the limbs are dealt with later. A rickety child is liable to catarrh of the bronchi and of the intestine; the former, with its weak chest-walls, is especially dangerous. Laryngismus stridulus is also frequent; chronic hydrocephalus occasional. Rickety tibia, thickening in concavity. Mollities Ossium (Malacosteon, Osteomalacia). This is a disease almost exclusively affecting adult women, especially mul- tiparse, in which the bones become softened and decalcified. In the first stage they are softened and extremely vascular; the marrow in the Haver- sian and cancellous spaces is replaced by a round-celled growth, and the laminae of bone nearest to this present a clear decalcified appearance. The decalcification is, therefore, eccentric; the bone may be absorbed all but an incomplete, thin, subperiosteal shell; and the cell-growth, at first dark or TUMORS OF BONE. 289 light red, becomes pale yellow, gelatinous, and often contains much serum. As the disease advances, the bones become somewhat thickened, and so soft as to be easily cut with a knife. The disease is constitutional, and usually affects almost every bone in the skeleton, although two instances were reported by the late Mr. Hodgson in which it was confined to the lower extremity ; and in one of these amputa- tion was performed. It is liable in women to affect the pelvis, either alone or before any other part. Symptoms.—At the commencement of it, the patient is observed to be out of health, emaciated, complaining of violent achings in the bones, and of very great feebleness and profuse perspiration. Then, from a fall, or other slight injury, a bone breaks; at first, fractures unite, but not so finally, when bone after bone breaks from the slightest cause; the weakness increases, and the patient becomes bedridden ; and now, as the bones bend or break from the slightest influences, the chest and the ribs become distorted to an almost inconceivable degree, and death at last occurs from exhaustion, or from the obstacle which the distorted thorax opposes to the action of the heart and lungs. The fatal issue may not occur for several years in the less severe cases. Softening of the bones of the pelvis in women is indicated by violent aching pains about the hips and pain or difficulty in walking. The result is a heart-shaped pelvis, with long conjugate, and short oblique diameters, the acetabula and sacrum all being pressed toward the mid-point of the pelvis. Of the causes or nature of this disease nothing is known. It is evidently not a mere atrophy. The extreme vascularity of the bones in the earlier stages, and the results of microscopical examination show that they are the seat of a morbid cell-growth. It is stated that this is acid from lactic acid. That the urine is loaded with phosphate of lime (which in a case related by Mr. Solly formed a renal calculus) is an intelligible point in the history of the disease. The relation to repeated pregnancies is marked. The disease is endemic in some places, such as certain Rhine valleys; but sporadic cases, especially those affecting the pelvis only, occur everywhere. It is almost unknown in men. No available treatment is known, beyond common meas- ures for supporting the strength and allaying pain.1 The deformity of the pelvis may necessitate Caesarean section. Tumors of Bone. These are divided into central, arising from the medulla or spongy bone; and peripheral, arising from the periosteum or compact layers. We shall first speak of the primary tumors of bone, all of which really belong to the connective tissue series; then of the secondary, which may be epithelial. Fibroma is not common. It is met with chiefly growing from the perios- teum of the base of the skull, ethmoid bone, maxillary sinus, or lower jaw as a variety of epulis. Myxoma may occur more rarely in similar seats. Removal is the treatment, in either case, with the surface-bone whence the tumor grows. Chondroma is one of the commonest tumors of bone. It occurs most often in the long bones of the hand, and here frequently calcifies and under- goes mucous degeneration, but rarely ossifies. It is common also on the 1 See a remarkable case of softening of the hones, by Mr. H. Thompson, Med. Ohs. and Injuries, vol. v., 1776 (the urine deposited a copious mortar-like sediment); Solly, Med. Chir. Trans., vol. xxvii.; Paget's Lectures, i. 135 ; Dr. Eobert Lee's Midwifery, p. 18; Rokitansky, vol. iii. 19 290 DISEASES OF BONE. Fig. 108. shafts of long bones near the epiphyseal lines, especially at the lower end of femur, upper of tibia and humerus, forming more or less pedunculated growths. These always ossify and form the spongy exostosis (Fig. 108). Lastly, enormous tumors having a large element of cartilage occur about the pelvis and ribs; these frequently are malignant (chondrosarcoma). Treatment.—Chondroma of the fingers is frequently multiple. Little can be done beyond amputating, if the inconvenience or unsightliness is great. Excision may be tried in single tumors, but is not very successful. The ossifying chondroma may be removed if it gives trouble; but the surgeon should be sure of his anti- septics, as the joint may inadvertently be injured. Removal may be attempted in some favorable cases of chondrosarcoma. Osteomata are also common. The spongy exos- tosis has just been dealt with. The ivory exostosis grows chiefly from the skull and face bones. Special seats are the external auditory canal, causing deaf- ness, and the roof of the orbit, causing protrusion of the eyeball. The former has several times been re- moved by working through it with a dentist's drill, which would probably be the safest instrument for the orbit. Sarcomata of every kind occur primarily in bone, even the melanotic and epithelial-like alveolar, which are rare. Sarcomata of bone spread by the blood path and do not involve lymphatics. The central growths are less malignant than the peripheral; they are often myeloid, which growths are common in the lower jaw, less so in the upper, and occasional in the epiphyses of long bones. They cause " expansion of bone " most typically, and in the long bones not uncommonly pulsate, they are so rich in arteries. Sarcomata, largely destroyed by hemor- rhage into their substance, were formerly described as " blood-cysts" of bone. The diagnosis of these tumors must be made from chronic disease of the joint, the chief point being to establish the limitation of the swelling to one or other bones. Freedom and painlessness of movement, steady increase, pulsation or egg-shell crackling may help. The peripheral growths are usually round or spindle-celled, and are in- tensely malignant. They usually have a supporting skeleton of bone (Fig. 19), and may be so completely ossified that they would be taken for an osteoma but for a narrow layer of gray semitranslucent sarcoma-tissue on the surface. The treatment of these growths is the freest removal so soon as a diagnosis can be made; in the limbs by amputation well above the mass—at the next joint if possible. Primary Carcinoma has not been proved to occur. If an undoubted case were brought forward it would have sprung from some misplaced epi- thelial germ. Secondary Carcinoma—either by direct extension from skin or mucous membrane, or by transmission through the blood-path—is common ; the latter especially after cancer of the breast. The first evidence of a secondary Spongy exostosis, King's Coll. Museum. INJURIES AND DISEASES OF JOINTS. 291 deposit may be spontaneous fracture; no tumor may be felt even then, and its growth subsequently may be very slow. The treatment of secondary cancer by extension is that of the primary disease. The probability that where one secondary growth by embolism has occurred there are several, renders it very doubtful whether anything serious should be done for the one discovered or suspected. CHAPTER XXVII. INJURIES AND DISEASES OF JOINTS. Sprains and Contusions. These result from violent twists and blows, and are really contusions and lacerations of synovial membrane, ligaments, tendons, and other tissues in the neighborhood of articulations. The symptoms are pain, often very acute, tenderness, more or less complete loss of function, and rapid swelling—at first from hemorrhage into and around the joint, later from inflammatory effusion from the damaged vessels. This is usually accompanied by a good deal of heat and redness. It is often difficult to eliminate fractures with little or no displacement, especially in sprains of the ankle. The treatment should be absolute immobilization, combined, if possible, with uniform, firm, elastic pressure. This is best obtained by surrounding the part immediately with a large quantity of good cotton-wool, and com- pressing it down to a thickness of about two .inches by bandages applied at first loosely, then tighter and tighter. A splint may be added if necessary to control so large a joint as the knee. Some surgeons employ a splint and ice from the first. When inflammatory symptoms have appeared, fixation and frequent fomentation give most relief. When swelling has subsided, the part may be placed in plaster of Paris, and kept immobile for two to four weeks or longer, varying with the size of the joint and severity of the strain. After a bad sprain, a joint often remains weak or stiff and painful, much affected by changes of weather, especially in the aged or sufferers from gout or chronic rheumatism. Sometimes chronic arthritis is started by such injuries. The best safeguard against all these untoward results is the above treatment, especially absolute rest for a sufficient length of time. The tendency to regard a sprain as a trifle to be made nothing of is at the bottom of the common saying that a bad sprain is worse than a broken leg. Wounds of Joints. A small wound may often, but not invariably, be known to have pene- trated a joint by the escape of glairy viscid drops of synovia. Treatment.—If there is any doubt as to the wound having penetrated the joint, treat as though it had; any but the most cautious use of a probe may produce the penetration which it is so desirable to avoid. The object is to avoid septic arthritis (p. 316), and this is done by washing 292 INJURIES AND DISEASES OF JOINTS. the part with some reliable antiseptic, syringing out the joint, making ample provision for drainage, applying an antiseptic dressing (permanent, if pos- sible), and immobilizing the part in the best position for ankylosis in case stiffness should result. There is no reason why large wounds should not be sewn up carefully if ample drainage is provided. Even in small wounds the above treatment is always preferable to closing the wound with collodion or tinct. benzoini co. on lint, and packing the immobilized joint in ice. Should suppuration set in, reliance must be placed upon the freest drainage and drying up of discharge in antiseptic dressings, the joint being kept at perfect rest. Thus the knee should be laid open from top to bottom along each side, along the line of reflexion of the synovial membrane, a finger being passed into the joint through the wound, to discover the exact level of this line, and cut down upon; and it is best to make the plane of the wound shelving backward from the above line. Further, dressing forceps should be thrust through the joint to the back of the external condyle of the femur, and there cut down upon; they must then be used to draw a tube into the joint. In these cases irrigation through the tubes may be used in default of antiseptics. A careful watch upon the temperature and local state must be kept to detect burrowing of pus and formation of secondary abscess at the earliest date. In many cases secondary excision will be necessary to afford sufiicient drainage and to remove infected and ulcerating bone and cartilage; and, not uncommonly, danger of death from hectic will necessitate amputation to save life. Primary excision is indicated by splintering of the bones, and in the upper limb is greatly preferable to amputation. As much as six inches of the upper end of the humerus have been removed with good result. In these operations the periosteum should be preserved with the greatest care. Great injury to soft parts, vessels, or bones, especially in the lower limb, necessitates primary amputation. In gunshot injuries the facilities for anti- septic treatment and the necessity for transporting the wounded must be taken into consideration in deciding between excision and amputation. Dislocation or Luxation. A dislocation means the separation of two bones, a bone and cartilage, or two cartilages, at an articulation. It is complete when the surfaces are quite separated, partial when portions of them still touch. Other varieties are: traumatic, due to injury, with the subheadings, simple and compound; com- plicated—by much laceration of soft parts, of large vessels or nerves, or by fracture of one or other bone concerned; pathological, due to inflammation of a joint, will not be treated of here; congenital, due to original malforma- tion of the bones entering into the joint. Traumatic dislocations are rare before adult age, fractures and separa- tions of epiphyses occurring instead; they are always much rarer than frac- tures, and compound dislocations are very much rarer than compound frac- tures. Articular ends do not tear through the skin except as a result of very great violence. Causes.—External violence or muscular action. The circumstances that enable muscular action to produce it are—a peculiar position (as when the jaw is very much depressed); paralysis of an antagonistic set of muscles; elongation of ligaments; and fracture or ulceration of some process of bone. Thus ulceration of the acetabulum permits the head of the femur to be dis- located upward, and fracture of the coronoid process permits the ulna to be dislocated backward. DISLOCATION IN GENERAL. 293 External violence, as a rule, uses the shaft of a long bone to tear the cap- sule and lever its head out of its socket in a certain direction; this is the primary displacement; then the head is carried by secondary displacement to some more or less permanent position determined by the action of muscles, the resistance of bones, the tension of untorn ligaments, the weight of the part, and external violence. Morbid Anatomy.—In all traumatic dislocations there is necessarily more or less tearing of the ligaments holding the bones together, or these bands are torn from their attachments, bringing away scales or even pro- cesses of bone to which they were attached ; more or less laceration of the soft parts round about must also occur, and bleeding of course follows, but is usually less than in fractures. If the dislocation is at once reduced, all th'ese lesions heal in three or four weeks. In unreduced cases the displaced bone does not come to rest until it finds some firm point of support; thus if muscle separates it from a bony surface, the muscle will gradually disappear, and the bone come into contact with bone. The fibrous tissue round about the displaced bone thickens greatly and forms a kind of new capsule for it; but for several months no changes occur which would prevent reduction, though considerable force may be required to tear through the dense fibrous tissue. In the course of years a concave socket becomes filled up by dense fibrous tissue beneath which the cartilage disappears, and the head of the displaced bone may become similarly altered; but when it rest againgt peri- osteum, a bony cup usually forms round it and becomes lined with dense fibrous tissue or even cartilage, whilst the cartilage on the displaced bone is more or less preserved. All this, if movements are executed in the false joint or nearthrosis; if the bones are kept at rest, the whole of the inflam- matory capsule may ossify. Such changes as these render reduction impos- sible; but it would seem to be impossible much earlier, and the reasons are not quite evident. Signs.—These are made out by inspection, palpation, manipulation, and measurement. They are changes in length of the limb—generally shorten- ing ; the presence of certain attitudes of the limb which clinical experience has associated with certain dislocations; contour changes—abnormal promi- nences or depressions—sometimes concealed by swelling from the eye, but usually recognizable by the finger, which can gradually press through ex- travasated blood, and in all cases the displaced end of the bone is the most important point to be discovered; movement is obtainable, but is painful, abnormally limited in certain directions, abnormally free in others, in which perhaps no movement at all is usually allowed. Pain is, as a rule, less acute than in fractures. Diagnosis.—Dislocations have to be distinguished chiefly from fractures occurring near joints, for, as already pointed out, the deformity present in some of the latter may cause them closely to resemble certain dislocations. (1) It must be remembered that to prove the existence of a dislocation it must be shown that the joint surfaces of two bones are separated from each other; and for this purpose it is necessary carefully to compare the injured joint with its fellow to see whether the relations of bony points about them are altered. In dislocation the relation of these points is abnormal, in fracture it is normal, the deformity being due to displacement of the fragments. Luxa- tion differs from fracture also, (2) in the absence of true crepitus, though a soft crepitation is often present from extravasated blood. (3) A fractured bone can be moved by the surgeon more freely than natural, and a dislo- cated one less so. (4) Measurement of the distorted bones will show one or other of them to be shortened if a fracture is the cause of the deformity, but they are of normal length in dislocation. (5) If a fractured bone be drawn 294 injuries and diseases of joints. into its proper shape, the distortion will return when the extension is dis- continued ; if a dislocated bone be drawn into its proper place, it will usually remain there. But the greatest difficulties in diagnosis will arise when, in addition to dislocation, the displaced bone is also fractured close to its head; all the signs of fracture will then be present, and the diagnosis of dislocation can be made only upon demonstration that the joint surfaces are separated from each other. Treatment.—There are two ways of reducing dislocations; the old one of dragging the bones into position by brute force, all resistance of soft parts being removed by their laceration ; the more modern plan by manipulation, based upon a study of the mode of production of dislocations in the various joints, in the belief that the easiest way back for the head of a bone is that by which it left the joint. The shaft of the dislocated bone is therefore used as a lever to produce in reverse order those movements by which the head left the socket—to correct first the secondary, then the primary displace- ment. It is only in the two ball-and-socket joints, and especially the hip, that complex proceedings are required. In most other cases the socket, the point of leaving the capsule, and the point at which the displaced bone is lying, are in a fairly straight line, and it is therefore sufficient, in order to correct both primary and secondary displacement, to fix the socket or prox- imal bone with one hand and to pull on the distal or displaced bone till the resistance of the muscle is overcome. The extension should be made so as to draw the head directly toward the socket, the limb being in such position as will relax resisting muscles most completely; gentle rotation, and such other movements as may help to disentangle the dislocated bone, should at the same time be employed. After reduction, the joint must be fixed for fourteen to twenty-eight days, the latter in the hip. It is unnecessary to maintain any extension, preven- tion of movement whilst healing of the torn capsule is proceeding being all that is required. Ice may be used for a few hours to check extravasation, fomentations to assist absorption. After rest for the above-mentioned times varying with the size and importance of the joint, movements must be carried out, both passive and active, those which produced the dislocation being postponed until it is thought that healing is really sound. Dislocations should be reduced under anaesthesia if muscular resistance causes the slightest trouble. Formerly, in spite of the free use of nauseants and depressants—tartar emetic, tobacco, hot bath—reduction of a hip-joint dislocation was regarded as a capital operation ; now with manipulation and narcosis it rarely presents real difficulty. In the case of dislocation and fracture the patient should be at once anaes- thetized, and an attempt made to push the displaced head back into the socket; or, if the bone is broken so far down in the shaft that it is possible by putting it up very firmly in splints to obtain sufficient hold upon the upper fragment to employ the whole shaft as a lever, manipulation may be tried. This failing, fix the bone in such position as to obtain union to the displaced head, and then after six to ten weeks reduce by manipulation; in attempts at this, fracture may again occur, and it is useless to try again to reduce. The best result in the shoulder is then obtained by thrusting the end of the shaft up into the socket; in the hip by formation of a false joint with good movement and the limb in good position. Compound dislocation of the larger joints is a dangerous accident, because of the acute suppurative inflammation, rapid destruction of cartilage, and violent general disturbance which are sure to follow upon decomposition of the wound fluids; they are more serious than simple luxations, also on ac- particular dislocations. 295 count of the greater damage to soft parts by which they are attended. These cases must be considered and treated in very much the same way as com- pound fractures. In deciding what to do, the possibility of rendering and keeping the part aseptic is of the first importance. The successful applica- tion of antiseptics, of course, does away with the dangers due to the existence of a wound. If this is impossible, the probability is that even an uncom- plicated case will end in ankylosis. If the wound is clean-cut it may heal quickly if the dislocation is redueed, the limb fixed, and some simple ab- sorbent dry dressing is applied. Difficulty in reduction must be met by skilful enlargement of the wound, not by removal of sound bone. If rapid healing is impossible on account of laceration, the same treatment may be adopted with the addition of a well-placed and extremely free incision into the joint such as shall render bagging of pus difficult or impossible, and a similar incision must be practised at once should an endeavor to obtain union by first intention fail and septic arthritis ensue; otherwise, there is no knowing where the burrowing of pus will cease. Except to keep open channels leading to joints, the bones of which are in apposition, tubes are of little value in draining them, for they get compressed if passed through from front to back. If the endeavor to drain the joint thoroughly fail—and some joints are extremely difficult to drain, and constant irrigation does not pre- vent burrowing—the sooner a secondary excision is done the better. As to the question of primary excision or amputation, the decision must rest upon the age and constitution of the patient, extensive bruising and laceration of soft parts, laceration of large vessels, and shattering of the bone. The probability of employing antiseptics successfully must always be taken as a point greatly in favor of the patient. When one or other operation is necessary, excision is, as a rule, to be preferred, especially in the upper limb. Particular Dislocations. Dislocation of the Jaw may be caused by a blow on the chin when the mouth is wide open, or by spasm of the external pterygoid muscles during yawning, by which the condyles are drawn over the articular eminence in front of the glenoid fossa. The dislocation may be on one side only, or on both. It may also be partial or complete. Symptoms.—The mouth fixedly open; speech and deglutition difficult; saliva dribbling away; the chin protruding forwards, or a little on one side (if the dislocation is one-sided) ; the condyle is felt to project unnaturally under the zygomatic process, whilst there is a hollow in the upper part of the parotid space, corresponding to the empty glenoid fossa. Treatment.—Let the patient sit on a low stool with the head against a wall. The surgeon next wraps some rag round his thumbs, and places them at the roots of the coronoid process behind and outside of the molar teeth; then he should press them downward and backward, elevating the chin at the same time with his fingers. Or a piece of cork may be put between the molar teeth whilst the chin is elevated. After reduction, the chin must be confined for two weeks by a four-tailed bandage, to prevent accidental re- displacement from involuntary yawning and to allow the capsule to heal thoroughly. This is important, as luxation of the jaw is one of the most common to become habitual. Dislocations of the Clavicle.—The sternal extremity of this bone may be dislocated by blows on the shoulder ; either forwards on to the anterior surface of the sternum, or upwards into the suprasternal fossa. There are also a few cases on record of dislocation of this end of the clavicle backwards 296 INJURIES and DISEASES OF JOINTS. by violence, with the pain and difficulty of breathing as consequences; the reduction and subsequent treatment the same as for the dislocation for- wards.1 The sternal end may be dislocated forwards from sheer relaxation of the ligaments. The treatment is in all respects the same as for fractured clavicle, with the addition of pressure by the thumb, and afterwards by a pad and bandage on the displaced end of the bone. Dislocation of the sternal end backwards has been caused by lateral curvature of the spine. In one case it produced so much pressure on the oesophagus as to threaten starvation, and was excised by Mr. Davie, of Bungay. The outer extremity of the clavicle is much more frequently dislocated, and almost invariably upwards on the acromion. The shoulder is depressed, and on tracing the spine of the scapula the end of the clavicle can be felt upon the acromion. The outer extremity of the clavicle has been dislocated under the acromion by a kick from a horse on the shoulder. The treatment, after replacement, is the same as for fracture of the clavicle or acromion; but it is unsatisfactory as regards keeping the bone in place, though the patient recovers with a strong limb. Dislocation of the Shoulder-joint is far commoner than any other, which is easily accounted for by the shallowness of the socket, the laxity of the capsule, and the violence to which the upper limb is often exposed. The displacement is caused by falls on the hand or elbow, but it seems likely that violent contraction of the muscles forming the anterior and posterior axillary folds may have a good deal to do with dragging the bone inwards from its socket. In ordinary falls upon the hand, the whole length of the upper limb forms a lever, the insertions of the axillary muscles are the ful- crum, and the upper end is thrown against the lower and inner, or weakest part of the capsule, and the bone escapes usually between the subscapularis and the long head of the triceps. According to the direction of the force which subsequently acts upon the shaft, the head of the bone may come to rest low down in the axilla just inside the axillary border of the scapula; or it may lie higher up and more superficially beneath the coracoid process, or, travelling along the same line, it may be forced up and in beneath the clavi- cle. In rare falls upon the posterior and outer aspect of the flexed arm, the head of the humerus is driven through the lower posterior part of the cap- sule, and comes to lie on the dorsum scapulae, below the spine. The disloca- tions of the shoulder may therefore be divided into two sets by the axillary border of the scapula; one, the subspinous, occurs behind this line; three, the subglenoid or dislocation into the axilla, the subcoracoid, and the subclavicular, are in front of it. The term subglenoid, though commonly used as synony- mous with into the axilla, is not so; it should be reserved for very rare cases in which the head lies on the edge of the scapula just below the glenoid fossa (the arm being abducted to a right angle), whence it readily slips into the axilla. The three dislocations forward must be regarded as accidental va- rieties of one kind. As to relative frequency, the subcoracoid occurs most often (Malgaigne, Flower, Trans. Path. Soc, vol. xii. p. 179), then that into the axilla, which is also common; the subclavicular is uncommon, and the subspinous rare. If the student will detach the humerus of an articulated skeleton and place its head in the different positions which it may assume between the lower part of the capsule and the clavicle or spine, he will at once appre- ciate the differences which may be expected in the direction of the limb, its apparent length, and the relation of the elbow to the side. 1 See a case by Mr. Brown, of Callington, Medical Gazette, August 1, 184o. dislocations of the humerus. 29' Fig. 109. Dislocation of the shoulder downward. 1. In the dislocation downward, or into the axilla, the head of the bone slips through the capsule between the subscapularis muscle and the long head of the triceps, and rests pressing upon the axillary plexus of nerves, between the subscapularis muscle and the ribs (see Fig. 109). Symptoms.—The elbow sticks well out from the side, and cannot be made to touch the ribs; the shoulder is flattened all round, and the deltoid tense; the fingers can be pushed in beneath the acromion revealing a hollow where the head of the bone ought to be; the arm is lengthened; the head of the bone can be felt in the axilla if the limb be raised, and this movement causes pain and numbness along the arm and fingers. Diagnosis.—To examine the shoulder after injury, bare both joints and inspect from the front and from behind. Then, standing behind, place a hand on each shoulder, and commencing at the sternal end of the clavicles feel successively the clavicles, the coracoid processes, heads of humeri, acromia, and spines of scapulse, comparing the injured with the corresponding sound part. Any displacement will thus be detected. Now with one hand grasp the injured shoulder from before back, and with the other seize the flexed elbow and gently rotate the humerus to see whether the head moves with the shaft. If it does so, stronger and more extensive movements may be made in all directions to endeavor to elicit evidence of abnormal mobility or crepitus in the bones of the shoulder girdle. There are three fractures liable to be mistaken for this dislocation; viz. fracture of the acromion; of the neck of the scapula; and of the neck of the humerus. The first two may be known by the facility with which the form of the joint is restored by pushing up the elbow vertically, wTith an instant redisplacement on ceasing the support. In fracture of the neck of the scapula crepitus is felt on doing so. In fracture of the cervix humeri, the limb is shortened, instead of being lengthened, as it is in dislocation; the shoulder immediately below the acromion is of normal shape; the round head is felt in situ, but does not move with the shaft, and crepitus may be obtained; the deltoid is tense and flattened, and about one and a half inches down, opposite the fracture, the fingers can be made to sink in somewhat; and the rough angular end of the shaft may be felt in the axilla, instead of the smooth head of the bone. 2. In the subcoracoid dislocation the head of the bone, having escaped below the subscapularis tendon, ascends in front of it to lie below or just internal (Fig. 110) to the coracoid process. Symptoms.—The elbow stands out a little from this side, being pushed to it with difficulty, and is also carried a little backward; the shoulder is flat- tened externally and behind, and the acromion is prominent, especially behind ; the resistance of the head is gone from beneath it; on rotating the bone the head is felt, somewhat obscurely in muscular or fat people, close to the coracoid process, and there is more or less fulness over it; the limb may be slightly lengthened or shortened according as the head is below or inside the process. 298 INJURIES AND DISEASES OF JOINTS. 3. The subclavicular dislocation is produced from the subcoracoid by push- ing the head further up and in beneath the clavicle, where it causes more marked fulness and is more easily felt, whilst the elbow is directed more out and back, and the shortening is greater. Fig. 110. Fig. 111. Subcoracoid dislocation of the shoulder. Subspinous dislocation of the shoulder, unreduced, new socket formed. St. Mary's Museum. 4. In the dislocation backward or subspinous (Fig. Ill), the head of the bone may be felt on the dorsum scapulse, and the elbow projects forward. There is a fulness behind, and a hollow under the acromion in front. 5. Partial dislocation forward is described, in which the head of the bone is thrown partly off the glenoid cavity against the coracoid process. By some it is regarded as due to rupture of the tendon of the biceps. The symptoms are: projection of the acromion, and a hollow under it at the back of the joint, whilst the head of the bone is prominent in front, and may be felt to move on rotating the elbow ; cramps of the hand; and difficulty in raising the elbow, because the head of the bone strikes against the coracoid process. It is said to be very liable to recur after reduction. Injuries of the shoulder-joint are liable to be followed by various obstinate and intractable affections, owing probably to the supervention of chronic rheumatic arthritis. The capsular tendons and long head of the biceps waste away, and the articular surfaces are altered in shape, and partially displaced. Such cases were described by Sir A. Cooper as dislocation upward and rupture of the biceps. Sometimes the deltoid muscle wastes, owing probably to injury of the circumflex nerve. Violent spasms and neuralgic pains of the arm may occur from injury to the other nerves. Very rarely the head of the humerus has been dislocated upward, break- ing off the acromion (supraglenoid) or the coracoid process, or in front of the latter process (supracoracoid). Treatment.—There are four methods of reducing dislocations of the shoulder. 1. By the heel in the axilla. The patient lies down on a bed, and the surgeon sits on the edge. He puts his foot (without his boot)1 into the axilla, 1 A case is related by Dr. "Warren, of Boston, in which a person made a violent attempt to reduce a dislocation by putting the heel of his boot into the axilla. The result was a rupture of the axillary artery. Yide Banking's Abstract, vol. iii. p. 43. METHODS OF REDUCING DISLOCATIONS OF SHOULDER. 299 the heel resting against and fixing the axillary edge of the scapula, the wide anterior part of the foot being used to press the head of the bone outward ; at the same time he makes extension in the line of the limb, by grasping the wrist. By means of a towel or skein of worsted clove-hitched round the arm above the elbow, an assistant may aid in making traction should extra force be necessary; but it is far better to give an anaesthetic, and to employ rota- tion of the humerus, rather than direct traction, to break down adhesions in old cases, or to enlarge the opening in the capsule. The clove hitch is shown in Fig. 112. Fig. 112. The clove hitch. "When the head has been drawn down to the level of the rent in the cap- sule, it is levered outward over the foot by carrying the elbow to the side, when it usually slips in with a jerk and an audible snap. Both these signs may be absent, especially in cases which are not quite recent; reduction is then evidenced by return of the normal fulness of the shoulder given by the head in its socket, also by greater freedom of movement. The extension used in reducing any dislocation forward must be made in a direction downward and backward. For the dislocation backward, extension should be made forward. 2. By the knee in the axilla. The patient is seated in a chair, and the surgeon abducts the arm and places one of his knees in the axilla, resting Fig. 113. Reduction of dislocation of the humerus by hyper-abduction. the foot on the chair. He then puts his hand on the shoulder to fix the scapula, and with the other extends and depresses the elbow over his knee. The method is altogether inferior to that by the heel in the axilla. 3. According to the method of hyper-abduction, invented by Charles White, 300 INJURIES AND DISEASES OF JOINTS. of Manchester, and revived by Malgaigne, the patient lies down, and the surgeon sits behind him. The scapula is well fixed by placing one hand or a foot upon the shoulder ; then the arm is raised from the side, and drawn straight upward strongly till the bone is elevated into its socket (Fig. 113). Modifications of this process have long been in use on the Continent. English bone-setters have a plan by which the leverage afforded by the length of the limb is made available for tilting the head into its socket. For this purpose the elbow is straightened, and the limb raised and moved in a circular direction, so as to dislodge the head of the dislocated bone, and enable the muscles to draw it into its socket. This is, in fact, a closely similar proceeding to that of manipulation in dislocation of the hip-joint (see the " Flexion Method," p. 306, and Fig. 119). 4. Kocher's method is very successful, and must be conducted in the fol- lowing steps : 1. Push the abducted elbow to the side. 2. Bend the elbow, and, using the forearm as a lever, rotate out the humerus through about 90 degrees, when a distinct check will be felt. 3. Flex the humerus fully—i. e., carry the elbow forward and upward through 90 degrees. Rotate the humerus in, when its head will enter the glenoid fossa. These movements first render tense the coraco-humeral band and other untorn parts of the capsule, and then employ them as a fixed point round which to move the head. The method fails when this band is torn from the humerus, but White's plan then succeeds. In subspinous dislocation strong abduction and forward traction coupled with direct pressure forward on the head, must be practised. After reduction fix the arm to the side by a few turns of bandage and treat any extravasation. Begin passive movement in fourteen, active in twenty-eight days, abduction last. Habitual dislocation is more frequent in this joint than in any other. When dislocation has occurred more than twice, absolute rest for four or six weeks should be given to the joint, and some kind of band should be used to limit the movements, especially abduc- tion of the joint. Old Dislocations.—These have been reduced even so long as a year after their occurrence, and attempts made within six months will, as a rule, be successful. Owing to the matting of soft parts which always occurs around the head, it is necessary to free the latter by movements of rotation and to open up again the way into the capsule. There will probably be no sudden slip or snap when an old dislocation is reduced, and often the bone slips out of place with the greatest ease; when, therefore, the natural form is restored, the arm must be firmly fixed with the hand upon the opposite shoulder so as to preserve it. Kocher's method has been very successful in this class of cases, and it would avoid the possibility of several of the accidents which have occurred during reduction of both old and recent dislocations by the heel in the axilla. These are: (1) Fracture of the neck of the humerus, and of this in Kocher's method there is most danger when producing the second movement. (2) Rupture of the axillary artery or vein, an accident which is not always avoidable by any method, as the vessels sometimes contract adhe- sions to the displaced head. (3) Rupture of smaller vessels, resulting in great extravasation. (4) Injury to the brachial plexus, causing more or less last- ing paralysis. (5) Laceration of the skin and pectoral muscles. (6) Avulsion of the arm at the elbow (Guerin) without the employment of any great amount of traction. If the neck breaks during an attempt to reduce an old dislocation, the shaft should be pushed up at once into the glenoid fossa, to imitate as nearly as possible the result of an excision, and the case must be treated accord- ingly. Subsequently, if the displaced head is a source of pain, it may be DISLOCATIONS OF THE ELBOW. 301 removed. In a recent dislocation union should be allowed to take place between the shaft and head, and another careful attempt made to reduce. Rupture of the axillary artery gives rise at once to a false aneurism (arte- rial hematoma), which must be treated by laying open the sac, turning out the clots, and tying above and below the wound in the artery, whilst the subclavian is compressed. This should not be done until it is obvious that the swelling is steadily increasing, as it has done in cases hitherto reported. Rarely an ordinary aneurism has formed several weeks after the reduction of a dislocation; this may be treated by ligature of the third part of the subclavian. When small vessels of the axillary vein is injured, the probability is that with some elevation of the limb and friction upward constantly practised, the danger of gangrene will be escaped. Should it set in, amputation must be practised. Every endeavor must be made to improve the power of movement in an old dislocation; should it, however, ultimately prove unsatisfactory, the question of excision of the head may be entertained; as also in cases of much pain due to pressure of the head upon the brachial plexus. The shoulder is the joint in which luxation tends to become habitual—i. e„ to recur again and again till the head can be shaken out of joint, perhaps by missing a step coming down stairs, or by the performance of almost any over- hand movement. The pathology is unknown: too early use of the joint after reduction certainly tends to cause the state, which may consist in the persistence of a wide communication between the synovial membrane and the subscapular bursa produced by the primary injury (Roser). In con- firmed cases, Hiiter suggests excision as a remedy. Congenital Dislocation of the shoulder is rare; it is usually subcora- coid, a false socket lying at the base of this process to receive the malformed head. Attempts to improve the position have generally failed. Dislocation of the Elbow presents many varieties. It is remarkable for the great frequency with which it occurs in children. Falls on the hand are its cause. Both radius and ulna may be dislocated : 1, backward ; 2, back- ward and outward ; 3, backward and inward ; 4, forward. The ulna alone may be dislocated, 5, backward ; the radius alone either, 6, forward ; 7, back- ward ; or, 8 outward; 9, the humerus may be driven between the forearm bones, the ulna being behind, the radius in front. Fig. 114. Dislocation of radius and ulna backward. l/,When both radius and ulna are dislocated backward, the elbow is bent at a right angle and is firmly fixed. The olecranon projects much behind ; a hollow can be felt at each side of it, corresponding to the great sigmoid cavity; and the lower end of the humerus forms a hard protuberance in front. The coronoid process rests near the olecranon fossa (Fig. 114). The 302 INJURIES AND DISEASES OF JOINTS. head of the radius and its superior hollow can be felt unless the swelling is great. 2. In dislocations of both bones backward and outward, the coronoid process is thrown behind the capitellum; and, in addition to the preceding symp- toms, the head of the radius can be very plainly felt on the outside of the joint. 3. The dislocation backward and inward is known by a great projection of the outer condyle, in addition to the symptoms of the first variety. 4. Dislocation forward without fracture of the olecranon is very rare; the elbow is flexed, the forearm lengthened, and the heads of the forearm bones are felt in front of the humerus. Considerable movement is permitted. 5. In dislocation backward of the ulna solely, the olecranon is much pro- jected backward, the elbow is immovably bent at right angles, and the fore- arm is much twisted and pronated. The Treatment of these five varieties is much the same. The surgeon must bend the elbow across his own knee, using this as a fulcrum over which he can lever apart and disentangle the bones: the muscles will then effect their replacement. 6. The head of the radius alone may be dislocated forward, being thrown in front of the capitellum (Fig. 115). The elbow is slightly bent, and, in Fig. 115. Dislocation of the radius forward. bending it more, the head of the radius can be felt to strike against the front of the humerus. The hand is usually more supine than prone. Treatment.—Straighten the elbow and press the radius into place; put a pad in front of it, and apply a stright anterior splint for three weeks or a month. In all cases where the orbicular ligament is torn, the dislocation is likely to recur. Dislocation of the radius backward is very rare, outward much less so. The diagnosis is easily made by feeling the head in its abnormal position. Reduction is effected by flexion, abduction from the hand, and direct pres- sure on the head. Angular splints must be applied for three or four weeks. When the forearm bones lie one on each side of the humerus, there is much deformity; the position of the bones is easily recognized if the case is seen before the onset of swelling, which is apt to be great and rapid. Re- duce and treat like dislocation backward of the ulna. Diagnosis.—To examine the elbow, stand in front of the patient, flex the sound like the injured joint, and take an elbow in each hand, placing a fore- finger on each olecranon, a thumb on each external epicondyle, and a second finger on each epitrochlea. The relation of these points belonging to the forearm and arm respectively can now be exactly examined, unless swelling obscures them. Dislocations of the elbow may be distinguished from fractures of the lower extremity of the humerus—1, by the impaired mobility of the joint, and by the absence of crepitus; 2, by carefully observing the relative position of the epicondyles of the humerus to the olecranon; 3, by measuring the length dislocations of the thumb and finger. 303 of the humerus from its condyle to the shoulder—which in dislocation will be equal to that of the sound limb, but will be diminished in fracture of the lower extremity of the humerus. The forearm from epicondyle to styloid process, is usually shortened. When it is considered that these dislocations may be combined with various fractures of the condyles of the humerus, and of the bones of the forearm, and that great and rapid swelling is char- acteristic of injuries about this part, it will be admitted that the injuries of the elbow present a complicated study. When exact diagnosis is impossible, put up the elbow on an inside angular splint and treat the extravasation. If the dislocation is complicated by fracture, passive movement should not be commenced till after four to five weeks; limited movement is likely to result. These dislocations may be rendered compound by projection of the lower end of the humerus in front. The treatment will vary according to the damage to soft parts there. Reduction of dislocations many months old is very difficult. Should it fail and the arm be useless from ankylosis in the straight position, excision may be done with benefit. Dislocations of the Wrist are rare. They occur, with almost equal frequency, backward and forward, and are readily recognized by the altera- tion of the relations of the styloid processes of the radius and ulna to the bones of the carpus. They are reduced by simple extension. Such injuries are very rarely compound, and their treatment will depend on the amount of injury the bones and soft parts have sustained. Dislocations of the Carpal Bones.—The os magnum and os cuneiforme are sometimes partially dislocated through relaxation of their ligaments, and form projections at the back of the hand, which must not be mistaken for ganglia. The os pisiforme has been dislocated by the action of the flexor carpi ulnaris muscle. Treatment.—Pressure, mechanical support, and cold affusion later. Dislocations of the Thumb and Fingers are not very uncommon. They are almost always due to movements of over-extension, the distal bone being displaced backward upon the proximal. Displacement is more common at the metacarpo-phalangeal than at the interphalangeal joints, the lever upon which the force acts being longer. The anterior ligament tears, and most frequently at its attachment, which is very loose, to the proximal bone. The displaced bone is found in a position of over-exten- sion ; some further extension is possible, but flexion is almost immediately checked. Reduction is effected by seizing the displaced bone, extending it as fully as possible, then pushing it forward round the head of the proximal bone. This is far more successful than extension in a straight line, even though much more force be used. Occasionally great or even insuperable difficulty has been met with in the reduction of these dislocations, especially in that of the first phalanx of the thumb on to the back of the first metacarpal. This difficulty has been variously attributed to nipping of the head of the metacarpal by the lateral ligaments of the joints, which are short and strong, or by the tendons of the flexor brevis pollicis with their sesamoid bones, to interposition of the tendon of the flexor long, poll., or of the anterior ligament of the joint which has remained attached to the displaced phalanx. Roser and Hiiter regard the latter as the chief difficulty, having found it to be so in experiments on the cadaver; but Hiiter thinks the others probably occur. He recommends an antiseptic incision into the joint to find out exactly the cause of the difficulty and to remove it; the part must then be carefully fixed with plaster of Paris in 304 injuries and diseases of joints. straight position. English surgeons usually recommend subcutaneous sec- tion of the ligaments and tendons above mentioned, and enlargement of the opening in the capsule, though how this is to be done behind the flexor longus is not clear. In compound dislocations reduce, enlarging the wound if necessary, and dress antiseptically. Amputation may be required by laceration of soft parts. Dislocations of the Ribs and Sternum.—The costal cartilages may be torn from the extremity of the ribs,- or from the sternum, when the longer fragment usually overrides the shorter; or the posterior extremity of the ribs may be dislocated from the spine by falls on the back ; but these acci- dents are very rare. A case is related in which the heads of the last two ribs were driven forward from the spine, in a boy of eleven, by a violent blow on the back; abscess formed, and the case terminated fatally.1 The body of the sternum also has been dislocated forward from the manubrium, and the ensiform cartilage is sometimes separated. In all these cases the same local and constitutional treatment must be adopted as was prescribed for fracture. Dislocations of the Symphysis Pubis and Sacroiliac Joints have been noticed under fractures of the pelvis, which they resemble and often accompany. Dislocations of the Hip-joint.—The strength of this articulation, given by the depth of its socket, its thick, short capsule, and the powerful muscles by which it is surrounded, is very great; Fig. 116. but, on the other hand, the lower limb forms a long lever to multiply the action of any force, and the rim of the acetabulum forms a fulcrum against which the neck of the femur may rest whilst the head is levered out of the socket. A glance at the cap- sule shows that it is immensely strong in front, where it is formed by the Y-liga- ment of Bigelow (Fig. 116), one of the stoutest ligaments in the body; behind and below it is comparatively thin, and its attachment to the femur posteriorly is weak. The greatest violence is required to tear the Y-ligament; both its branches, as a rule, remain attached to the femur in cases of dislocation, and exercise a most important influence upon the position ulti- mately assumed by the head, besides pre- venting it from passing out of the socket through the front of the capsule ; and last, and by no means least important, its at- The Y-iigament (Bigelow). tachment to the anterior inferior iliac spine serves as a fixed point round which the head may be made to play by movements imparted to the shaft, for upon this our ability to reduce dislocations of the hip by manipulation—i. e., to produce in inverse order the movements by which the head reached its ab- normal position—depends. Again, an examination of the bones entering into the hip-joint shows that the position of standing is one of perfect security, the femur being in contact 1 Dublin Med. Press, Feb. 3, 1841. dislocations OF the hip-joint. 305 with the widest part of the acetabular cartilage which overhangs the head; but the surface of contact becomes much smaller as the hip-bone is flexed upon the femur, and the position is one of obvious danger if at the same time the femur is adducted and rotated in. This is the position—one of flexion, and adduction, and rotation in—in which it is believed by most that dislocations of the hip generally occur. Another precarious position is that of flexion and abduction, and H. Morris supports the teaching of Fabbri, of Milan, that all dislocations are produced by extreme and forcible abduction, the head passing backward when the thigh is at the same time flexed and rotated in, forward when the femur is extended and rotated out. Bigelow regards the tendon of the obturator internus as of considerable im- portance in the dorsal dislocations. In the upright position this tendon runs horizontally outward behind and about the level of the middle of the hip; but as the joint is flexed, it rises more and more above the point of chief pressure of the hip-bone against the femur. Bigelow has found experiment- ally that when the femur is flexed to 45 degrees and pushed out of the socket, the head passes back above the pyriformis ; at 90 degrees it escapes between the pyriformis and obturator internus; and in extreme flexion, below the latter tendon. Inward rotation causes the head to pass out much lower than it otherwise would for a given amount of flexion. Bigelow thinks that the head usually passes out below the tendon, and reaches points high on the dorsum ilii by secondary displacement with stretching or rupture of the obturator internus and other external rotators, rather than that the head reaches its position primarily by a direct thrust back; and in this view Morris agrees with him. From the above remarks it will be seen that dislocations of the hip may be divided into two classes: the regular, in which the Y-ligament or one of its branches remains unbroken, and in which, therefore, the symptoms are fairly constant for the different positions the head can assume; and the irregular, much more rare, in which the ligament is torn or its point of attachment broken, the femur being free to assume any position and the signs being correspondingly variable. In the regular dislocations the primary displacement occurs through the lower and hinder part of the capsule, or even as far forward as the edge of the pubio-femoral band. The head is thrown against different points of the capsule according as the hip is flexed, adducted, and rotated in to various degrees, flexed, abducted, and rotated out, or extended, abducted, and rotated out. When the femur is in the first described position its head passes back- ward to the tuber ischii, or back toward the great sciatic notch—in either case " below the tendon" of the obturator internus—or it may escape " above the tendon" on to the dorsum ilii; in the second position the tendency of the head is down and in toward the thyroid foramen on to the obturator externus; and in the third position the head will be forced up and in on to the pubic bone. These are the chief forms of dislocation of the hip ; they are like the cardinal points of the compass, between which there are many subsidiary points at which the displaced head may lie. If the student will take a hip- bone and femur united by the Y-ligament, he will find it easy to produce all the above dislocations and also the following. From the pubic, by pushing the femur up and a little out, so that its neck is immediately below the in- ferior spine and crossed by the Y-ligament, we get the subspinous; by pushing the head further down and in from the thyroid foramen, the dislocation into the perineum is produced ; passing outward from the ordinary thyroid dislo- cation, the position of the dislocation directly downward is reached, and then of that down and out on to the tuber ischii. If in a dislocation above the tendon the femur is placed across the symphysis, it will be fcund that some 20 306 INJURIES and diseases of joints. force will now evert it, both branches of the Y-ligament remaining sound and the femur lying across the upper part of its fellow—the anterior oblique— dislocation ; by diyiding the outer branch of the Y, the femur can be brought down straight, its head passing in above the inferior spine and origin of the rectus—the supraspinous dislocation; and from this position the femur may be carried out on to the dorsum ilii, and being attached only by the inner band of the Y, it is everted—everted dorsal dislocation—but can be inverted at will. Starting from the subspinous position by flexing, circumducting, and rotat- ing in the femur, its head may be carried through all the positions it can assume between the inferior spine and the dorsum ilii; and the production of the anterior oblique, supraspinous, and everted dorsal dislocations—all rare—is explained above. Clinically, therefore, we must expect to find that by handling and other accidental circumstances, any one form of dislocation may be converted into neighboring forms (so to speak). It is easy to note such points as whether the limb will be shortened or lengthened, inverted or everted, or either flexed or extended, etc.; and practice with the dissected joint is the only way of obtaining any real knowledge of these dislocations. There are two methods of reducing dislocations of the hip: 1. By extension in the line of the displaced limb, or the overcoming of all resistance by force, gained by the use of pulleys, if necessary. 2. By manipulation, the principle of which has already been explained (p. 294). As a patient is anaesthetized, the limb descends from muscular relaxation, and the Y-ligament gets even tighter than before. Extension by pulleys in the line of the limb has, there- fore, to overcome the maximum of resistance of this ligament, and does so probably by more or less laceration of it. Manipulation makes no attempt to draw the head straight to the socket; flexion is its chief movement, by which the head is brought to the level of the socket in the upward dislocations, or the Y-ligament relaxed in the downward ; flexion is aided by circumduction or rotation in one or other direction and by direct traction. Hippocrates speaks of reduction "by flexion at the joint with gentle shaking;" and this rocking movement is useful in all manoeuvres. Manipulation has almost universally replaced force in the reduction of recent displacements; but many hold the pulleys to be necessary in old luxations to overcome the resistance of cicatricial tissue. Bigelow, however, says that he should expect always to succeed by manipulation so long as the bones remained normal; and it seems that we ought to do so, when it is re- membered that by circumduction of a displaced femur it is not difficult to tear through everything which may resist the passage of the head from the anterior spine round to this point again. For treatment by manipulation the patient, fully anaesthetized, must lie on a mattress on the floor; the surgeon, standing by the injured side, grasps the ankle with one hand and places the other hand behind the top of the calf and flexes the hip and knee each to 90 degrees. He can now with ease cause the limb to perform any movement. Dislocations not more than two months old have generally been reduced; then the failures have increased rapidly, but successes are recorded as late as nine months. Much, probably, depends upon the skill of the surgeon in performing manipulation ; but there is one difficulty, met with four times by Gelle in 150 experiments, which proved insuperable—the capsule tore close to the femoral neck, and hung as a curtain between it and the socket. Where attempts to reduce fail, a new socket forms for the head in its ab- normal position, power of extension is gained, and the limb, though shortened, is ultimately useful. Accidents from attempts to reduce dislocations, especially those of old dislocation on to the dorsum ilii. 307 standing, are not very rare. The chief are fracture of the cervix femoris and suppuration about the joint, perhaps ending fatally. With respect to the relative frequency of these dislocations, Sir A. Cooper believed that out of twenty cases twelve would be on the dorsum ilii, five on the ischiatic notch, two on the foramen ovale, and one on the pubes. Fig. 117. Dislocations due to Flexion, Adduction, and Rotation In. Dislocation on to the Dorsum Ilii.—This and the following disloca- tion usually result from accidents, such as a heavy weight falling on the back whilst the patient is stooping. Symptoms.—The thigh is flexed, adducted, and rotated in, so that its line crosses the lower third of its fellow and the toes rest upon them opposite the instep (Fig. 117); the trochanter is less prominent and higher than natural, and nearer the anterior spine; eversion and com- plete extension of the hips are impossible; the head is felt on the dorsum ilii unless concealed by fat, muscle, or blood ; the thigh is shortened one to three inches. The dislocation backward (on to the sciatic notch) may be regarded as a modification or as the early stage of the above, the head lying below and be- hind the tendon of the obturator internus (Fig. 118), which causes difficulty in reducing this luxa- tion by extension—the tendon being drawn down with the head and preserving its relation between the head and the socket. Symptoms.—These vary with the time which has elapsed after the accident. Immediately after, the thigh is more flexed, adducted, and rotated in than in the dorsal luxation, so that the thigh may cross its fellow as high as the middle. But the flexion soon becomes less, and the sciatic is then distinguished from the dorsal dislocation by the slighter shortening, half to one inch. Bigelow says the inversion is more, Sir A. Cooper that it is less, marked than in the dorsal dislocation. The head of the femur is more difficult to feel, and the trochanter is rather behind its natural position and not so prominent. Diagnosis.—Fracture of the cervix femoris may be distinguished from these dislocations by the circumstance that the limb can be freely moved in any direction, although with some pain; that the toes are usually turned outward instead of inward; that the limb is neither flexed nor adducted, and that it can be drawn to its proper length by moderate extension, with some crepitus, but becomes shortened again as soon as extension is discon- tinued ; whereas in dislocation it requires a forcible extension to restore the limb to its proper length and shape, but when once the head of the bone is replaced in its socket it remains there. Treatment.—Reduction of dislocations backward by manipulation. The thigh must first be flexed and rotated in rather more to enable the head to pass easily down behind the socket, and behind the obturator tendon when this lies in front of the head; it is then to be abducted to carry the head toward the lower and hinder part of the capsule, and finally circumduction downward accompanied by rotation out, raises the head over the brim and thrusts it through the aperture in the capsule. Bigelow gives the formula: Dislocation on to the dorsum ilii (Sir A. Cooper). 308 INJURIES AND DISEASES OF JOINTS. lift up, bend out, roll out for reduction by rotation. A simple method, that by traction, will usually succeed. The pelvis is steadied by the hands of an assistant or the foot of the surgeon (without his boot), the thigh is flexed to Fig. 118. Dislocation below the obturator internus tendon, in the neighborhood of the sciatic notch. (Bigelow, " The Hip.") 90 degrees, and a slight pull forward is given by the hand behind the calf, with the result that the head slips in. Formerly, forcible traction in the line of the limb w7as the method employed. Fig. 119. Diagram of the reduction of a dorsal dislocation by manipulation. In old and young, muscularly feeble patients, or even in the strong whilst faint from the injury, reduction was sometimes effected by a method analogous to the heel in the axilla. The surgeon sits and presses his bootless foot against reduction of dorsal dislocations. 309 the pubic arch and tuber ischii, whilst extension and rotation are effected by his arms, aided by assistants. Usually traction by pulleys was resorted to. The patient, thoroughly chloroformed, was placed, on his sound side, on a mattress on the floor; a leather girth or strong towel was passed inside the upper part of the thigh, so as to bear firmly against the tuberosity of the ischium and crista ilii (Fig. 120); and this was attached to a ring or hook securely fastened into Fig. 120. Reduction of dorsal dislocation by the pulleys ; after Sir Astley Cooper. the side-wall or post in the line of the thigh. A wetted roller was next applied to the lower part of the thigh, and over it the strap belonging to the pulleys, or a thick skein of worsted arranged in a clove-hitch, and this is fastened to the pulleys fixed to the opposite wall or to a post in the line of the thigh. Then extension was made in the direction of the thigh. After a Fig. 121. Thyroid dislocation (Sir A. Cooper). little time the surgeon gently rotated the limb out, or lifted the upper part of it by a jack towel round the thigh, and the head of the bone often re- turned to the acetabulum. A long splint was then applied, a spica being used, and the patient kept in bed for from two to four weeks. 310 INJURIES and diseases of joints. The sciatic dislocation was found to be much more difficult of reduction by direct traction than the dorsal. This difficulty is said by Bigelow to have resulted from the interposition of his tendon and subjacent portion of capsule which were rendered tense by traction, and so prevented the head of the femur from becoming replaced. By manipulation it is reduced as easily as the dorsal. Should stronger traction than the surgeon, unaided, can exert ever be re- quired, Bigelow advises that it should be made with the hip flexed to 90 degrees to relax the Y-ligament. The pulleys act from a tripod over the patient, being fastened to a special rectangular splint which keeps the limb bent, and counter-extension is made by a perineal band fixed to the floor. Dislocations from Flexion and Abduction. The dislocation on to the thyroid foramen covered by the obturator externus is the chief of these; as rare varieties due to secondary displacement, may be given the dislocation directly downwards below the acetabulum, down and in to the perineum, down and out on to the tuber ischii. The symptoms of the thyroid dislocation are: the limb is a little flexed and somewhat abducted and the body is bent forwards; the heel is raised from the ground and the toes point down and either straight forwards or a little outwards; the head usually cannot be felt; there is a hollow over the situa- tion of the great trochanter; inversion and extension are impossible; and the limb is lengthened one to two inches. In dislocation directly downwards, the limb is greatly flexed ; the toes may point in or out. When the head passes out on to the tuberosity, there are great flexion, adduction, and inversion, the head can be felt, and the hollow over the trochanter disappears; and when it passes in to the perineum marked flexion persists, but the limb is greatly abducted and the toes may be turned in or out; the head is plainly felt and may compress the urethra; the hollow over the trochanter is very deep. Treatment of Thyroid Dislocations by Manipulation.—Flex the limb to 90 degrees, and abduct it slightly to disengage the head; then rotate strongly in and circumduct inwards, keeping up a little traction by the hand beneath the knee. Or the thigh may be flexed and head drawn out by a towel, pushed out by the foot in groin, or jerked up and out; or a log may be placed between the thighs of the patient whilst he sits, and the head levered out over it, the thigh being rotated in. The variations in the above procedure necessary to reduce the rarer down- ward dislocations will be obvious; traction at 90 degrees is useful in all. Forcible traction may be applied to the reduction of thyroid dislocations in two ways: (1) The patient may be laid on his back on a bed, with one of the bedposts between his thighs, and close up to the perineum, protected by a small pillow or cushion. Then the foot is drawn inwards across the median line by a hand passed beneath the sound limb to grasp the ankle, so that the bedpost, acting as a fulcrum, may throw the head of the femur out- wards. The foot must not be raised, otherwise the head of the femur may slip round under the acetabulum on to the sciatic notch. (2) The pelvis may be fixed sideways by a broad band, and the pulleys applied to the upper part of the thigh, to draw it outwards at right angles to the body; whilst the knee is at the same time pulled downwards and inwards. dislocations of the hip. 311 Dislocations Caused by Over-extension and Abduction. Dislocation upwards and forwards on to the pubes and subspinous dislocation. Symptoms of Pubic Dislocation.—The thigh is slightly flexed and abducted, but completely everted, the toes pointing straight outwards; there is a more or less deep hollow over the trochanter; the head is felt near Pou- part's ligament, sometimes beneath, sometimes inside the vessels; inversion is impossible on account of the resistance of the inner limb of the Y and of the obturator internus; the limb is shortened about one inch. When the head passes in as far as the symphysis, the inner branch of the Y is torn. In the subspinous dislocation there is less flexion, abduction, and eversion, and the head lies external to the vessels. The support given to the neck by the Y-ligament over it may enable the patient to walk. Treatment.—Reduction by manipulation. Draw the femur downwards and gradually flex it to 90 degrees, thus causing the head to descend to the level of the rent in the capsule; now rotate in and circumduct inwards, carrying the femur as far over towards the sound side as possible. A towel may be used to draw the head outwards. In reduction by extension, traction should be made in a direction back- wards and outwards, and counter-extension by a perineal band running in the opposite direction. When the femur is drawn down sufficiently its head must be lifted over the edge of the acetabulum by a towel and traction slacked off. Of the remaining very rare regular dislocations—the anterior oblique, in which the Y-ligament is sound, and the supraspinous and everted dorsal, in which its outer branch is torn—only the symptoms can be here given. In the anterior oblique the limb is much flexed, completely adducted, and everted, lying across the top of the other thigh; the head is felt on the dorsum ilii not far from the anterior superior spine, and the limb is greatly shortened. Very little movement is possible. In the supraspinous the limb is a little abducted, and everted so com- pletely that the toes may point backwards; sometimes this is easily cor- rected ; the head is felt below the anterior superior spine, but the trochanter is found with difficulty. The limb is greatly shortened and cannot be drawn down, being hooked over the rectus; movements are tolerably free. In the everted dorsal the toes may be pointing backwards, but inversion can be produced ; the head is felt on the ilium internal to the trochanter, and shortening is proportionate to the height at which it is situate; move- ments are free. Irregular dislocations may simulate any regular one; but manipulation soon changes their signs, the stability due to the Y-ligament being gone. They are reduced by direct traction towards the socket, aided by local guid- ance ; and two months' rest would not be too much after such an injury. The treatment of dislocation of the hip complicated by'fracture of the femur high up, is (1) to endeavor to manipulate the head into the socket; if this fails, (2) to obtain union, and after eight weeks again attempt reduction by manipulation. If this also fails, or the bone refractures, there is nothing for it but to obtain a false joint with as good movement as possible. Congenital dislocation is more common in the hip than in other joints. It may occur on one or both sides, usually on both, and is most common in females. The hips are wide, flat, the trochanters are prominent and too near the crests; the lumbar spine is unduly hollow. The patient walks with a peculiar waddle. Both the head of the femur and acetabulum are usually malformed. Nothing can be done beyond drawing down the femora by 312 injuries AND DISEASES OF JOINTS. weight-extension for some weeks, and then applying a well-fitting pelvic band having two strong pads descending from it to press on the tops of the femora and afford them firm points of counter-pressure. Dislocations of the Knee.—Dislocation of the tibia from the femur is not common; and, when it does occur, is rarely complete. In most cases the tibia is thrown inwards or outwards, with the outer tuberosity on the inner condyle, or vice versa; less often it is thrown forward and still more rarely backward. The deformity and impediment to motion will distinguish the accident. The displacement must be rectified by simple extension, the knee be kept at rest and ice applied till inflammatory symptoms have sub- sided, and the limb supported by a well-padded straight back-splint for several weeks afterward. There often remains a permanent inability to keep the joint firm in the straight position, especially after complete dislo- cations in which the laceration of soft parts is necessarily severe. As a con- sequence of this and of the great stretching of vessels, inflammation and gangrene are more common after this than after any other luxation. When compound, the laceration of tissue is very great, and amputation will often be required ; but if the structures of the ham are sound, an attempt should be made to save the limb. Dislocation of the Patella may occur inioard, which is extremely rare; or outward, which is much more common and natural, seeing that the rectus and ligamentum patellae form at the patella a very obtuse angle open- ing outward. This dislocation may be caused either by direct mechanical violence, or by a sudden contraction of the extensors of the thigh in knock- kneed, flabby people. The knee cannot be bent, and the bone can be felt in its new situation. There is, in general, no difficulty in reducing it by means of the finger and thumb, if the knee is straight and the leg raised. There is one variety, vertical, of this dislocation, in which the patella is turned round on its long axis, so that one edge, usually the inner, lies im- mediately under the skin, and the other rests on the trochlea of the femur, where it is firmly fixed. It is sometimes extremely difficult to replace, at others quite easy. In one instance, the surgeon was unable to reduce it, though he divided the ligamentum patellae, and cut through the quadriceps at its insertion into the patella; death followed in eleven months, in conse- quence of his wounding the joint. Three cases of this kind are given by Cooper, and one by Ballingall; Streubel states that of 120 cases, about one- sixth were vertical. In one case Mayo succeeded in overcoming the diffi- culty by bending the knee to the utmost, so that the patella was drawn out of the groove in which it was lodged. Bending the knee and then suddenly extending it whilst pressure is made on the free border of the patella is usually successful. The difficulty alluded to must arise from entangling of the bone among the aponeurotic structures about the joint; and there is little doubt but that, in a case of real difficulty, it would be right to open the joint antiseptically and to seek and remove the cause. The patella is dislocated upward after rupture of its tendon by the ex- tensor muscles. This rare displacement must be treated like a fracture of the patella. Partial Dislocation of the Semilunar Cartilages.—In sudden twists of the knee-joint from tripping and like accidents, the internal, or much more rarely the external, semilunar cartilage may slip out of place and become wedged in between the tibia and femur. The symptoms are sudden, extreme, and sickening pain, and inability to stand or straighten the limb, with an interval between the bone3 on the side of the joint affected; sometimes the displaced cartilage may be felt under the skin. Effusion DISLOCATION OF THE ANKLE. 313 quickly sets in. This accident generally happens to people of relaxed habits, and is very liable to recur, especially if the joint becomes the seat of effusion. In a case dissected by Sir W. Fergusson, the external semilunar cartilage was found to be torn from its connection with the tibia except just at its extremities, and Godlee found it in the intercondyloid space. The best way of restoring the part to its place is to place the patient on the affected side, with the knee bent, and rotate the tibia gently on its axis. This manoeuvre may be repeated at intervals until success is attained. Sometimes the fibro-cartilage becomes replaced by its own elasticity, exten- sion then becomes possible. The patient should rest for a fortnight and put on an elastic knee-cap before he moves about. When the displacement is irreducible, movement must be practised, and after a time the knee will become quite useful. In recurrent displacement prolonged rest with a view to obtaining fixation is useless. It might in some cases be possible to find the cartilage and sew it to the capsule. Dislocation of the Head of the Fibula is infrequent, except as a consequence of rickety deformity or relaxation of the ligaments from weak- ness, which must be treated by cold douche, friction with liniments, and Fig. 122. Fig. 123. Unreduced dislocation of the tibia inward, with Astragalus displaced upward between tibia and fracturo of fibula ; from a cast taken by Mr. Wil- fibula. Accident of five years' standing; no at- mott, of St. Mary's Hospital, a year and a half tempt had been made at reduction. There was after the accident. There was no attempt at re- no fracture. From a cast by Mr. Wilmott. duction. bandages, with a pad to press on the head of the bone; or it may result from rheumatic effusion into the joint cavity, to be treated by pressure, iodine paint, and iodide of potassium. Two cases caused by violence are given in Sir Astley Cooper's work; the head of the bone could be felt to pass more backward than natural, and could be moved by the finger. The pad of a tourniquet was employed to keep it in its place. Dislocation of the Ankle is generally caused by jumps from great heights, or from carriages in motion, or by violent twists, and may occur in four directions, each of which is often complicated with fracture of the tibia or fibula, or both. 1. Dislocation of the foot outward or tibia inward is the 314 INJURIES and diseases of joints. most common. It is usually attended with fracture of the lower third of the fibula (Pott's fracture), and may be easily known by the side of the foot turning outward, and its inner edge turning downward, with great projection of the internal malleolus and crepitus of the fibula on being straightened. 2. Dislocation of the foot inward, or tibia and fibula outward, is attended with fracture of the internal malleolus, and may be known by the side of the foot turning inward. 3. In dislocation of the foot backward the foot appears shortened, the heel lengthened, and the toes point downward. There is also a partial dislocation backward, in which the tibia is half displaced from the astragalus, and the fibula broken; the foot appears shortened and immov- able, and the heel cannot be brought to the ground. 4. A dislocation for- ward has been described, but it must be very rare. Sir A. Cooper never saw it. The case described by Mr. Colles was probably a transverse fracture of the tibia and fibula just above the joint, with displacement backward. 5. The astragalus may be thrust up between the bones of the leg, as represented in Fig. 123. Treatment.—These injuries may be so various and complicated that it is impossible to lay down particular rules for every variety, although the general principles are clear. Reduction must be effected as soon as possible, and for this purpose the patient may either be laid on the side or back, with the knee and hip bent. Then an assistant holds firmly the leg just below the knee, and the surgeon grasps the instep with one hand and the heel with the other, and makes extension (aided by pressure on the end of the tibia), till he has restored the natural shape of the parts. The limbs must be put up with a Cline's splint on each side and slung in a swing, in the same manner as in fracture of the lower part of the leg—taking care to keep the great toe in its proper line with the patella. After swelling has subsided, the starch bandage may be applied. Chloroform may be administered, to render reduction more easy, and opium in regular doses afterward, to pre- vent displacement by twitcbing and spasm. Compound Dislocation Of the Ankle-joint is the most frequent example of this kind of injury. If the wound in the integument does not heal by the first intention the joint becomes septic, it inflames; suppuration occurs in about five days ; much of the cartilage is destroyed by ulceration; at last the wound is filled with granulations, and the patient may recover with a tolerably good foot in from two to twelve months, more or less anky- losis having occurred. The first thing to be done is to wash away all dirt with some reliable antiseptic, with which the recesses of the joint are to be well syringed (p. 239); to remove any shattered pieces of bone gently with the fingers, and then to reduce the bone to its place; slightly enlarging the wound in the skin, if necessary, to effect this without violence. If it is very difficult to return the end of the tibia, or, if it is much shattered, or stripped of periosteum, it is better to saw it off. The foot must be held at a right angle whilst either a large gauze or a permanent wool dressing is applied. If desired, drainage holes may be made before reduction by cutting down on dressing forceps thrust from the wound backward to one side of the tendo Achillis. The leg may then be placed on a Macintyre or Arnold's splint, or two side- splints may be used; care must be taken not to let the foot be pointed, nor be-turned to either side. The remaining treatment is the same as that of compound fracture, and the rules which are given as to the necessity of amputation are the same in both cases. Dislocations of the Foot.—The most important of these are the dislo- cations of the astragalus, which may be separated from its connection with the tibia, fibula, scaphoid, and os calcis in various ways. Sometimes it is thrown forward and inward, so as to project on the inner surface of the foot; DISEASES OF JOINTS. 315 and in this case there appears an unusual projection below and in front of the inner ankle, and a corresponding depression below the outer one whilst the foot is more or less everted; more often it is thrown forward and outward, and rests upon the greater process of the os calcis whilst the foot turns in. If these dislocations are simple, reduction should be immediately attempted by extension; chloroform will be needed, and perhaps the pulleys, for the reduction is often a work of difficulty; but patience and good management will usually succeed. Chloroform ought to render unnecessary the dividing of the tendons of refractory muscles, unless they intervene between the bone and its socket in such a way as to prevent replacement. Lastly, the astrag- alus may be dislocated backward, projecting behind the ankle-joint, and pro- truding on one or other side of the tendo Achillis. This displacement, if only partial, it will be extremely difficult to rectify ; and if complete, it will most likely be impossible. If the dislocation is compound, and the bone cannot be replaced, or, if it is much shattered, it may be dissected out. It was formerly considered that if the skin be not broken, it is better to leave the displaced bone. Even if the skin does not slough and render the dislo- cation compound, these dislocations generally cripple the foot. With anti- septics, therefore, the surgeon would probably do the best for his patient by at once excising an irreducible bone. If, however, sepsis after operation is to be feared and sloughing is not imminent, it is best to wait till the parts round the ankle are healed, and then to dissect out the displaced bone, ren- dering the foot bloodless first. In some dislocations (subasiragaloid) the astragalus may be separated from the other tarsal bones, preserving its con- nections with the tibia and fibula, so that these may be regarded merely as varieties of dislocation of the ankle-joint, in which the tibia and fibula carry the astragalus with them in their displacement. Besides these, the anterior tarsal bones with the toes may be dislocated from the os calcis and astragalus. The cuneiform bones may be dislocated upward from the navicular, the metatarsal bones from the tarsal, and the toes from the metatarsal. In any of these cases, the proper position of the parts must be restored as much as possible by pressure and extension, and be preserved by bandages ; but reduction will often be very difficult, if not impossible, and excision necessary. Diseases of Joints. General Pathology.—A joint is made up of four parts : (1) the bone- ends, covered by (2) cartilage, held together by (3) ligaments, which are lined by (4) synovial membranes. It is surrounded by soft parts to which disease may spread from the joint, or vice versa. Of the four above-named structures, two—the synovial membranes and the bones—are of infinitely greater impor- tance as starting-points of disease than the others—cartilages and ligaments— which are dense and non-vascular, or almost so, and therefore little prone to exhibit the primary signs of inflammation ; secondarily, they, especially cartilage, frequently suffer. The inflammations of joints may consequently be divided into two classes, synovial and osteal, according as they start in the synovial membrane or bone. But directly the causes of an osteal inflam- mation pierce the cartilage, the synovial membrane becomes affected; and it is very common for disease starting in the synovial membrane to extend to the bone. Inflammations which tend ultimately thus to involve all the structures of a joint are usually grouped under the name Arthritis; those limited to the synovial membrane under Synovitis. Every stage of inflammation may be met with in joints, as in bursae and sheaths of tendons. The slightest forms are those characterized by effusion 316 INJURIES AND DISEASES OF JOINTS. of serous fluid, acute or chronic, from the vessels of the synovial membrane into the cavity of the joint. We may find some swelling and hyperaemia of the synovial membrane, especially of its processes, and effusion of a clear or turbid pinkish-yellow fluid into the joint (Synovitis serosa acuta). Or, the hyperaemia may be very slight, the synovial membrane gets opaque and somewhat thick, and pours out a watery straw-yellow fluid, which, if in large amount, causes the ligaments ultimately to stretch, and renders the joint loose and insecure (S. serosa chronica, hydrops articuli). In these chronic inflammations it is common to find hypertrophy of the synovial fringes and multiplication of their processes, so that the interior of the joint shows a few small pedunculated, connective tissue growths, or (Fig. 124) is universally papillary (S. papillaris), or some of the Fig. 124. growths may be of considerable size and tuberous (& tuberosa). This hyperplastic synovitis is especially common in rheumatoid arthritis ; and in cases of hydrops this state of the membrane often seems to keep up the effusion. In more acute cases shreds of fibrin ap- pear in the fluid and on the surfaces of the joint, the hyperaemia of the synovial mem- brane increasing (S. serofibrinosa); but the shreds have no tendency to organize as in the peritoneum. At the same time the number of white cells in the fluid increases, it becomes cloudy, and in still more intense forms ultimately purulent (S. purulenta). This may occur with very little swelling or other change, remaining post-mortem, of the synovial membrane, the pus coming from the surface of the membrane much as it escapes from a mucous surface in purulent catarrh. Consequently, these cases are spoken of as catarrhal suppuration (Volkmann). But in acute " idiopathic" or septic suppuration St (suppurative arthritis) the pus is thick, the synovial membrane greatly swollen, injected, and ecchymosed, its folds and processes prominent, the superficial parts hyperaemic and cedematous for some distance. The cartilage seems to necrose and wear away rapidly at points of pressure; no cell-growth is found absorbing it. Caries and necrosis of bone follow. Commonly, in these cases the pus bursts out into surrounding tissues through weak spots in the capsule, or abscesses form in intermuscular planes as the result of deep lymphangitis. It is by no means uncommon in these cases of acute suppuration to find the effusion more or less markedly hemorrhagic Naturally, an acute arthritis may occur without going on to suppuration, the pathological appearances being much the same, except that any fluid in the joint is not pus and is usually in small quantity. We have now to spealt of chronic arthritis, inflammation characterized by cell-infiltration of the tissues rather than by the accumulation of fluid in tissue interspaces ; it is the parallel of chronic osteomyelitis and similar dis- eases classed together by German writers under the heading " granulirende Eutziindungen." It is in this form that the distinction of primary synovial and osteal varieties is specially important. The first signs of chronic synovial arthritis would seem to be a tendency for Papillary synovitis of the knee. Mary's Museum. MORBID ANATOMY OF ACUTE ARTHRITIS. 317 the synovial membrane to advance over the cartilage in the form of a slowly contracting vascular rim; this is often seen in joints which have been kept long at rest, especially in the neighborhood of fractures or ostitis. When resulting from simple rest, the exciting cause and nature of the process are not evident, and it can scarcely be regarded as inflammatory. As the disease advances the synovial membrane thickens, in some cases from one-half to three-quarters of an inch, in others but slightly ; any natural folds, such as the alar ligaments in the knee, become much enlarged and new folds appear. The tissue of which the synovial membrane now consists is of pinkish-gray or yellowish aspect, often granular on the surface, or when torn, and its vascularity is slight in the commonest form (tubercular). Not un- commonly the morbid granulation tissue grows out through some weak point in the capsule, forming apparently an extra-articular focus. Folds consist- Fig. 126. Caries of the astragalus, with incipient separation of the cartilage. From the King's College Museum. iug of this tissue push inward over the cartilage, adhere to and erode it, not regularly but in a wormeaten manner—hollows and actual holes alternating, with perhaps here and there a bit of healthy cartilage. In time the cartilage is entirely removed by molecular disintegration; or the granulation tissue, which now invades the bone, may spread between the cartilage and the bone, and separate the former in flakes of considerable size that are sometimes found loose in the cavity of the joint. Ordinary caries of the bone now begins and advances most rapidly at the points of greatest pressure between the bones, the irritation of pressure being here added to that of the primary cause of the disease. It is by no means uncommon to find the bones deeply eroded at the points of maximum pressure whilst the cartilage is fairly healthy at other places. The thickening of the synovial membrane may, however, continue for many months or even years without destroying carti- lage or bone, or invading ligaments and surrounding soft parts; the swollen membrane may then be almost shelled out of the capsule. In other cases, presumably of more intense irritation or of feebler resistance on the part of the tissues, the round-celled infiltration spreads widely and rapidly, the infil- trated ligaments are softened, and the more or less eroded bones become easily displaced upon each other (Fig. 125). Thus is produced one form of pathological dislocation by the combination of softening of ligament, erosion of articulating surfaces, muscular contraction, and faulty position of the limb. Another form occurs early, in ball-and-socket joints, from distention of the capsule witn fluid and faulty position. Fig. 125. Disorganization of the knee-joint, with ulcera- tion of the cartilages, and softening of the ends of the long bones. From a preparation in the Hun- terian Museum, No. 918 A. 318 INJURIES AND DISEASES OF JOINTS. When the above disease starts in the bone (chronic osteal arthritis), it is secondary to a chronic osteomyelitis of the epiphysis. The granulation tissue eats its way to the deep surface of the cartilage, and frequently spreads out between this and the bone (Fig. 126), detaching large pieces: it also eats its way through the cartilage at several spots, round nodules of granulation tissue sprouting through small holes into the joint. The cavity of the joint and the synovial membrane thus become infected by the noxa, and the result is much the same as that above described. Osteomyelitis of the epiphysis may produce simple caries (p. 279) of the end of the bone, slight or very extensive, or small sequestra may form (C. necrotica, p. 279); but in more acute cases, pieces of large size or even the whole epiphysis may die. Sclerosing ostitis is rare, but may occur; and in some forms, osteoplastic periostitis is found about the bone-ends, causing thickening of them or the growth of irregular osteophytes. There are many causes which may give rise to a chronic arthritis such as the above, and it is probable that all are of an infective nature. There is one, however, which acts much more commonly than any other, viz., the bacillus of tubercle. As a rule, it is very sparsely distributed, and is therefore difficult to demonstrate microscopically; and cultivations and inoculations not uncommonly fail. But the disease is notoriously scrofulous, frequently occurring with other more rapidly progressing lesions, the tubercular nature of which is consequently more easily demonstrable; and acute tuberculosis ranks high among the causes of death. Konig, Schuller, and others state that tubercles are constantly present in the granulation tissue; and it is now fairly established that the ordinary chronic arthritis is really a local tuber- culosis like the commonest form of chronic osteomyelitis (p. 279). The minute structure of the synovial membrane—the diffuse round-celled infil- tration, containing scattered tubercles, which may be rare—is shown in Figs. 8, 9, and 10. The tendency here, as elsewhere, of tubercular granulation tissue is to caseate and soften into thin puriform fluid, which sooner or later makes its way to the surface and escapes, leaving a sinus into the interior of the joint. Not uncommonly the abscess seems localized and extra-articdar, due to the softening of some cell-mass outside the capsule; but on laying it open freely, an opening in the capsule may almost always be found. Instead of suppurating, the infiltrating cells may be absorbed or trans- formed into fibrous tissue, which, in its turn, may ossify; fibrous or bony ankylosis results. The same may occur after suppuration. The term fungous arthritis is often applied to cases in which there is thick- ening of the synovial membrane but no suppuration. The peculiarities of rheumatic and gouty inflammations of joints will re- ceive notice in sections devoted to the subject. The Etiology of Inflammation of Joints.—The causes of inflamma- tion of joints may be ranged in four groups: (1) direct injury; (2) extension from surrounding parts; (3) infection through the blood; (4) nervous causes (?). These causes sometimes produce an acute, sometimes a chronic inflammation without our being able to account for the difference; though this doubtless lies in variation of intensity of the cause, or of the resistance of the tissues, or in the existence of undetected causes. 1. The traumatic causes include blows, wrenches and strains, over-use, penetrating wounds, burns, etc., and exposure to cold. The three former give rise chiefly to acute or chronic effusion into the joint, frequently follow- ing on haemarthrosis. Wounds may produce any degree of inflammation from serous effusion to the most intense suppuration, and the latter is always ETIOLOGY OF INFLAMMATION OF JOINTS. 319 much to be feared from a septic wound; it is due, of course, to the action of chemical irritants (products of decomposition) upon the synovial membrane, and not to the injury done by the wound. The effect of cold seems also to be very various, every stage of inflammation, from the most chronic to the most intense, being attributed to it. In the latter cases it probably acts only as a depressant, enabling some infective cause to settle and grow where pre- viously it could not do so. All kinds of injuries, especially the mechanical, act thus when they seem to excite chronic arthritis (synovitis granulosa, tuber- culosa). This seems to be the class in which gout should be placed, its char- acteristic arthritis being apparently due to the deposit of needles of urate of soda in the cartilage, and later, in synovial membrane, ligaments, and bones; but as such deposits are found in joints which have never been inflamed, the etiology is doubtful. 2. The origin of arthritis by extension is seen in the serous or purulent effusion which sometimes occurs in acute infective periostitis, especially with separation of the epiphysis, and in the epiphysitis of congenital syphilis, also in chronic arthritis, secondary to osteomyelitis of the epiphysis. Superficial inflammations, especially erysipelas, may cause some form of inflammation of a joint over which they pass. 3. Many infective poisons are conveyed to joints by the blood and excite inflammation in them; and the different poisons excite different effects. Hiiter speaks of these metastases as secretory, believing that the organisms are excreted into tbe joint with the synovia, and that they multiply in it and excite irritation; but it is quite as likely that they excite inflammation of the synovial membrane just as M. erysipelatis causes inflammation of the skin. The commonest acute infective arthritis is the pyemic; occasionally serous or serofibrinous, it is usually suppurative, the suppuration being fre- quently catarrhal, but often leading later to destructive and deep-seated changes. There is scarcely an infective fever which is not occasionally com- plicated by a metastatic joint inflammation ; farcy, scarlatina, typhus, and variola may be specially mentioned. In gonorrheal rheumatism an acute synovitis or destructive arthritis, which does not, as a rule, suppurate, occurs. In both early and advanced syphilis there may be serous effusion into joints with pain and high fever much resembling acute rheumatism; and in the latter stages chronic thickening of the synovial membrane may occur: but syphilitic disease of joints is uncommon. Its diagnosis rests chiefly upon a syphilitic history and the results of treatment (p. 114). Of tubercular arth- ritis we have already said much; it is usually the most typical synovitis granulosa, much more rarely a chronic catarrhal suppuration ; and the earlier stages of inflammation are met with at the commencement of the disease. The nature of acute rheumatism polyarthritis synovialis (Hiiter) itself is doubt- ful, but its very frequent association with endocarditis, in the lesions of which cocci are found, its relation to endocarditis maligna, and many points in its clinical history incline one to the belief that it is an infective disease char- acterized chiefly by acute serous or serofibrinous synovitis which very rarely suppurates. 4. Nervous Causes.—During the last few years the labors of Charcot and others have revealed the occasional association of somewhat severe forms of arthritis with certain diseases of the brain and spinal cord, and it is held by many that the nerve lesions stand to the joint lesions as cause to effect. The point will be more fully entered into in the section upon " Joint Disease of Nervous Origin." 320 INJURIES AND DISEASES OF JOI1STS. Synovitis. Acute and Subacute Serous Synovitis. Causes.—The commonest is some blow or strain, much less often a penetrating wound that heals quickly, or the impaction of a loose body between the bones; extension from some neighboring inflammation—e. g., erysipelas, or lymphangitis, or ostitis ; the rheumatic, gouty, gonorrhceal, and occasionally syphilitic poisons; sometimes a serous effusion occurs in pyaemia, and certain cases occurring in spinal and Fig. 127. Section of knee, enlarged with chronic synovitis. cerebral diseases are credited with a nervous origin. Of these causes that most frequently overlooked is probably a recent or old-standing gonorrhoea; an examination is necessary to eliminate this. Symptoms.—The joint is swollen, hot when compared with the other, and somewhat painful; the skin over it is very slightly, or not at all reddened, there is little or no periarticular oedema, the joint is not flexed unless the swelling is great, and the patient can move it freely without much suffering; the muscles are not wasted ; there is little or no fever unless the synovitis is but a symptom of a general disease, as acute rheumatism or gout. The swelling is the most characteristic symptom. It is due to rapid effu- sion of fluid into the synovial cavity, and it is most marked or points where the joint capsule and the surroundings are most yielding; the synovial mem- brane is, as it were, distended by an injection, and the eye soon gets to know the shape it assumes in the more superficial joints. In the knee, which is the joint most frequently affected, the patella is pushed bodily forward, the depressions on either side of it are obliterated, and there is a horseshoe- shaped swelling above the bone extending some three inches up the femur. Unless the joint is very tense, sudden pressure on the patella will force it down on to the femur with a clear tap; and this floating of the patella shows positively that the swelling is due, in part at least, to fluid. When there is but little fluid in the joint, floating of the patella may often be obtained if the suprapatella is emptied into the lower part of the joint by pressure on it with one hand, whilst two or three fingers of the other are placed carefully around the centre of the bone and used to depress it. Often the fingers are placed toward the lower end, depression of which may yield a tap in a healthy joint. But before seeking for this sign fluctuation must be obtained, and this is best done by using one hand as above described, and placing the other also astride the lower part of the joint; by now approximating the fingers and thumb of one hand, fluid, if present, will be forced between the fingers CHRONIC SEROUS SYNOVITIS. 321 and thumb of the other. When there is but little fluid, it should all be forced into the lower, smaller part of the cavity by the upper hand. It is very important before commencing this examination to see that the extensor tendon is lax and the patella freely movable. In the ankle, fulness is found behind between either malleolus and the tendo Achillis, and in front beneath the extensor tendons, raising them up; fluctuation may be obtained from in front of to behind the malleoli. In the hip, ill-defined fulness below Poupart and behind in the hollow between the tro- chanter and the pelvis is sometimes found. In the shoulder there is general fulness beneath the deltoid, most marked in front; and in the elbow there is a very characteristic horseshoe-shaped swelling fitting on top of the olecra- non, one and a half inches beneath the triceps, and divided into two lateral lobes by the pressure of the tendon of this muscle. Terminations.—The most common by far is resolution in the course of one to three weeks; but the effusion may persist, all acute symptoms subsid- ing (hydrops articuli). Much less commonly the effusion becomes purulent, or the synovial membrane becomes infiltrated, and the case ends as one of chronic synovial arthritis. Much care must be exercised in beginning to use the joint again, as relapses are easily induced. Treatment.—By far the most important point is the arrest of all move- ment, the prevention of friction, and this must be effected variously in the different articulations. In traumatic cases seen early, cold may be applied in the hope of checking effusion ; but when this has occurred, and in non- traumatic cases, glycerine and belladonna and hot fomentations are far pleasanter and more efficacious in promoting absorption. This may be hastened by aspiration, an operation which should always be performed to relieve pain from tension. When acute symptoms have subsided, counter- irritation by tinct. iodi., or blisters, or firm pressure may be employed ; and finally, a Martin's bandage may be worn for two or three weeks after aban- doning the splint. For Gonorrhceal Synovitis and Arthritis, see p. 106. This is too common a cause of apparently spontaneous joint disease to be forgotten. The importance of curing the discharge, in order to cure the joint, renders the discovery of the cause essential. But little is certainly known of syphilitic joint disease. Lancereaux recog- nizes two forms: a secondary synovitis with effusion and symptoms of acute rheumatism (p. 114); and a later form characterized by development of gum- mata in the subsynovial tissue. This is a subject to be inquired into. Mercury or iodide of potassium must be given, and if the health be broken, endeavor by every means to restore it. Chronic Serous Synovitis (hydrops articuli) may be left after an acute attack, or may begin as such, being due to injury, overwork, exposure to damp cold, gleet, chronic rheumatism or gout, presence of loose bodies, or of a papillary condition of the synovial membrane; often no cause can be found. Symptoms.—The chief or only physical sign is fluid swelling, having the shape given under acute synovitis ; there is no flexion, fixation, wasting, heat, redness, or pain, but only a sense of weakness or looseness about the joint which may render it unreliable. On palpating the joint, one or more papillary growths may be felt slipping beneath the fingers but evidently anchored to one spot; or a loose body may be found now here, now there. The knee is the joint most often affected. Treatment.—Rest on a splint is always of great importance, and, if the lower limb is affected, the patient should not walk, except with a Thomas's splint. Counter-irritation is of little value; and strapping over ung. 21 322 INJURIES AND DISEASES OF JOINTS. hydrarg. co. is not much better. For most cases repeated aspiration and the constant wearing of a Martin's bandage as tight as can be borne is the most successful treatment; and it is wise to wear the bandage for six months at least after cure. In cases which do not yield to this treatment, Hiiter, Volkmann, and Schede recommend the injection after aspiration of three to five per cent, carbolic lotion, as much as possible to be again withdrawn, and this is to be repeated if necessary. French surgeons similarly inject tr. iodi diluted with three parts of water, but suppurative arthritis has resulted from this treatment. It should here be said that the aspiration of a joint or other cavity requires the closest attention to asepsis; the instrument must be scrupulously clean, the surface to be punctured should be scrubbed with sublimate lotion, a bit of wool steeped in this may be kept round the needle, and the puncture must be carefully closed with a wisp of wool and collodion. Should all these methods fail, recourse may be had to drainage of the joint if the surgeon can rely upon his antiseptics. This is effected by opening the largest portion of the synovial membrane, inserting a tube and retaining it for a fortnight or so. Any loose body must, of course, be removed, and sometimes in thus opening a joint, synovial folds—e. g., alar ligaments—will be found red and swollen. Such may be excised. In cases of papillary synovitis, a few growths may be got at and removed from an incision, but cure of such a joint as that in Fig. 124 could be effected by excision of the synovial membrane. Arthritis. Acute Arthritis and Acute Suppurative Arthritis.—The causes are: septic wounds, exposure to cold (acute rheumatic arthritis) ; occasionally extension from erysipelas or other superficial inflammation, from the bursting of an abscess (suppurating bursa beneath the lig. patellae) of the soft parts or of the bone into the synovial cavity, or, much more commonly, from acute epiphysitis of syphilitic or other origin ; most frequent by far, infection during the course of an acute, infective disease, especially pyaemia; much less often of the acute specific fevers, glanders, or dysentery. Symptoms.—The disease begins usually with high fever and perhaps an intense rigor; the joint affected is the seat of extreme pain, is absolutely fixed and helpless, and the patient dreads the slightest movement; swelling is rapid, the oedema spreads up and down the limb considerably beyond the limits of the joint concealing the outline of the synovial membrane; the skin now reddens over the whole or part of the joint, the whole limb swells, the fever reaches 104°-105° daily, the rigor may be repeated, and the patient shows signs of rapid exhaustion. The part is so tender and the oedema so consider- able that it may be impossible even now to be sure of the presence of fluid; but under the above circumstances an exploratory aspiration should be made early. If nothing is done, pus escapes either superficially, or large abscesses form in the substance of the limb. The patient may die exhausted by pain and fever, or of some septic disease ; or may ultimately recover with an ankylosed joint or after amputation or excision. The acute rheumatic arthritis generally ends after some weeks in ankylosis without suppuration ; the effusion is sero-fibrinous. Catarrhal Suppuration (Volkmann) may develop in cases which are primarily serous effusions, or it may result from many of the causes of acute suppurative arthritis—especially puerperal and urethral pyaemia, and the pyaemia of infants; sometimes also from gonorrhoea. Symptoms.—These are intermediate in intensity between acute serous synovitis and acute suppurative arthritis. In many cases indeed the diag- CLINICAL COURSE OF CHRONIC ARTHRITIS. 323 nosis would be the former, there is so little exacerbation in the constitutional state, the signs of inflammation are so slight, whilst pain may not be com- plained of at all. But experience has taught that an aspirator will almost surely draw off a sero-purulent fluid from a joint which during the course of pyaemia had been accidentally discovered to be full of fluid. That there is no line between these cases and the last group goes without saying; and uuless the pus in a catarrhal case be soon removed, destructive arthritis will set in in most cases. It is right to add, by way of caution, that the most surprising differences occur in the symptoms of joint disease; thick pus may cause little local and still less general reaction, and after its evacuation recovery may occur with perfect movement, as is by no means uncommon in young children; a catar- rhal suppuration and still more an acute arthritis may be attended by very severe symptoms of both kinds. Treatment.—Absolute fixation is of the first importance, and if the joint is in a bad position it should be at once gently straightened under chloro- form, and fixed upon a reliable splint; then belladonna should be applied and fomentations assiduously used. If the local and general symptoms point to the presence of pus, but fluctuation is not obtainable, make an ex- ploratory aspiration. If the symptoms and the result of aspiration show the case to be one of catarrhal suppuration, the joint may be emptied and washed out with 1 in 20 carbolic; and this may be repeated if fluid re- gathers without more acute symptoms. But if the case is one of acute sup- purative arthritis, and probably in all cases in young children, the proper treatment is, aseptically, to lay the joint open as freely as possible. Thus in the knee an incision should run from top to bottom of the synovial mem- brane on each side along the line of reflection of the synovial membrane, and sharp hemorrhage may be expected from the enlarged articular arteries which retract into the dense fibrous tissue; dressing forceps should then be pushed through the joint on the outer side to the skin, cut down upon, and a large tube introduced here. Young children often recover under most disadvantageous circumstances; but in adults everything depends on the maintenance of rest aud asepsis. In their absence all the changes of septic arthritis ensue. Life and limb are now greatly jeopardized ; sometimes with good health to start, fixation, free drainage, and careful dressing, a cure will be effected by ankylosis; in other cases, excision of the joint may save the limb; in others again the patient's age and exhausted condition, and the existence of abscesses bur- rowing far up the limb, will necessitate amputation to save life. In the elbow and shoulder, excision may be performed earlier than in the lower limb joints; for the results of excision are better than those of ankylosis. In the hip-joint, excision should be done whenever possible to avoid the formidable amputation. When a cure by ankylosis is tried for, the humerus should be fixed to the side in the ordinary hanging position; the elbow should bfe fixed at 95°- 100°; the wrist straight; the hips straight; the knee at 170°-175°; the foot at right angles to the leg. Scrofulous Disease of Joints, White Swelling, Pulpy Degenera- tion, Articular Caries, Chronic Tubercular Arthritis.—It has already been stated that many causes lead to a chronic arthritis, but that the disease which bears the above names is of tubercular nature (p. 318). Its modes of origin—in synovial membrane or in the epiphyses—have been given, and attention has been drawn to the fact that the ultimate result is much the same in either case, except that cases commencing in bone are 324 INJURIES AND DISEASES OF JOINTS. much more liable to be complicated by necrosis and the presence of sequestra in the joint. The disease often begins subacutely in a serous synovitis from injury, but more frequently it starts without obvious cause. The great majority of the cases occur in children and young persons, from three to twenty years, but cases are not very uncommon even in quite old people (senile struma). Symptoms.—The first is uneasiness and pain in the joint, leading early to a limp if a lower limb joint is affected; not uncommonly pain is referred also to some other part supplied by the nerves which supply the diseased joint; thus, pain in the knee is almost more characteristic of hip-joint dis- ease than is pain in the hip. Very soon, if the joint be superficial, exami- nation shows swelling, and this is soft and elastic, " pulpy," but does not actually fluctuate, though it is sometimes very difficult to be sure of this. At first all characteristic hollows are obliterated, but the shape of the syno- vial membrane is not usually so well shown as it is by fluid; thus the knee- joint tends to assume a uniformly rounded aspect, the widest part being at the level of the articulation instead of above the patella, as in hydrops. The part is distinctly warmer than its fellow, but not red ; on the contrary, it is pale, the skin being stretched over the swollen joint, and through it the blue subcutaneous veins show plainly. The swelling is rendered more marked by the rapid wasting of muscle that occurs. There are two marked exceptions to the rule that swelling is characteristic of this affection—the shoulder, in which wasting of the deltoid often more than conceals swelling of the synovial membrane, and the hip, over which the glutaei waste. One of the earliest signs of this disease is limitation of the movements of the joint, and this limitation increases rapidly as the case goes on. At the same time many joints in this, as in acute arthritis, assume a characteristic position; the hip becomes flexed, adducted, and rotated in, the knee flexed and rotated out, the ankle more or less extended, the elbow more or less flexed, the shoulder remains in the humerus hanging. Various reasons have been given to account for this flexion of joints in arthritis. Bonnet believed the position assumed by the joint to be that in which it could hold most fluid, and to be due to distention; but we do not see these positions in serous syno- vitis, when the joints are much more tense than in chronic arthritis; others say that the flexor muscles are stimulated to contract by a reflex from the joint, an assumption based upon the fact that these muscles do contract. It seems most probable that many of the positions are voluntarily assumed to obtain security from injury and ease, slight flexion being the position in all joints in which the joint surfaces are least pressed together by tense liga- ments ; once assumed, the positions are involuntarily maintained. After a time, sooner or later, starting pains begin. These are shooting pains which occur just as the patient is dropping off to sleep, waking him up, and usually causing a child to scream. They are probably due to move- ment of tender joint surfaces, permitted by the relaxing muscles; they do not necessarily indicate ulceration of cartilage. If the case goes still further, the granulation tissue softens at one or more spots, an abscess forms, the skin reddens, thins, and bursts, and thin curdy pus escapes, leaving a sinus which may remain permanently open or heal after a time. A probe may or may not touch bone. In other cases the synovial cavity fills with a thin puriform fluid, when we get the signs of effusion into the joint together with those of arthritis. Sometimes the' thickening of the synovial membrane cannot be felt in cases which have begun apparently as hydrops; but if a markedly turbid fluid is drawn off, the prognosis becomes much graver and the diagnosis will need to be changed. Examination at a late stage will probably show that movements MODES OF TREATING CHRONIC ARTHRITIS. 325 which are normally prevented by ligaments—e. g., side to side movements in hinge joints—can be obtained, owing to softening and infiltration of the liga- ments, and at the same time the bones will be felt and heard to grate over each other. These signs should rarely be sought for unless the patient is under an anaesthetic; nor should the old and painful test of striking the heel, and thereby driving the bones roughly together at the ankle, knee, and hip, be practised. It is quite unnecessary for diagnostic purposes. Finally, destruction of ligaments and bones may lead to pathological displacements and dislocations. Terminations.—Recovery may occur at any period—before the bones are affected in synovial arthritis, after this event, or before or after suppu- ration has occurred. Cases which do not suppurate are spoken of as fungous arthritis, and are parallel with caries sicca. It is not uncommon to find a patient walking about, lame, but suffering little or no pain, possessing toler- ably free, smooth movement of his knee or ankle, of which the synovial membrane is swollen till it is one-half or three-quarters of an inch thick; and this state of matters may last even for years. It is met with chiefly after puberty in patients whose health is fair, and may end in recovery without or with abscess. Once this disease has become fairly established perfect move- ment can scarcely be hoped for, but very good movement may be left. On the other hand, ankylosis may be complete and either fibrous or osseous. The limb may be in good position, or in such faulty attitude as to be worse than useless. But in a large number of cases abscess after abscess forms, and the patient is worn out by pain, wasting discharge, albuminoid disease, and hectic, or acute tuberculosis carries him off. Prognosis.— Ceteris paribus, this depends chiefly on the age and health of the patient—the younger and more robust fare best. Treatment.—The first point is, by the most judicious use of the means given at p. 98, to raise to the highest point the general health; residence at the seaside is particularly beneficial. Next comes the provision of rest, of which we have spoken so often. The most important point is to prevent friction of the joint surfaces against each other; relief from pressure is quite secondary. When the shoulder is in- flamed, the arm should be secured to the side by a few turns of bandage, and the hand slung high ; the arm must not be put through sleeves. The elbow and wrist are best immobolized by plaster of Paris over wool, which exerts constant pressure. For the hip and knee-joints no splints compare with those invented by H. Thomas; for the hip, a Hamilton's splint with parallel uprights acts fairly well; for the ankle, plaster of Paris and a pin-leg having a support for the leg projecting backward. Weight extension, one to six pounds, may be used for the shoulder, and is commonly used for the hip and knee with distinct advantage. It acts really by steadying the limb, not by drawing the joint surfaces apart, for that would require a very heavy weight; and it is always well to fix the body and limb of the patient by a sheet thrown over them, and heavy sandbags laid along the sides of the trunk and limb. If a Thomas's splint can be ob- tained it should be used, not only for its much more perfect fixation, but because with it patients can live in the open air. Compression sometimes acts well, but it often disappoints ; it is best made by a Martin's bandage, and should be constant. Counter-irritation by iodine, blisters, and the cautery is of little value; it sometimes relieves starting pains for a time. The repeated injection of two to three grm. of three to five per cent, carbolic lotion into the swollen tissue was strongly recommended by Hiiter in fungous arthritis, and is well spoken of by a few German surgeons; most seem to 326 INJURIES AND DISEASES OF JOINTS. have failed with it, and in a few cases in which I have tried it no positive result was obtained. Ignipuncture has been used by Richet and Kocher in similar cases, but does not seem so good a means as a diffusible chemical on the one hand, or as erasion on the other if something radical is to be undertaken. The more radical modes of treatment are: erasion, excision, and amputa- tion, and it is still a moot point when the two former should be resorted to. Two views are held: 1. That good food, good hygiene, cod-liver oil, and sea-air, with perfect rest for the joint, will enable a large proportion of patients suffering from tubercular joint disease to recover—if they can devote two or three years or even longer to the cure, and are wealthy enough to obtain the advantages above mentioned. The result hoped for is a more or less complete ankylosis in the best position, and an important point urged in favor of expectancy is that, in growing bones (and most of the cases occur in children), the epiphyses are not removed, so full growth may be expected unless the inflammation leads to early ossification. It must be admitted that in spite of this treatment a good many cases go on to abscess, and some ultimately require complete excision or amputation. 2. Others say, if it is evident that, in spite of the most favorable conditions that can be secured for a patient, the disease does not improve within a reasonable time (three to six months), or that it is going on to abscess, no time should be lost in opening the articulation so freely as to be able to examine the synovial membrane and bone surfaces thoroughly, and then removing with the sharp spoon, gouge, scissors, etc., every particle of diseased tissue. This may be done in cases of synovial arthritis before the bones are affected, when only the synovial membrane may be dissected out; but if the disease has gone further, or is of osteal origin, holes must be gouged in the joint surfaces. It is only when the case has been treated too long on the expectant plan, that the epiphyses require removal, and excision must be done instead of erasion. After this operation it is well to sponge the cavity well with sublimate lotion, and then to rub it freely with iodoform. The wound must be drained, carefully sewn up, divided ligaments or tendons united, the joint absolutely fixed, and a permanent antiseptic dressing applied. Tolerably rapid union may be counted upon, but it will be necessary to wear a splint for a few months, that all may become solid. The advantages of early erasion are therefore held to be: that it greatly shortens the course of the disease, and gives at least as good results as the expectant plan in regard to mortality, length of limb, and movement of joint; that it is far better than the expectant mode in the case of the miserable children that crowd the London hospitals, for whom good hygienic conditions and often perfect rest are impossible; and lastly, that by this operation a possible focus of general infection is removed from the body (p. 96). Under antiseptic precautions the dangers are slight. To be successful, erasion must be early, free, and thorough; tubercular tissue left behind will probably lead to recurrence and require a repetition of the operation. The presence of septic sinuses of course increases the difficulty of treating the case, but does not require any change in principle. Against erasion it must be admitted that recurrence is not infrequent. Excision must be done in cases which are too advanced for erasion, and which are either stationary or getting worse. In the upper limb, the results in suitable cases are so satisfactory, that the operation may be undertaken with little reluctance, and it may be remembered that the periosteum regen- erates bone more freely after subperiosteal excisions for early disease than for advanced destructive arthritis (Oilier); but in the lower limb it must be confessed that excision of the hip not uncommonly leaves a limb which is of little value as a support, the head and neck being rarely reproduced to any GOUTY ARTHRITIS. 327 appreciable extent and union being ligamentous ; and that excision of the knee sometimes bends entirely out of shape even after the bones appear soundly united. In the lower limb, therefore, and especially where the hip is concerned, we maintain the expectant attitude longer than in other cases. The presence of sequestra, which can be guessed at only from early suppura- tion and chronicity of sinuses, necessitates opening the joint, though possibly excision may be avoided. In very young children, excision causes great shortening, and should be postponed as long as possible. Repair after excision and erasion is just such as occurs after compound fractures ; if the periosteum of parts removed is preserved, they will be more or less completely reproduced in young subjects. Amputation is the final resource, and is required where excision has failed to arrest the disease ; or where the disease of bones or condition of soft parts from burrowing of pus is such that excision could not succeed; or where, in septic cases, the patient is exhausted by hectic, and possibly suffering from albuminoid disease, and requires that immediate and complete relief which only removal of the part can give. Lastly, amputation is almost always required in cases occurring in and below the knee after thirty-five ; in the upper limb excisions may be done much later with fair prospect of success. Gout. Gouty Arthritis, unlike acute rheumatism, affects first the smaller joints and then the larger, generally more or less symmetrically. If the attack is not the first, there is a history of a first attack, probably between the ages of thirty and forty, which began almost certainly about 2 or 3 A. M., often during spring-time, and in the first metatarso-phalangeal joint. The pain is extreme, and is accompanied by moderate fever, which seems to depend on the number of joints affected (Charcot), and lasts several hours; then perspiration, having neither the profuseness nor sourness of that in acute rheumatism, breaks out, and the symptoms are relieved, but the joint is swollen, bright red, shiny, and very tender, the oedema involves the neigh- boring part of the foot, and the veins leading from the joint are full. The acute symptoms recur twice or thrice at night, and then with decreasing intensity for seven to fourteen days. Desquamation occurs as the joint symptoms subside. The tendency is for these attacks to recur—sometimes at very long intervals, again quickly; generally the second attack comes one to two years after the first, and later ones at shorter intervals. With each attack fresh joints are liable to be involved—from the periphery toward the centre; and the more widely distributed the disease, the less intense do its symptoms become. At the same time, masses of urate of soda (chalk- stones, tophi) have been accumulating in ligaments, bursae, and fibrous tissues around the joints, in the sheaths of tendons (usually those in connection with affected joints), and in the cartilages of the ear, eyelid, and nose, where they form small yellow nodules. As a result of these changes, and also from the fact that nodular outgrowths from the margin of the cartilage may appear as in rheumatoid arthritis, the joints become misshapen, and more or less fixed; ultimately they may become completely ankylosed, for the infiltrated car- tilage wears away, the exposed bone is irritated by friction and uratic infil- tration, rarefactive ostitis is set up (gouty arthritis), rest is given, the opposed surfaces blend, and ossification occurs. Lastly, the chalk-stones cause irri- tation, the skin ulcerates over them, and the most chronic sinuses form around the joints. This is very common in the hands. Gout may occur even in children, but when met with under thirty, or in 328 INJURIES AND DISEASES OF JOINTS. women, there is almost always a strong family history. The tendency of the disease to skip one generation is well known. The Diagnosis of gout is often of great importance in the matter of treat- ment ; it will be assisted by a family history of gout, which is strongly hered- itary ; by the patient's being of the male sex; by a history of free indulgence in strong alcoholic drinks, of high living, dyspepsia, and a sedentary, luxu- rious life; by the presence of lead in the system, and by the discovery of uric acid in the urine or in the fluid of a blister or blood-serum (Garrod). It is most difficult when in a first attack several joints, including large ones, are involved, or when one large one is first affected. Usually, the diagnosis of chronic gout from rheumatoid arthritis is not difficult. Treatment.—In gout the vin. colchici (n^x-xxx) with bicarbonate of potash is the main remedy for cutting short the attack and relieving pain; then a simple dietary, abstinence from alcohol, Turkish baths, and plenty of exercise are to be insisted on (F. 149, 151, 158, et seq.). Rheumatism. The synovitis of Acute Rheumatism may be hereditary, often follows exposure to cold, and the first attack generally occurs under thirty. It affects usually the larger joints—knees, ankles, shoulders, elbows, and wrists; but any may suffer, even those of the hands and feet. It is rarely monartic- ular, and then never attacks the great toe. The affected joints differ from the type of ordinary acute synovitis chiefly in the intensity of the fever and of the pain by which its onset is announced, the patient being afraid of the least movement; at the same time the joint becomes puffy and often slightly red, and after some hours effusion occurs into it with relief of symptoms. OSdema is not marked, the veins are not full, and desquamation does not occur. Only one joint may be affected, or very many, but, as a rule, only two or three are affected at once; it is, however, a strongly marked charac- teristic of the disease that as, after a few hours or days, one joint gets well, another becomes painful and swollen, and the same joint may be affected more than once in the same attack. The diagnosis will be facilitated by the marked continued but irregular fever (often out of all proportion to the joint lesions, and apparently primary or independent of these or of visceral com- plications), profuse sour sweating, endocarditis, and inflammations of serous membranes which occur more or less frequently in the disease, and charac- teristic early anaemia. It is chiefly in subacute cases that difficulty will occur. In these the fever is less intense, sweating less marked, the articular affections more persistent and less wandering than in the acute form, a joint being affected for perhaps six or eight weeks. When two or more joints sudddenly and without evident cause fill with fluid, it is sometimes difficult to know whether or not we are dealing with rheumatism. Always take the temperature in such cases. The joints very rarely suppurate; sometimes the disease leaves behind it ordinary chronic arthritis of one joint which ends in more or less ankylosis ; or, lastly, the disease may become subacute and finally chronic, thus estab- lishing, according to Charcot, its essential unity of nature with chronic rheumatoid arthritis. The Morbid Anatomy is said to point in the same direction. The car- tilage in acute cases is somewhat opaque and dull; local swellings may render it mammillated, and even erosions may occur. The microscope reveals changes which are probably constant. The most superficial cells divide early, and later, fibrillation of the ground substance occurs, giving rise to a velvety condition; the cell-capsules burst, and the cells escape into the MORBID ANATOMY OF RHEUMATOID ARTHRITIS. 329 synovia. The subjacent bone becomes very vascular, and the corpuscles increase in it. After two months Charcot has found a thickened, villous synovial membrane, erosions, and a well-marked velvety state of cartilage. In still more prolonged cases these changes are more pronounced, the car- tilage worn away, and the bone eburnating centrally, outgrowths are form- ing round the edge, and the epiphyses are becoming rarefied. Treatment.—The joints are here of minor importance. They may be wrapped in cotton-wool, and the pain is relieved by sod. salicylatis, 20-30 grains every three hours till the temperature falls. Chronic Rheumatic Arthritis, Rheumatoid Arthritis, Rheumatic Gout, Dry Rheumatic Arthritis, Arthritis Deformans, Chronic Osteo-arthritis.—This disease is much commoner in women than in men, in the lower than the upper classes (arthritis pauperum). Its onset gener- ally occurs during the cold season, and is often attributed to exposure to cold and wet, to which influences the patients are always very sensitive. In women, it usually appears about the time of the menopause, but it is quite common from sixteen to thirty, and may be met with even among children. Sometimes an injury seems to determine the joint in which the disease shall start. It may follow on acute rheumatism. Some writers regard it as of nervous origin. There are two chief forms of the disease, usually known as the polyarticular and monarticular, but better described as progressive and partial chronic artic- ular rheumatism (Charcot). They are bound together, in spite of consider- able differences between typical cases, by the occurrence of cases transitional between the two varieties, and by the following morbid anatomy which is common to both, and also, apparently (p. 328), to acute rheumatism. Morbid Anatomy.—The first change is seen in the articular cartilages toward their centres—i. e., at the points of greatest pressure; here they be- come velvety, and elsewhere they may be slightly mammillated. This ap- pearance is due to multiplication of cartilage cells, the capsules of which unite to form vertical spaces, and these burst into the joint; at the same time the interstitial tissue fibrillates. The cells often undergo mucous or fatty degeneration. Next the synovial membrane becomes very vascular, its processes, especially those round the cartilages, enlarge, and the synovia at this time is constantly increased in amount. This fluid is often acid, and is slightly turbid from presence of mucin, degenerate cartilage, epithelioid and white blood cells. As the joint moves, the soft velvety cartilage wears away more and more until the bones come to rub against each other. Thus irritated, a superficial sclerosing ostitis is set up, and the exposed bone be- comes extremely dense and ivory-like in appearance (porcellanous, ebur- nated); the dense layer, however, is said not always to have the structure of true bone, but to be sometimes rendered thus dense by simple calcification of soft parts. The opposed surfaces are neither equally nor uniformly hard, and consequently, as they move to and fro upon each other in hinge joints, they are worn into corresponding grooves and ridges, but they are smoothly worn away (Fig. 128) in universal joints. Meanwhile at the margin of the cartilage rounded nodules (ecchondroses) have been growing, until they may form a prominent continuous rim between the cartilage and bone; they ossify rapidly, and leave low, smooth, rounded osteophytes, " like drops of tallow," on the macerated bone. Thus, whilst destruction of cartilage is going on centrally, production is progressing at the margin. The ecchon- droses are formed partly by multiplication of cells at the margin of the artic- ular cartilage, partly by metaplasia of bone cells into cartilage cells which continue to grow (Ziegler). Occasionally plates of cartilage appear in the subsynovial tissue and ossify; but much more commonly the cartilage cells 330 INJURIES AND DISEASES OF JOINTS. normally in the synovial villi multiply, or cartilage appears there by meta- plasia, and by its growth gives rise to small pedunculated cartilaginous tumors which may become detached and form loose bodies in the joint either before or after undergoing calcification or ossification. Such loose bodies are common in the knee and shoulder, rare in the hip. In these advanced stages, synovia is no longer in excess (dry arthritis), the membrane is thick and often quite villous, or even tuberous, from overgrowth or its processes, and adhesions may exist between parts of it that touch. The capsule also has thickened, doubtless by inflammatory tissue, and become more or less rigid; and whilst, centrally, the bones have been wearing away more and more, such interlocking outgrowths may have formed at the margin that the joint is more or less completely fixed. This fixation may be aided by ex- tension of ossification into the ligaments and neighboring tendons. Bony ankylosis is rare, and is said to occur only in small joints (Charcot). When a perfectly fixed hip-joint is cut across, though all cartilage may have dis- appeared, the line of the articulation is generally visible; the femur is held by the growth over it, as it were, of the acetabular margin, and the irregu- larities of the surfaces correspond. By wearing away on its upper aspect and growth at its margin, the head of the femur may look like a mushroom (Fig. 128), and the acetabulum may become shallow and expanded. Changes in the shoulder are often very similar: the head flattened, glenoid cavity expanded by a new rim, the glenoid ligament and biceps tendon, with perhaps the upper part of the capsule, gone, and the head playing against an eburnated surface upon the acromion. Lastly, when joints are not moved, we find no eburnation, the capsule and synovial membrane thicken, the cartilage is converted into connective tissue, and a fibrous ankylosis (in most cases) results. A section through the epiphyses enteiing into joints thus affected shows the bone to be atrophied and unduly vascular from a chronic rarefying ostitis; and macerated bones fre- quently show worm-eaten holes on the artic- ular surface, even where this is eburnated. This atrophy is specially marked in malum coxae senile, causing shortening and sinking of the neck ; coincidently, osteoplastic peri- ostitis lays down masses of new bone on the surface (Fig. 128). Interarticular ligaments, fibro-cartilages, and tendons gradually wear away. All the above changes are seen most advanced in the monarticular or partial form of the disease, and in the more chronic among the polyarticular class. Pathological dislocations &xe rare, and occur only in the smaller joints, in which outgrowths from one bone may actually push the other out of place. Partial displacements from muscular contractions are common in all joints. 1. Progressive Chronic Articular Rheumatism. — In this form several joints are generally affected, those of the upper rather than of the lower limb, and preferably the smaller one*, especially the second and third metacarpo-phalangeal; they may suffer either alone or with other larger ones. The onset in a large joint alone is much more common than in gout. As a rule, symmetrical joints are affected. In young patients (sixteen to Fig. 128. Head of femur in rheumatoid arthritis, from a specimen belonging to the late E. Canton. It is worn away above, sur- rounded by a collar of osteophytes, where it joins the neck, and the neck is greatly atrophied. rheumatoid arthritis—localized form. 331 thirty) many joints usually suffer at once, but after forty a slow progression from the hand and foot joints towards the shoulder and hip is more common. The symptoms may appear in a joint or two, and subside once or twice, before steady advance sets in. The affected joints are painful, red, hot, and swollen, the inflammatory symptoms being of moderate intensity and the tendency to shift slight. Pain may be constant, though varying much in acuteness, and much affected by change of weather; and similarly the inflammatory symptoms die away and return. When the joint can be moved, we at first feel soft crepitation from velvety cartilage, and perhaps villous synovial membrane; later on, perhaps, the loud, coarse crepitus of eburnated surfaces; finally, little or no movement can be obtained. Outgrowths, much enlarged villi, or loose bodies may be felt. Quite early in the disease spasmodic contractions of the muscles round the affected joints occur and give rise to characteristic deformities; they are best marked in young patients. The finger-joints may be flexed and extended in every imaginable way; very often all are straight, flexed at the meta- carpo-phalangeal joints, and deviating toward the ulnar side. The hand becomes more or less flexed, the forearm pronated, the elbow flexed, and the shoulder may become rigid and fixed against the side. The lower limbs generally suffer after or with the arms, the knees become flexed, and the hips also, though these generally retain mobility. The foot may be in a position of talipes valgus or equino-varus, and the big toe turns outwards. The spine and jaw usually suffer late. Thus in two or three years a patient may be so crippled as to be unable to do anything but lie quiet. She may live thus for many years. At first, in rapid cases, there is a good deal of fever and profuse sweating, and cardiac disease may occur. After a time the temperature becomes remittent, then intermittent, recurring with acute exacerbations. After two to four years, in these acute cases, pain usually almost ceases and a status quo is established. In the most chronic progressive cases there are no general symptoms, no local signs of inflammation, no muscular contractions; deformities are due to outgrowths. Cases of all intermediate degrees of acuteness are met with, and rapid cases may occur in the old, slow in the young. 2. Partial Chronic Rheumatism (Monarticular).—In this form but few joints, and often only one, are attacked; the larger, even the shoulder and hip, which are avoided in the progressive form, are selected, and the disease belongs to the latter half of life. This fojm is generally chronic from the first; but it may start subacutely or even remain after acute rheumatism. Cases of this disease frequently occur to surgeons, the hip, shoulder, or knee being affected; much less often other joints, as those of the spine or jaw. The symptoms in all these cases commence with pain of rheumatic char- acter and increasing stiffness; but, as a rule, some movement is preserved for a considerable time. The pain may be very severe and varies much. Usually there are no signs of active inflammation, and there is no effusion into the joint nor around it. The movements are at first accompanied by soft crepitation, then by the most marked bony grating; nodular outgrowths are plain if the joint is superficial, and enlarged villi and loose bodies may be felt. As movement of the joint becomes less, the muscles which act upon it waste—e. g., glutei and thigh muscles in malum coxe senile. In this dis- ease we find also progressive shortening from wearing away of the femoral head and atrophy of the neck, and thickening of the trochanter from forma- tion of bone about its base. This process of bone seems unduly prominent 332 INJURIES AND DISEASES OF JOINTS. on account of the wasting and slight adduction—the pelvis being often raised on the diseased side, because the patient, to interpose another spring between the hip and the ground, walks on the toes. The toes may turn in or out. When this disease starts subacutely, the question of senile struma may arise, and some little time may be required to render the diagnosis sure. Treatment.—Very little can be done to check the progressive form beyond placing the patient under hygienic circumstances, in a dry situation where the temperature is fairly uniform. The anaemia which is always present must be treated, and cod-liver oil and a nutritious diet are, of course, beneficial. The drug said to have been serviceable is iodine in quanti- ties of iti^x to grm. vj (!) in the day, taken during meals in eau sucree or wine; it may be continued for months if necessary without causing poison- ing. Arsenic and the ammoniated tincture of guaiacum sometimes do good in early cases, but frequently produce an exacerbation at first. Salicin and salicylate of soda in large doses relieve the pain at the cost of deafness, headache, etc., next day. Simple warm, Turkish, or mud baths give relief, as also do fomentations round painful joints. Baths in natural waters containing sulphur, arsenic, or iodine are all recommended. Something may be done to prevent the contractions in the progressive form of the disease—e. g., to keep the knees straight, the foot flat, the elbow near a right angle; and faulty positions may sometimes with great advantage be forcibly remedied. In most cases rest and warmth will be found to give relief. Flannel should always be worn round the joints. Cf. Charcot, Lectures on Senile Diseases, translated for the New Sydenham Society by W. S. Tuke. Joint Disease of Nervous Origin. Charcot's Disease: the Arthropathy of Locomotor Ataxy.—Ex- amples of this disease appear to be rare, although Charcot once stated that he could show five examples among fifty patients resident at one time in the Salpetriere. Symptoms.—In a tabetic patient, without any appreciable external cause, and especially without any injury, an arthritis appears which is totally dif- ferent in its characters from the joint diseases due to cold, and diathetic states such as gout or rheumatism. It develops usually at an early stage of locomotor ataxy, between the prodromal symptoms (frequent and painful micturition, satyriasis, Argyll-Robertson pupil, accelerated pulse (90-100) without fever, and especially lightning pains) and the phenomena of inco- ordination. When the disease appears late in the course of ataxy, it almost always affects the upper limbs, in which incoordination is still slight or absent. As to the local signs—suddenly, and without any prodromata, except, perhaps, a little crackling noticed by the patient for a few days before, the whole or a large part of a limb swells greatly; and this tume- faction consists (1) of a considerable hydrarthrosis forming the centre of the swelling, to which is added (2) a firm oedema, scarcely pitting. As a rule, these phenomena are accompanied by no fever or pain; exceptionally both are present. After some weeks or months the swelling vanishes, and all be- comes normal (benignant form); in other cases (malignant), the swelling may pass away rapidly, crackling is present from the first, or soon appears, and within a few months luxation of some kind may occur, so rapid is the de- struction of bone. These dislocations may appear suddenly and without obvious cause. A laborer at work suddenly found one leg much shorter Charcot's joint disease. 333 than the other: the hip was dislocated and the man had symptoms of ataxia. The signs of dislocation are extremely plain, for the headless shaft often projects beneath the skin (Fig. 129). In spite of the above state of their joints, patients are prevented from using them only by their becoming flail-like, or by incoordination; suppuration does not occur in spite of this constant irritation. Fig. 129. Sketch from a patient of Dr. Paul's, at Camberwell House Asylum. The tibia and fibula dislocated back- ward, in consequence of the action of the hamstring muscles after destruction of the ligaments and ends of bones. Several joints may be affected and the patient rendered helpless. The knee is most often attacked; then the shoulder, elbow, hip, wrist; but the smaller joints do not entirely escape. Morbid Anatomy and Pathology.—In this the disease closely resembles rheumatoid arthritis, the chief difference being that in well-marked cases of the malignant type, erosion of bone proceeds rapidly, often destroying a whole articular end, whilst there is little or no bone formation—no eburna- tion, no growth of osteophytes. The rarefaction of the epiphyses which was noted in rheumatoid arthritis is here more marked and may affect the whole bone, hence the occurrence of spontaneous fractures, which generally affect the ends of bones (p. 229); but in less marked cases it is impossible by an examination of the joint to say whether it came from a case of ataxy or from one of rheumatoid arthritis. It is, therefore, held by many that Charcot's disease is only rheumatoid arthritis in an insensitive patient who persists in grinding his joint ends away when the ordinary rheumatic would keep quiet. It is not, however, by morbid anatomy that this question must be decided ; the clinical history must be taken into account. Even this fails to carry conviction, and as yet attempts have failed to demonstrate a lesion of certain anterior cornual cells in constant relation with disease of any given joint. In support of his view that ataxic arthropathy is really of spinal origin, Charcot alludes to similar affections occurring in connection with other dis- eases and injuries of the brain causing paralysis. Thus acute effusion with redness and more or less severe pain occurs in hemiplegia from hemorrhage or softening; it appears two to four weeks from the onset, together with secondary rigidity. Similar arthropathies have been noticed in paraplegia from Pott's disease (generally the knee), in pro- gressive muscular atrophy, and, most obviously of all, in connection with wounds of the spinal cord. Two cases are quoted of division of half the cord, causing paralysis of motion of the leg on the same side, followed in a few days by great swelling of the limb and arthropathy of the knee, and an acute bedsore on the opposite buttock. Lastly, typical rheumatoid arthritis sometimes occurs in ataxics and retains its peculiarities. There are not wanting those who believe the dis- ease also to be of nervous origin. 334 INJURIES AND DISEASES OF JOINTS. Treatment.—Little is required in the benignant form ; nothing can be done in the malignant beyond applying such apparatus as will steady the joints and render their use possible. It must be remembered that the symp- toms of ataxy may not be striking; the cases must not be taken for rapidly advancing strumous disease and the limbs amputated. Cf. Charcot, Lectures on the Nervous System, first and second series, New Sydenham Society, and discussion in Trans. Clin. Soc, 1885. Loose Bodies in Joints. The following varieties' are met with: 1. Melon-seed bodies, consisting apparently of fibrin and sometimes con- taining haemin crystals, may be found in cases of chronic hydrops. They are thought sometimes to originate as a kind of deposit from the fluid in the joint; at others, to form from the fibrin of blood effused. They may be very numerous, but do not of themselves give rise to symptoms necessitating their removal, though the concomitant hydrarthrus may do so. 2. Small fibrous bodies are met with which apparently owe their origin to detachment of enlarged villi in cases of papillary synovitis (Fig. 124). 3. Pieces of cartilage occur. They are usually of small size, round or oval on the whole, but irregular and nodular on the surface, single as a rule, but sometimes numerous. They may be due to detachment of synovial villi in which cartilage cells have developed; to the escape into the joint of carti- laginous masses from the subsynovial tissue, where they form in rheumatoid arthritis—the most frequent source, according to Billroth; to the detachment of the marginal ecchondroses in rheumatoid arthritis; and lastly to the sepa- ration by fracture of portions of the articular cartilage, perhaps with more or less bone. These cartilaginous bodies are frequently ossified or calcified; usually small, a single one, an inch long and largely ossified, has been found in the knee- joint of a child, quite disabling it. The source of bodies so large as this is doubtful, but it seems probable that bits of cartilage actually grow in the synovial fluid, just as transplanted bits of cartilage have grown into little tumors in the anterior chamber, and that calcification and ossification go on in this medium. Joints affected by rheumatoid arthritis are obviously likely to furnish loose bodies, but these occur in articulations otherwise seemingly healthy. The knee is by far their most frequent seat; then the shoulder and elbow. But they are uncommon anywhere. Bodies entering from without are not usually included under this heading. Symptoms.—The body or bodies can be felt when they present themselves near the surface. They, may be very difficult to find, even in the knee, and after one has been felt it may slip away and not present itself to touch for weeks after. They usually keep up more or less effusion into the joint, and the patient is often aware of their presence. Enlarged villi, which are felt always about the same spot, must not be taken for loose bodies. When the latter get between the ends of the bones, as they are very apt to do during exercise, they cause sudden excruciating pain and faintness, followed by more or less effusion, the symptoms in the knee being very like those in- duced by dislocation of a semilunar cartilage; until the dislocation is re- duced, and this generally requires some manipulation, the joint cannot be extended, but a history of flexion persisting some time after pain due to a loose body may be given. Treatment.—Cure can be effected in three ways, (1) by obtaining fixation of the body in some part of the joint where it shall be harmless, and this THE DIAGNOSIS OF JOINT DISEASE. 335 may be attempted by transfixing it with a pin for a few days (which is not without danger) or by shutting it up in a corner with strapping. Both methods usually fail. (2) By removing the body from the joint. This may be done by cutting down upon it directly with antiseptic precautions; before doing so it is always well to transfix the body with a pin lest it slip away at the last moment; but this cannot be done Avhen the body is much calcified or ossified. (3) There is also the plan of removal by subcutaneous incision, which seems to have been proposed almost simultaneously by Professor Syme and M. Goyrand to avoid the danger of a direct wound into the joint. The cartilage is to be pushed up as high as possible into one of the synovial pouches by the side of the patella, and a tenotome is passed down upon it through a puncture in the skin two or three inches above, and made to divide the synovial membrane to such an extent that the cartilage may be squeezed through into the subcutaneous cellular tissue. There the cartilage must be kept by strapping till the wound in the synovial membrane has had time to heal; when it may, if desired, be easily removed by an incision through the skin; but if it causes no inconvenience, it may be allowed to remain. The Diagnosis of Joint Disease. In examining a case of joint disease, symmetrically placed articulations should always be compared. The first point is to determine whether it is one of sthenic or asthenic inflammation, or, as is more usually but less cor- rectly said, acute or chronic. The sudden onset, the intensity of the local symptoms, pain, heat, redness, and swelling from involvement of parts around the joint, the absolute or almost complete fixation of the joint, usually in some faulty position (flexion), the agony caused by attempts to move it, and the severity of the general disturbance will decide this point. Of course, subacute cases occur which may with almost equal propriety be placed in either group. Most of these cases are of a rapidly destructive nature; but it will be remembered that the symptoms in acute gout and rheumatism may be very severe, and yet the tendency to destruction of the joint is compara- tively slight. If a case is not of an intense kind, it will be either a synovitis (effusion) or a chronic arthritis, of which for clinical purposes we may make two classes—granulation arthritis and chronic rheumatic arthritis. The diag- nosis between synovial effusion and granulation arthritis is that which has most often to be made. Here we rely first upon the presence of fluid and absence of thickening of the synovial membrane in synovitis, upon the pres- ence of the latter or of both in arthritis. But these points can be made out only in superficial joints; much more important are symptoms which show that destruction of the joint is progressing—such as movement, limited more than fluid in the joint will account for mechanically, or even fixation of the joint, usually in a position of flexion ; marked wasting of the muscles; more or less pain excited by attempts to obtain movement; abnormal movement— e. g., side to side motion in a hinge-joint; evidence of destruction of cartilage in the shape of grating from surfaces of bone passing over each other; or evidence to sight or touch of wearing away of the ends of the bones and of their displacement. All these symptoms are absent in cases of simple effusion. We must add that, rarely, one meets with a chronic suppuration in tuber- cular cases in which the symptoms are indistinguishable from those of hy- drarthrus, the only sign of disease being fluid in the joint; and we may here recall the not infrequent absence of local or general symptoms in cases of pyaetnic suppuration. In the partial form of rheumatic arthritis there will be no fluid in the 336 INJURIES AND DISEASES OF JOINTS. joint, wasting and stiffness may be marked, and there may be a good deal of pain of rheumatic character, much influenced by weather; the age and probably the history of the patient will help in recognizing the disease, and the soft crepitation followed sooner or later by rough bony grating, unac- companied by any such pain and general disturbance as would certainly be present in so advanced a case of strumous disease, will make the diagnosis more clear. The history and clinical course of joint trouble connected with cerebral and spinal disease are so very special that nothing need be said on their diagnosis. Limited Movement, Contractions, and Ankylosis. Limited Movement may be due either to (1) disease external to a joint; or (2) to disease of the joint itself. As examples of limitation due to disease external to a joint may be men- tioned the effect of abscess in the iliac or psoas muscle or inguinal glands upon extension of the hip; of contraction of scars in the skin, especially after burns; of contraction of muscles after injury—as in wry neck from tear of the sterno-mastoid during birth, or from adaptive shortening, as in paralytic equinus; of adhesions of tendons in their sheaths, most often seen in the hand. But by far the greater number of cases of limited movement are due to changes in the joints. These may be due to old fracture with some dis- placement or growth of callus into the articulation, or to adhesions which form when joints in the vicinity of a fracture are kept long at rest. Much more commonly they are the result of inflammation, present or antecedent. Active inflammation may limit movement by tensely distending the joint with fluid, by rendering the synovial membrane and other joint structures abnormally tender, or, in the case of rheumatoid arthritis, by causing the growth of osteophytes. Past inflammation, on the other band, may leave behind it contraction of the capsule and periarticular connective tissue, or adhesions between portions of the synovial membrane which normally come into contact in certain positions of the joints, or long or short adhesions be- tween the ends of the bones. Frequently the limitation of movement prevents the straightening of joints, which are then said to be " contracted." Such contraction may be accompanied by marked displacement of the articular surfaces upon each other, as has already been noted. Ankylosis, which means " angular position," is a term used to signify absolute or almost complete fixation of a joint, and this may occur either in the bent or straight position. Ankylosis may be (1) false or spurious, the fixation being voluntary or involuntary, and disappearing under chloroform; or (2) true, the loss of movement being due to close union of the joint sur- faces by fibrous tissue, cartilage, or bone. In fibrous ankylosis the bands come from the granulation tissue folds which grow in over the cartilage, eroding it more or less deeply; they may be few and long, or widespread, short, and inextensible. In the latter case no movement may be perceptible in the joint; but usually in this form, slight movement may be detected, or the attempt to obtain it causes a contraction of the muscles which oppose the movement, and may induce some pain. Bony ankylosis results from ossification of fibrous tissue formed from granu- lations which have eaten through the cartilage on opposing surfaces so as practically to render the two bones continuous (Fig. 130); the union may be quite localized or general. When this form of ankylosis is established, limited movement and ankylosis. 337 Fig. 130. loss of movement is necessarily absolute, and the endeavor to obtain it causes neither muscular contraction nor pain. Cartilaginous ankylosis (Volkmann) is uncommon. It is said to occur after fractures into joints and slight inflammation, a thin layer of connective tissue which unites the joint surfaces being converted into cartilage. It may be found even after suppuration, localized to spots where the inflammation has been less severe. It is said sometimes to ossify. It appears, therefore, that ankylosis is first fibrous, and may remain such; or it may become cartilaginous and perhaps ultimately bony; or the fibrous tissue may ossify directly. Treatment of Contractions, Limited Movement, and Ankylosis.— In certain cases of disease, especially those of tubercular nature, a cure by ankylosis is frequently the best thing that can be hoped for, as attempts to move the joint injure the granulation tissue and di- minish its resisting power; in such the surgeon has to see only that it occurs in the most favorable position (p. 323). In others, especially after injuries in healthy subjects, and in cases in which limited movement is threatened by matting of tendons and other structures, the surgeon will endeavor, by systematic passive move- ment begun when acute symptoms have subsided, to preserve the freedom of the joint. In cases in which all morbid action has ceased, range of movement may be in- creased by (1) passive movement—i. e., movement of the joint produced without action of its muscles, and best performed by some one other than the patient. Sufficient force to cause a little yielding and little pain must be used; and all the move- ments of the joint should be systematically gone through. The treatment should be combined with friction, shampoo- ing, and local warm baths. There are machines by which a patient can exercise the knee and ankle. (2) Forcible movement under an anaesthetic assisted by the division of bands of deep fascia, of tense tendons or muscles. After this the joint is to be fixed in the most advantageous position on a splint till traumatic inflammation has subsided ; after which passive motion must be practised daily for some weeks. This method requires care in its use, serious accidents having happened—e. g., knee-joints torn open, united fractures rebroken, etc., and in the knee-joint forcible extension is particu- larly liable to throw the head of the tibia back into the popliteal space. This is the means by which bone-setters have gained much credit in cases of limited fibrous adhesions after injury which render attempts to move the joint most painful; having stated that the joint is "out," they proceed to "put it in" by a sudden sharp movement which frequently ruptures the ad- hesions ; a crack is heard by by-standers (caused, of course, by the bone slip- ping into place), and the sharp pain of the movement being over, the patient finds that he can use the joint freely, and goes on his way rejoicing. (3) Sometimes, in order to obtain ankylosis in a good position, weight extension is used to remove deformity. It is specially valuable in cases in which dis- ease is still present and the resistance not very great. For the knee-joint 22 Result of long-continued disease of the ankle-joint. The bones are completely welded together by bony ankylosis. 338 DISEASE OF THE HIP-JOINT. Schede's plan is the best to prevent displacement backward of the tibia. In addition to the ordinary weight extension from the leg, the femur is fixed to the bed and vertical traction by weight over a pulley is made upon the tibia immediately below its head. (4) A constant pressure or traction machine may be used to correct deformity and increase range of motion. (5) In the hip and knee, H. O. Thomas recommends the use of his splints iu such a manner that the weight of the limb shall act constantly so as to undo the contraction. The process is easier the more recent the disease; it may be impossible after resolution, when firm fibroid ankylosis has ensued. More or less pain and local excitement must be expected during the reduction of deformity by any of the above methods. When they fail, as they certainly will in cases of cartilaginous and bony ankylosis, in many cases of stout fibrous ankylosis and of complete or partial pathological dislocation, we must resort to (6) Resection or (7) Osteotomy. Re- section will be chosen especially in the upper limb, in the joints of which its results are so good ; it often gives the best results also in angular ankylosis of the knee. But in some cases of firm angular ankylosis of the knee and in all of the hip, osteotomy should be done, and the limb brought into the straight posi- tion. For the knee the operation is similar to that for genu valgum (q. v.) ; for the hip, the femur may be divided through its neck (W. Adams) or through the shaft just above the small trochanter (Sayre). Adams's operation is the easier. A short incision is made from the buttock on the neck of the bone, and with a pistol-handled saw the neck is divided at right angles to its long axis. The use of the chisel (Maunder) facilitates matters, and probably Gowan's new osteotome would be still simpler to work with. When the bone is divided, the femur is brought down straight, any tense bands in front being cut; then a permanent antiseptic dressing and a Thomas's hip-splint are applied. Union in the new position should be allowed to take place, firmness being here of greater importance than mobility. In 1876 Adams (Trans. Med. Clin. Soc.) collected twenty-two cases of this operation, of which two died (one pyaemia, one suppuration and " kidney disease ") and one was still under treatment. Sayre's operation is performed with a chain saw; its object is to obtain movement, and the upper fragment is cut so as to present a hollow socket- like surface to the lower. In very exceptional cases of contracted limb3 useless from paralysis, imper- fect development, and perhaps ulceration, amputation will be required. CHAPTER XXVIII. DISEASE OF THE HIP-JOINT, OR MORBUS COX.E. This joint is exceedingly liable to chronic disease of tubercular nature, and " disease of the hip-joint," in common surgical language, means tuber- cular arthritis. But, like other joints, the hip is liable to other forms of acute and chronic inflammation; thus serous and purulent inflammations from injury and wound are by no means uncommon, the joint may suffer in the course of pyaemia, typhus, and rheumatism, suppuration may arise from CHRONIC ARTHRITIS OF THE HIP. 339 acute osteomyelitis of the head of the femur, and the hip is exceedingly liable to be affected in partial chronic rheumatoid arthritis. Other causes of joint disease less commonly select the hip as their seat of action. Acute Arthritis of the Hip. There is little to add to what has been said as to the symptoms of this dis- ease in general. In the hip we have the same more or less intense pain, starting, utter helplessness of the limb, fear of every movement, and rapid wasting, and the same general disturbance. In the less acute forms, and especially in synovial effusion from injury, the limb is often slightly flexed, abducted, everted, and apparently lengthened ; and it is said (but it seems very doubtful) that actual lengthening of the limb may be present from separation of the joint surfaces by the effusion. In the more acute and painful forms, the limb rapidly assumes the position (often in an extreme degree) of flexion, adduction, and rotation in (Fig. 131), which is character- istic of the more advanced stages of chronic hip disease. This is the position in which dislocation on to the dorsum ilii most easily takes place (p. 304), and it is said that the head may be thrown out of the socket without the occur- rence of suppuration. In the vast majority of cases this is the result of an acute suppurative arthritis which causes distention of the capsule and soften- ing of its posterior portion, when the head is levered out by excessive rotation in and adduction ; it escapes below the obturator tendon. This seems to be the pathology of most cases of early dislocation (p. 317). An acute arthritis may, of course, stop short of suppuration, and subside or pass into a chronic state; but if the synovial membrane has been infil- trated with round cells at all deeply, movement is sure to be more or less limited, and may be altogether lost. On the other hand, all the destructive changes consequent upon suppurative arthritis (p. 316) may ensue, abscesses of huge size may form and point in various directions, and may lead to the death of the patient in several ways. The Treatment consists in giving absolute rest to the joint by means of a Thomas's splint, a double one if possible, wrapping the hip in frequently renewed hot fomentations, relieving pain by anodynes, keeping a careful look- out for abscess, and opening it freely should it appear. In many cases, and always in those apparently spontaneous, rapidly suppurating cases in which necrosis of the head of the femur from acute osteomyelitis is suspected, the appearance of pus should be the signal for a free posterior incision into the joint, examination of the head, and removal of a sequestrum should one be present. Chronic Arthritis of the Hip. Etiology.—This disease is infinitely more common in children than in adults. It is rare under three, most common from five to ten, common from ten to fifteen, and becomes very much less frequent with completion of growth. It ranks third in order of relative frequency among carious bones (Billroth), being less common only than caries of the spine and of the knee- joint. Very commonly the disease is attributed to an injury; sometimes it is left after an acute specific fever, especially measles; perhaps most frequently no cause is assigned. Essentially the disease is tubercular. Opportunities of examining hip-joints in early stages of this disease are rare, and examination in later stages does not yield conclusive results as to the starting-point of the morbid process; for wherever it starts, the ultimate 340 DISEASE OF THE HIP-JOINT. effects are very similar (p. 318). It is, however, generally believed that hip- joint disease is very frequently of osteal origin, beginning as a chronic osteo- myelitis of the head of the femur or acetabulum, the latter chiefly in adults. Doubtless, it sometimes commences in the synovial membrane. Symptoms.—The onset may be subacute, accompanied by a good deal of pain, inability to get about, and slight fever; but much more commonly it is gradual and insidious. The first signs are almost always lameness and pain, felt chiefly in the knee, as a rule, but sometimes about the hip. It is noticed that the child in standing bears all his weight on the sound limb, and that in walking the toes turn more or less outward, and tend to drag a little as they are carried forward. If now the child is stripped, laid on his back on a smooth firm surface, and examined, it will often be found that there is slight fulness below Poupart's ligament on the affected side, and pressure here sometimes causes pain ; there may be, also, some flattening of the buttock and diminution of the gluteal fold from wasting of the gluteus max. If the two limbs are placed together, it will be noticed that the line of the linea alba crosses the sound limb instead of running down between the two, that the toes point too much out, that the anterior sup. iliac spine and internal malleolus on the diseased are lower than on the healthy side, but measurement from the spine to the malleolus shows that the length of the limb is not increased. If both knees are pressed down flat upon the couch, the lumbar spine will arch up more or less markedly; if the sound limb is completely flexed upon the body, this arching disappears, the back touches the couch everywhere, but the knee on the diseased side has now risen more or less from the table (fixed flexion) ; if an endeavor is made completely to flex, extend, or rotate the diseased joint, it will be found to be impossible, the pelvis more or less closely accompanying the femur in all its movements, of which rotation is the most limited. Inspection, manual examination, and measurement, therefore, show that, in the early stage of hip-joint disease, the limb is usually somewhat flexed, abducted, rotated out, and apparently lengthened, and that the movements of the joint are limited or abolished. This is owing to fixation by the muscles, for under chloroform the move- ments are complete. The explanation of the above position, described as characterizing the first stage or stage of apparent lengthening, of hip-joint dis- ease, is probably that the patient, in standing, throws his wbole weight upon the sound limb, using the diseased leg only to steady himself with ; for, when a healthy man does this, it will be seen that his resting limb is in a similar position, and that his ant. sup. spine is lowered. Were his knee straightened without elevation of the ant. spine, his limb would appear longer. The pain in this stage is not severe; the above position relieves it from nearly all pres- sure in standing, and sufficient ease is given to the joint in walking by keep: ing the knee slightly bent, so that it greatly lessens shocks transmitted along the lower limb. In this movement the ant. spine and side of the pelvis are depressed to bring the abducted lower limb vertically under the body-weight. As the case progresses, the lameness and pain become more marked, start- ing pains occur at night, the whole limb, especially the thigh and buttock, waste, the trochanter is abnormally prominent (Fig. 132) on account of this wasting and of adduction, and the patient often loses flesh and strength, and becomes anaemic. At the same time the limb changes its position to that characteristic of the second stage, viz., one of greater flexion, adduction, rotation in, and apparent shortening (Figs. 131, 132). Sometimes this atti- tude is assumed from the first; but very often the earlier flexion and abduc- tion are missed by unskilled observers, being masked by sinking of the side of the pelvis (Bonnet). The cause of the assumption of this second position would seem to be fear of injury to the painful joint. Every one has noticed SYMPTOMS OF HIP-JOINT DISEASE. 341 that a child cowering from fear of a blow or other injury almost always throws the most exposed lower limb into the position above described; it is assumed instinctively as being that of greatest security, and once assumed in hip disease, it is maintained involuntarily, for a movement back into another position would be painful. The patient now walks on the toes, which are turned in, and thus a second elastic break (that of the ankle-joint) is inter- posed between the painful hip and the ground. The ant. sup. spine is raised in order to bring the adducted limb to the ground, and to render it capable of supporting the body-weight. Fig. 132. Hip disease, showing position of flexion, adduc- tion, und rotation in ; also apparent shortening. Hip-disease, showing wasting, flattening, and widening of buttock, prominence of the trochanter, adduction, and elevation of side of pelvis, with sec- ondary spinal curvature. Finally, the pain may become so great that walking is impossible. The child now lies constantly, and mostly upon the sound side, never on the dis- eased ; the diseased limb seeks support, and to obtain it gradually sinks into more or less complete adduction, until it lies upon the opposite thigh. This movement is accompanied by increased flexion and rotation in, and the atti- tude of the second stage is then seen in an extreme degree. Walking with an abducted limb and a flat foot necessitates some sinking of the side of the pelvis, whilst with an adducted limb the side of the pelvis must be raised to bring the leg vertically under the body-weight. Either of these abnormal positions of the pelvis is necessarily followed by some lateral curvature of the spine; and this is best seen in the second stage (Fig. 132). At first, when the patient lies down, the malposition of the pelvis is easily corrected, but after some time this cannot be immediately effected. By far 342 DISEASE OF THE HIP-JOINT. the most marked spinal change is that known as lordosis—i. e., increase of the lumbar curve to compensate flexion of the hip; in proportion as move- ment in the hip-joint becomes limited, that in the lumbar spine increases, and thus, once more, a defect is to some extent made up for. Hitherto we have spoken only of apparent changes in the length of the limb, but real shortening may now occur. This results—1. From impaired nutrition of the limb, and from damage to the growing epiphysial line. 2. From erosion of the head of the femur and of that portion of the acetabulum against which it presses; almost always it is the upper and posterior part of the margin which thus suffers—rarely, when abduction persists into the second stage, the lower and anterior part towards the thyroid foramen ; and sometimes perforation of the floor occurs (Fig. 133). In chronic cases, as Fig. 133. Late stage ; acetabulum perforated and enlarged chiefly downward and inward ; great erosion of head and neck of femur; dislocation of the femur toward the thyroid foramen, formation of new bone where the head rested, as if for ankylosis or false joint. the erosion advances, new bone may be thrown out beyond, and a kind of fresh socket formed; the acetabulum then seems to have enlarged in that direction—migration of the acetabulum. 3. From separation of the upper epiphysis, which is perhaps as common a cause as the next. 4. From patho- logical dislocation, which occurs much less commonly than many suppose. No sharp line can be drawn between cases of dislocation and cases of en- largement of the acetabulum. Dislocation is most common in cases of total suppuration of the joint with destruction of the ligaments, and it is said to be specially frequent in coxitis after typhus (p. 319). Shortening from the three latter causes is accompanied by approach of the trochanter to the iliac crest, but an accurate diagnosis between them may be impossible. Strong rotation in is characteristic of dorsal dislocation, but when the head is destroyed this sign may be wanting. Strong adduction with flexion points rather to enlargement up and back of the acetabulum ; and the signs of separation of the epiphysis are variable. PROGNOSIS AND DIAGNOSIS OF HIP DISEASE. 343 It now remains to speak of the occurrence of suppuration, which is so lamentably frequent; of 401 cases at the Hospital for Hip Disease, 69 per cent, suppurated. It is almost always present when there is marked dis- placement, and frequently occurs without such displacement. Abscess presents itself most frequently toward the lower part of the tensor vag. fem., and next in the buttock beneath the gluteus maximus. Much less commonly the acetabulum is perforated through the Y-cartilage, and an intrapelvic abscess forms beneath the obturator fascia and usually points just above Poupart's ligament—rarely it bursts into the rectum or vagina. Lastly, an abscess, perhaps commencing in the bursa between the ilio-psoas and the joint, which often communicates with the synovial membrane of the latter, seems to be not very infrequent; it takes the course of the psoas, and may be discovered as a swelling just above Poupart's ligament. The diagnosis from intrapelvic abscess must be made by a rectal or vaginal examination, by which in the latter fluctuation should be obtained from the examining finger to the superficial swelling. In a case of pyaemic suppuration of both hips, I have traced a huge abscess into either psoas muscle; on one side it ex- tended quite up to the transverse processes, which were covered by peri- osteum, and down almost to the popliteal space; and on both sides there was great oedema of the legs from pressure on the femoral vein. Such an exten- sive abscess as this from hip-joint disease is very rare. The Duration of the disease varies from two or three months to several years. The Prognosis is very much better in children than in adults, the latter rarely if ever recover after suppuration has occurred unless excision is per- formed, and even then the outlook is not hopeful. Much always depends on the stage at which treatment is begun, the general health, and the possibility of placing the patient under favorable hygienic and nutritive conditions. Children frequently recover even after suppuration has occurred. Of 260 cases of suppuration at the Alexandra Hospital, 31.6 per cent, died of the disease against 10.5 per cent, of 124 non-suppurating" cases. The chief cause of death seems to be general tuberculosis and tubercular disease of other organs, especially lungs; naturally albuminoid disease ranks high as a cause of death in cases which suppurate. Of 446 cases, excision or amputation was done in 62; no operation beyond opening abscesses was performed in the others. 154 died (34.5 per cent.), and in 39 the cause is known to have been meningitis or some form of tubercular disease (9 per cent, of the whole number of cases). It will therefore be seen that hip dis- ease is very fatal. (" Report of Committee on Excision of Hip-joint," Clin. Soc. Trans., 1871.) Diagnosis.—Acute inguinal lymphadenitis, or abscess in the iliac fossa or anywhere in front of the joint, will prevent either full extension or flexion of the hip, and when beneath the pectineus may by pressure on the obturator nerve cause pain in the knee (Erichsen). In these cases, when the parts in front of the joint are relaxed by flexion, full rotation of the femur may be obtained ; swollen glands would probably be felt, and tenderness in front of the joint would probably be excessive for hip disease. It is not very uncom- mon to find that the knee on the diseased side is being treated instead of the hip, on account of the pain complained of in it; but examination at once shows that the form and movements of the knee are perfect. Confusion with disease of the spine complicated by commencing abscess in the psoas is fre- quent: for the abscess may cause persistent flexion of the hip. But all movements of the hip except extension are free, and there are no other signs of hip-joint disease, whilst those of spinal caries, especially limited movement of the spine, are more or less marked. When a spinal abscess presents in the 344 DISEASE OF THE HIP-JOINT. groin it may, of course, be taken for an abscess entering the psoas from the hip; but it is again easy to demonstrate that the hip is free from disease. Sacro-iliac disease causes pain about the hip and lameness; and the patient will fix the hip-joint against movements so executed that they jar the sacro- iliac articulation. But the seat of pain, swelling, and tenderness, and of abscess if it be present, is quite different from that in hip disease; care in moving the femur shows the hip to be sound, and pressing the hip-bones together or pulling them apart causes pain in the sacro-iliac joint. Suppuration in the bursa between the gluteus max. and the great trochanter may give rise to symptoms closely resembling those of hip disease (Teale); slitting up and examination of the sinus will enable the diagnosis to be made. Caries and necrosis of the trochanter cause chronic sinuses, but do not affect the position or movements of the joint. Sciatica and hysterical tenderness need not to be mentioned as a possible source of error. From chronic rheu- matic arthritis hip disease is distinguished, even when it occurs in the hip of a young person, by much greater fixation of the joint and more severe pain when movement is attempted. Treatment.—Attention to the general health is of the first importance. Next comes absolute rest of the joint, and H. O. Thomas (Diseases of the Hip-, Knee-, and Ankle-joints, 1876) is doubtless right in his assertion that prevention of friction is of infinitely greater importance than prevention of pressure. The value of every apparatus used in this disease varies directly with its power to prevent all movement. Weight extension with a sheet over and sand-bags alongside the limb and trunk, the long splint, Hamilton's splint, Bonnet's grand appareil (a wire trough to receive the trunk and both lower limbs), and Thomas's splint are the only varieties of apparatus worthy of mention ; and of these Thomas's splint is by far the best, for it affords the most perfect fixation, renders nursing painless, allows the patient at the same time all the advantages of getting about in the open air, leaves the joint free for the application of fomentations 01 dressings, and can frequently be used for the correction of deformity. It is easily made by the surgeon with the assistance of a blacksmith and a saddler, and is not very expensive. To use it will require some mechanical aptitude and a good deal of experience. The instrument maker can only make the splint to measure; the surgeon must apply it and be prepared to make such alterations of form as will insure a perfect fit. Thomas's directions for the making of the splint are as follows; The patient should, if possible, stand on the sound limb, and books must be placed be- neath the diseased one until the lumbar spine is straight. Now take a long flat piece of malleable iron (lxi inch for adults, I x -fy for children), long enough to extend from the lower angle of the scapula to the lower end of the swell of the calf, and model it to the sound side. The iron must pass down- ward perpendicularly over the lumbar region, then just external to the pos- terior superior iliac spine, along the course of the sciatic nerve to a point slightly internal to the centre of the end of the calf. The lumbar portion must be practically plane; then comes a slight curve forward under the but- tock, and the leg portion is plane, or almost so, and parallel to the lumbar part. Now, the gluteal bend being fixed in one wrench, the lumbar portion just above is seized with another aud rotated in its axis toward the spine, so that it shall lie flat upon the hip, just external to the iliac spine; the rota- tion needed is less in fat than in thin subjects. Its effects are seen in Fig. 136. Next take a piece of hoop iron (1 x £ inch) in length equal to five-sixths the circumference of the chest below the angles of the scapulae, rivet it firmly at one-third of its length from the end next the diseased side in front of the upper end of the upright; model it to the outline of the trunk, which is oval THE MANAGEMENT OF THOMAS'S HIP-SPLINT. 345 in shape, paying special attention to the fit across the back. A second cres- cent of hoop iron (f x I inch), in length two-thirds the circumference of the thigh, is to be riveted to the upright, one to two inches below the fold of the buttock; and a third similar crescent, half the circumference of the leg, is to be fixed to the lower end of the upright. These, like the upper cres- cent, are fixed eccentrically, their long ends being inside the limb, and they are to have the form shown in Fig. 136. A splint with two uprights (Fig. 134) gives more perfect fixation in acute cases while the patient is confined Fig. 134. Fig. 135. Thomas's splint fur hip disease, with two up- rights ; if one is removed, it becomes a single splint. Rotation in of the lumbar, out of the leg portion occurs at G, just above the com- mencement of the gluteal curve (Thomas). to bed, and is essential in cases of double hip disease and in the reduction of marked deformity; except in the latter case, the crossbar between the splints below should be added. Finally, when a hip with many sinuses has to be treated, a double splint may be applied in which the upright on the diseased side has been removed between the upper and second crescents, whilst a second crossbar connects the uprights at the latter spot. The instrument must now be padded with one layer of No. 1 boiler felt, and over this with basil leather. The patient being placed in the splint, a strap and buckle close the upper circle round the chest, the limb is bandaged to the upright from the calf up the thigh crescent, and finally the machine is prevented from slipping down by braces from the upper crescent over the shoulders. However carefully modelled, the splint is almost certain to require modi- fication in the first few days, and this the surgeon must effect with proper wrenches. Fig. 136 shows how the splint should fit; the long end, a, of the upper crescent lies close to the trunk, exercising some pressure on the sound side, the short end, b, not quite in contact. The upright must pass just ex- Thomas's hip-splint applied (Thomas). 346 DISEASE OF THE HIP-JOINT. ternal to the posterior spines, but internal to the centre of the popliteal space, S2; this is gained by bending up the long ends of the lower crescents, and prevents inversion of the limb, being aided by the slight rotation out of the leg portion upon the lumbar portion. Should the splint rotate away from the spine, contract the long wing of the upper crescent, expand the shorter, and increase the rotation of the up- right where it crosses the iliac crest; should it shift toward the spine, the opposite changes are required. It is essential that this splint be made of inelastic iron sufficiently stout to be free from tremor or bending in moving and lifting the patient, or the nursing will be painful. In a proper splint well applied, a child with acute hip disease may be raised without suffering pain, by means of the strap of the upper crescent and a loop of towel round the splint and legs. Usually no local treatment is required, but every- thing possible must be done to improve the general health. During an acute early stage, Thomas keeps the patient in bed on a soft mattress till satisfied that suppuration has been avoided. When all acute symptoms are absent, the child goes about on crutches, wearing a single splint and a patten at least four inches deep (Fig. 138) under the sound foot. This he continues till the muscles are well atrophied round the trochanter, the process being more distinctly felt on the diseased than on the sound side. Then the frame may be removed at night, and worn during the day; and after a vary- ing time, if all goes well, the frame is totally dis- carded and the crutches and patten alone used. These are set aside when permanence of cure seems assured. Usually the treatment occupies one to two years; if suppuration occur, it may be a good deal longer. The splint should be applied at once, even though deformity be extreme, the weight of the lower limb being equal to reducing any angular deformity of hip or knee not due to true ankylosis. In bad cases, a double splint must be used, that on the diseased side being modelled to the limb, by bending at g (Fig. 134), until the flexion of the splint almost corresponds to that of the hip. Inversion is corrected as usual, but does not demand much attention, as it is always spontaneously corrected after com- plete cure. Quickly the muscles yield, feeling that they are giving over the limb to safe keeping; and every few days the angle at g is slowly opened out, without removing the splint, by suitable wrenches. Thomas records the case of a boy aged seven, with disease of four years' duration, leaving several scars about the hip, some tenderness, and flexion to somewhat less than 90 degrees; the gluteal angle of the splint was opened every seven days, in seven weeks the deformity was reduced, and in nine weeks the patient was up on crutches. During the reduction of any marked deformity there is sure to be more or less pain, and perhaps some local heat and swelling, accompanied by a little fever, and the patient should be warned to expect this for a week or more (varying with the stage of the inflammation) when the apparatus is applied, or he is likely to be soon dissatisfied. In reply to questions, Mr. Thomas has most kindly sent me his latest Fig. 136. Sections of trunk and lower limb, showing application of cross-bars and relation of up- right to limb. INDICATIONS FOR EXCISION OF HIP. 347 views as to the treatment of cases in which there is marked abduction or ad- duction. He corrects abduction by bringing down the wing of the upper crescent on the side opposite to the disease until it lies over the lower ribs, or, in severe cases, between them and the iliac crest, and keeping it strongly contracted ; the wing on the healthy side runs forward and upward, ending perhaps a little above the nipple, and does not fit closely to the spine. Otherwise the splint is applied as usual; and as the limb comes toward the mid-line the upper wing on the sound side is contracted. In extreme cases, or such as cannot be watched for a week, Thomas adds to an ordinary hip- splint a half crescent, to embrace lightly the interval between the pelvis and the ribs on the sound side. Abduction is to be corrected by connecting the outer wings of the two lower cross-pieces by a bar, and then bandaging the limb to this and the lower part of the upright. Should abscess form, repeated aspiration should first be tried; this failing, open aseptically. Should sores or sinuses interfere with the splint on the diseased hip, use the modification mentioned on p. 344. Excision is to be resorted to only under conditions mentioned below. Up to 1876, Thomas had excised only one hip-joint, the knee-joint never. We have thought right to devote so much space to Thomas's treatment of hip-disease, being assured of its great value, and believing that many who use the splint are not nearly so successful with it as they might be. Weight extension is usually employed whilst a splint is being made, or even throughout slight cases. If the patient is a child, he should be pre- vented from sitting up by a girth of webbing under the armpits secured from slipping by braces ; a bandage is passed through the girth on each side and tied under the bed. The foot of the bed must be raised, the stirrup should reach well on to the thigh, and extension should always be made in the line of the limb; gradually the normal line is approached. When the limb is straight, further fixation may be obtained by a sheet over body and limb, and heavy sand-bags down the sides of each. But the joint is necessarily disturbed in nursing. |r When a Thomas's cannot be procured, a Hamilton's double long-splint should be worn ; a cross-piece behind the sacrum may be used, if the child is placed chiefly on his face. Whatever method of treatment be employed, the cure is satisfactory only if the limb is in the straight position ; its permanence is then evidenced by the non-recurrence, after use, of fixed flexion of the joint. Indications for Excision of the Hip.—We have already pointed out that shortening of the limb and looseness and insecurity of the joint are, not uncommonly, marked after this operation, whilst in recoveries without excision, though the joint may be stiff, this is covered by increased mobility of the lumbar spine, and the limb remains firm, is less shortened, and therefore more useful for progression. Excision is here, consequently, a dernier res- sort. It must not be practised until the above treatment has failed and sup- puration has resulted ; and then only : 1, in certain cases of rapid suppura- tion (in a few weeks) with severe local and general symptoms, leading to the suspicion of necrosis of the femoral head or neck; 2, in cases of extensive burrowing, fever, and loss of ground in spite of careful treatment; 3, when sinuses persist for months, and no improvement in the joint results in spite of every obtainable advantage; 4, when exhaustion from hectic and suppu- ration, or albuminoid disease (p. 83) is feared or is present; 5, in cases of intrapelvic abscess it is probably the best treatment, trephining of the ace- tabulum being performed if necessary for drainage; but an incision above Poupart's ligament may first be tried. In the four latter cases, the disease 348 DISEASE OF THE HIP-JOINT. is probably kept up by the presence of sequestra, or there is spreading tuber- cular ulceration of the bones and soft parts which the patient is unable to cope with and which must therefore be excised as fully as possible. It may be necessary to remove large portions of the pelvis, and this always renders the prognosis more grave. The mortality after excision of the hip is considerable. The most recent statistics are those of Jacobsen, which embrace the earlier ones of Leisrink. Of 250 cases, 58.4 per cent. died. Contrary to what English experience shows, Jacobsen found that of 63 cases of suppuration from the Copenhagen hospitals, no fewer than 73.2 per cent. died. Croft, of St. Thomas's Hospital, lost 18 of 45 cases of excision (40 per cent.); and of these 4 died of pyaemia —a septic mortality which might well be lower. Amputation may ultimately be required after excision when profuse sup- puration continues and fresh abscesses keep forming, when disease of bone slowly progresses beyond a point removable by excision, or when acute osteomyelitis of the femur after excision leads to extensive necrosis with the symptoms given at p. 282. White Swelling of the Knee. A few words may be said upon this subject, chiefly for the purpose of in- troducing the student to the use of Thomas's knee-splint. The symptoms of the disease are usually marked. Pain and tenderness about the anterior and inner part of the head of the tibia, slight elastic swell- ings first obvious on either side of the lig. patellae, and fixed flexion or dis- tinctly limited movement of the joint, causing the patient to walk upon the toes and to limp a little, are the first signs. As the disease progresses, all the above symptoms increase and starting pains at night are added. Wast- ing of the thigh muscles is marked, and renders more evident the swelling of the synovial membrane. Sometimes this is slight, sometimes very great; the outline of the suprapatellar pouch may be quite plain, but as, from wasting, the thickness of the muscles is always subtracted from the limb above the knee, the widest part of the swelling is not above the patella—as in synovial effusion, p. 320—but opposite the interval between the bones, and the swollen joint has rather a rounded appearance, or it is pyriform with its larger end down. The skin oecomes pale, tense, thin, and often shiny, while many blue veins are seen through it; the part is hot to the touch, and the swollen parts elastic and semi-fluctuating; there may be some fluid in the joint. Flexion increases, but the tibia is dragged backward on the femur out of proportion to the flexion; at the same time it becomes rotated out more or less markedly. In some cases the inner condyle grows exces- sively and the deformity of genu valgum results. Abscess may form at any time. Often for a long time the patient gets about on the crippled and motionless joint; but sooner or later it becomes incapable of bearing weight, the ligaments become infiltrated and softened, also the parasynovial tissue ; great destruction of the ends of the bones may occur, leading to extreme displacements, but this is not common. Once the ligaments are softened, lateral movement may be obtained by the surgeon. It always indicates great destruction of the joint. The diagnosis from synovitis has already been given (p. 335). Formerly cases of joint disease in ataxy ran some risk of amputation; but that is hardly probable now that the disease is better known. From hysterical joint the diagnosis may be very difficult, as a certain amount of redness, heat, and puffiness may develop in association with fixation and great tenderness. Other evidences of hysteria must give the clew; but it must be remembered the making of thomas's splint. 349 that a hysterical patient may have a strumous joint. Lastly, fungous arth- ritis must be distinguished from malignant growtJis of the end of one of the bones entering into the joint, chiefly by limitation of the disease to this end, possibly by pulsation or eggshell crackling, by rapid and steady growth, by extension beyond the limits of the synovial membrane, etc. Treatment.—1st. Attention to the general health. 2d. The provision of absolute rest. This is best made by means of Thomas's knee-splint (Fig. 137). The upper ring is made of an iron rod three-eighths of an inch thick —more or less, according to the weight of the patient; it is almost an ovoid, and is covered with boiler felt and basil leather. From its upper and lower portions two iron rods pass down to a lower smaller oval across which is a small staple, used only for fixation in the reduction of flexion. Fig. 137. Fig. 138. Fig. 139. Thomas's knee-spliut, Upper ring of a left knee-splint, Thomas's knee-splint and with apron, patten, and actual shape ; points of insertion patten applied (Thomas). staple for retention of stems. Below a patten (Thomas). (Thomas). The upper ring should join the inner stem at 55 degrees, which angle is by proper padding reduced to 45 degrees; the padding gets rapidly thinner toward the outer side (Fig 137). The anterior crescent, e, of the upper ring is much straighter than the posterior, d ; and inside stem, c, is connected to the ring in front of the mid-lateral point, the outer stem, A, being fixed to the central and uppermost point outside (Fig. 138). The stems are so long that one to two inches intervene between the toes of the fully extended foot and the ground. A strap passes over the shoulder of the sound side, and is attached by buckles to the front and back of the upper ring (Fig. 139). Across the two bars is stretched an apron of basil leather, having in it two slits for the insertion of the bandage (Fig. 137). When the patient walks, 350 DISEASE OF THE HIP-JOINT. the splint must fit well; a patten, high enough to make the shoulders level, is worn under the sound foot. For use in bed the fit of the upper ring need not be very exact, and the stems may be made of one rod bent at right angles below, and here a small staple is easily bent for fixation. Later, if necessary, this can be removed, and a patten welded on. In a regular bed-splint the upper ring is oval, and the inner stem attached to the end, so the splint fits either limb. In advanced cases, when the knee is larger than the thigh at the groin, a caliper splint, opening either below or above, may be used. To make room for a dressing, the stems of an ordinary splint may be bent out at the joint. When the patient is confined to bed, the splint should be slung to a cradle by its lower end, to keep the limb from the bed. The splint is fixed to the limb by two flannel rolls, one for the thigh, firmty applied, that the splint may move with the thigh rather than with the leg; the other for the leg, put on less firmly, that the leg may not resist downward pressure of the femur, but may be kept from chafing (Fig. 139). When there is much flexion the patient must be confined to bed ; the apron cannot be used, but the limb must be fixed by a stirrup to the staple and bandages round the leg and thigh. The lower end of the splint must be fixed to an angle on wheels which raises the calf from the bed and keeps the patient on his back, so that the weight of the limb is constantly tending to open out the angle at the knee; or this fixation may be effected by other means. No traction on the leg should be made by the stirrup, it must be kept just tense as the limb comes down. Flexion is reduced during the stage of inflammation much more easily than after resolution. When the joint contains fluid it should always be drawn off. Repeated aspiration should be tried for abscesses, or they may be opened aseptically, and all diseased tissue removed. In acute and chronic general suppuration, the joint must be laid open, and there is no doubt that perfect fixation renders the dangers of this procedure much less. With regard to the length of time that the knee (or the hip) must be fixed, Thomas states that the longer the fixation, the less likely is ankylosis to occur; bony ankylosis after correct mechanical treatment is, he says, very rare. Temporary stiffness always occurs after resolution, but it will wear off without interference. Cure is evidenced by the patient being able after using the joint volun- tarily to place it in the position it occupied in the splint. Excision will be required only in cases similar to those mentioned under hip disease; the objections to it are that it causes much shortening of the limb, and sometimes leaves a weak or deformed union. But erasion may be done much earlier as a truly conservative operation, and combined with Thomas's splint will yield fair results. We may here repeat that no splint affords such perfect fixation of the knee as does this; that without the apron it is an excellent splint after excision of the knee; that it is very valuable in the treatment of fractures of the shaft of the femur (p. 268), and may be used for fractures of the patella (p. 271). Amputation is required after failure of excision in young patients, and in others too old or otherwise unfit for this operation. Thomas believes that the main obstacle to recovery from chronic arthritis are, friction and pressure, and that the former is, by far, the most serious. Important as they doubtless are, we must still remember that we are dealing with an infective inflammation which will continue to extend so long as the conditions are favorable, and may perhaps prove generally infective. This indeed constitutes the chief argument in favor of erasion and excision, especi- ally among the poor. INJURIES OF ARTERIES. 351 CHAPTEE XXIX. INJURIES OF ARTERIES—ARTERIAL HEMORRHAGE AND HEMATOMA. Contusions of Arteries leading to symptoms are rare in civil, commoner in military practice. They are usually the result of the passage close by the vessel of some blunt object, as a railing spike or a bullet, but symptoms may follow bruises through the uninjured skin. The elasticity of bloodvessels frequently enables them to escape rupture by such bodies, but they sustain more or less severe contusions. Guthrie (Commentaries on the Surgery of the Peninsular War) records a case in which a bullet passed between the femoral artery and vein in Hunter's canal without opening either, but bruising both. The result was thrombosis of both vessels and gangrene of the limb; but it is hard to say how much of this was due to the presence of a septic wound. In other cases a contused piece of artery sloughs, and thrombosis being insuf- ficient, secondary hemorrhage follows; this is almost surely due to sepsis. Lastly, injuries of the nature of a contusion or strain are rarely followed within a few weeks by the formation of a true aneurism (see p. 246) probably an arteritis is excited which softens the vessel-wall and causes it to yield. Varieties and Causes of Wounds of Arteries.—These may be incised, punctured, contused, or lacerated ("ruptures") like the necessarily accompanying wounds of other parts. A few cases of non-penetrating wounds of arteries have been recorded, chiefly of the carotid in cut throats; there would be no danger of hemorrhage from rupture or sloughing, or, later, of aneurismal dilatation. Penetrating wounds and solutions of continuity of arteries are generally due to instruments which have entered through skin or mucous membrane, inflicting an open wound. But large arteries are sometimes wounded by fragments of bone in simple fractures, or " subcutaneously " in the operations of venesection or tenotomy, or by rapier thrusts—the small wounds healing rapidly ; or they may be torn, especially when diseased, by strains (extension of knee in jumping), or blows not lacerating the skin. In these cases the blood forms for itself a cavity or becomes widely diffused in the soft parts, and the tumor-like swelling which appears—communicating, as it does, with a main or large artery—is called an arterial hematoma, or traumatic aneu- rism, a term leading only to confusion. For the present we shall turn our attention to arteries injured in incised or punctured, lacerated, or contused wounds. Characters and Diagnosis of Arterial Bleeding.—The sign of wound of an artery is hemorrhage of the following character. The blood is of bright red color and issues per saltum, in forcible jets; even from vessels smaller than the radial at the wrist, blood will be projected three or four feet at each heart-stroke, but during diastole the stream falls much nearer the patient. In conditions of asphyxia and deep anaesthesia, however, arte- rial blood may be quite dark. The pulsating flow is best seen in cases of transverse division of large arteries upon the face of a wound; it is absent in wounds of very small arteries, the stream from which is more or less steady, 352 INJURIES OF ARTERIES. but well projected. When the wounded vessel lies deeply and cannot be seen, the wound fills intermittently and gushes of bright blood occur from it. The only arterial bleeding likely to be misunderstood is that known as re- current or regurgitant, which comes from the distal end of a divided vessel. Such bleeding in the lower limb occurs in a continuous stream of dark color (Guthrie, loc. cit.); in the upper, the circuit is so much shorter and the anas- tomosis so free, that even in recurrent hemorrhage the blood is bright and may even pulsate. Results of Partial Division.—When the wall of an artery is wounded the opening, especially if transverse or oblique, tends to gape; the natural elasticity of the vessel drags the edges apart in the longitudinal direction, being slightly assisted by longitudinal muscular fibres, and in the transverse direction the circular fibres act. There is not the slightest tendency to the closure of such wounds, and, when other than very fine punctures, they usu- ally bleed most persistently. A firm clot seems to be the only thing that can arrest it, naturally, for they can neither retract nor contract; but clot is rarely firm enough in man. Guthrie says that bleeding from an artery as large as the brachial divided for one-fourth its circumference usually ceases spontaneously before syncope occurs in dogs; whilst in horses and sheep it continues till they die. Should the wound in man heal under pressure, it does so by obliteration of the canal at the point. Smaller wounds, especially longitudinal and punctured, may heal without such obliteration; but the scar may subsequently stretch, giving rise to a true aneurism. Results of Complete Division. — After cross-section two important phenomena appear: 1. Retraction of the vessel within its sheath owing to its elasticity and to the constant tension which obtains in the arterial system from the heart to the capillaries. When a limb is extended the ends of a divided main artery will separate at least a centimetre, and full flexion will not bring them quite together. 2. Contraction of the lumen, due partly to the elasticity of the previously distended vessel, but chiefly to active con- traction of the irritated circular muscular fibres. This contraction is not immediate, as it would be with voluntary muscle, reaching at once its maxi- mum, but commences a few seconds after the application of the stimulus, slowly increases, and endures for some time; it may also extend up the vessel for half to one inch. The result of these two processes is that the end of the artery, much diminished in size and of conical form, lies at the bottom of a short canal or sheath from which it tends to shrink; and blood escaping from the mouth of the vessel has to flow over the rougb and foreign surface of the sheath. It therefore coagulates on the surface of the canal and in the meshes of the connective tissue forming it; and clot forms also between the conical end of the artery and the sheath, making some lateral pressure upon the vessel-end, which will at least support it and hinder its dilatation when the muscular contraction has passed off. All this clot is called the external coagulum. It is owing to the above three processes—retraction and contrac- tion of the end and formation of an external coagulum—that small vessels, which bleed strongly when cut across, gradually cease to do so after a few seconds; and natural or spontaneous arrest of hemorrhage is assisted—1, by weakening of the heart as loss of blood and nervous shock induce faintness; and 2, by the greater tendency to coagulate which is induced by hemorrhage in the blood remaining in the body. When bleeding has been arrested, an internal coagulum usually forms. This starts upon the foreign surface of the cut and inverted internal and middle coats, and extends until the movement of the blood becomes too strong to permit further clotting—usually up to the first collateral branch, below which there is almost complete stasis. It is more or less conical, and PERMANENT ARREST OF HEMORRHAGE. 353 not at first adherent to the vessel-wall; and it acts as an elastic b*ffer be- tween the blood-wave and the clot closing the orifice of the vessel. It is not essential to the temporary arrest of hemorrhage, for it does not form until bleeding has stopped ; nor is it required for its permanent arrest, as in some cases it never forms. Lateral wounds of arteries are similarly closed, if, indeed, Nature suffices to arrest the bleeding from them. An external clot prevents the escape of blood, and then an internal, totally obstructing clot forms. Should these succeed in resisting the arterial wave, permanent closure of the wound or vessel takes place, just as in instances of complete transverse division, which will now be described. Permanent Arrest of Hemorrhage is due to the healing of the wound in the vessel. There is nothing special in the means by which this is accom- plished. The vessels round about the end of the artery, irritated by injury, Fig. 140. Contracted artery, from the umbilical cord of a calf. pour out the usual exudation of fluid and cells; the red corpuscles in the clot break down and their coloring matter is absorbed, so that in a few days the external clot is replaced by more or less round-celled exudation which is becoming vascularized. The site of the artery in septic stumps is marked by a patch of yellowish or greenish lymph. Similar changes take place in- ternally. Here exudation occurs from the vessels in the wounded arterial tissues, and a button of firm lymph, adherent to the cut edges of the vessel, appears about the third day in the base of the internal clot.1 This increases, the vessel goes on contracting upon it, loses its endothelium, and becomes ad- herent; its walls also are more or less infiltrated with leucocytes. New vessels communicating with the vasa vasorum form in the cell-mass, converting it into granulation tissue; and this, both inside and outside the vessel, changes as usual (p. 59) into contracting fibroid tissue, which ultimately reduces the end of the artery into dense connective tissue, adherent to surrounding parts. The permanent barrier thus opposed to the blood may be very narrow, simply rounding off the end of the vessel; or it may be a fibrous cord of some length—differences depending apparently upon the force of the circu- lation in the immediate neighborhood of the wound. Thus Guthrie tied the common iliac five-eighths of an inch from the aorta and three-eighths of an inch from the internal iliac; one year later, the separated ends were just closed and connected to each other by new connective tissue. Though re- maining pervious, an artery always atrophies above a point of obliteration in proportion as its work (as a conduit) is diminished ;—e. g., after amputa- tion at the middle of the arm, the bracbial atrophies at least as high as the origin of the subscapular. In this process of healing it will have been noted that the actual throm- bus takes no part; it is not the thrombus, but the lymph which is " or- ganized." 1 Some authorities describe the endothelium as proliferating, and sending many vascular processes of cells into the clot. 23 354 INJURIES OF ARTERIES. When the internal coagulum is long, and it may measure some inches after ligature of the base of the carotid, it is infiltrated only at its base; beyond this it is rapidly decolorized, and may remain for several months as a non- adherent fibrinous cord, but usually it is short, and soon disappears after closure of the vessel is accomplished. When an artery is simply divided, healing in the lower end is much less perfect than in the upper. The lower end retracts and contracts less com- pletely ; and internal coagulum forms scantily (Guthrie). The reason of these differences is unknown, unless it be the interruption, more or less com- plete, of blood and nervous supply to the lower end. But their result is that secondary hemorrhage after division of ligature in the continuity of an artery occurs much more commonly from the distal than from the proximal end. If all goes well, the last act in these cases is the establishment of collateral circulation (p. 42); then the vessels in the scar between the ends of the di- vided artery enlarge markedly, and may, it is believed, bring about a direct communication between the proximal and distal portions. It would appear from experience that natural processes are ordinarily sufficient to arrest permanently the bleeding from small vessels such as the digital or temporal, especially if they are completely divided ; puncture and partial divisions even of these may give rise to recurring losses of blood. When the injured vessel is as large as the brachial or posterior tibial, bleed- ing will cease for a time when syncope supervenes; but as the heart recovers, the coagulum in the orifice of the vessel will probably be dislodged, and bleeding will recur again and again until it is checked by art or the patient dies. Lastly, when a large artery, as the femoral or subclavian, is divided or freely opened, and the escape of blood is in no way opposed, bleeding will be so great as to occasion death, perhaps, within a minute. But if the wound be little more than a puncture and longitudinal, it may be closed firmly by clot during syncope, and the patient may survive if properly treated. The spontaneous arrest of hemorrhage is rendered difficult by any inter- ference with the processes upon which it depends. Deserving of special mention in this respect are: incomplete division of a vessel; dense surround- ings, preventing the usual movements of a divided artery—e. g., the rigid connective tissue of the galea—the bony canals in which the superior pala- tine, dental, and other vessels run ; abnormality of the vessel-wall, hindering or preventing its contraction, such as results from chronic inflammation of a part, or from atheroma or calcification of the artery ; the effects of irritation, particularly septic, are of special importance; and there.is the condition known as haemophilia (q. v.), the mode of action of which is doubtful. Results of Complete Transverse Laceration.—When an artery is torn across by lacerating or contusing violence, even though it be the axillary or the femoral, it may not bleed at all. This is explained as follows: the inner and middle coats, which are much softer than the adventitia, tear early when subjected to strain, contract and roll up into the lumen of the vessel; but the tough adventitia resists longer, and is drawn out and twisted into a conical cap which covers the end of the vessel, just as after torsion. After avulsion of a part it is not uncommon to see the main artery hanging exposed for some distance, and pulsating apparently to its very end; it is usually distinctly conical. In other cases, lacerated wounds of large arteries, such as resulted from the old round bullet, were followed by severe hemorrhage, ceasing in a few minutes; being arrested apparently by violent contraction of the muscular coat assisted by faintuess. The arrest was sometimes permanent, but often hemorrhage recurred as shock passed off or wThen the patient was moved; ARREST OF HEMORRHAGE. 355 and the blood then came almost always from the distal end. In the lower limb, if the temporary arrest lasted twelve hours, the dangers to be feared were, according to Guthrie, bleeding not from the proximal, but from the distal, end, or mortification of the limb. An artery torn across heals in exactly the same way as one cut across. An internal clot first forms. The Artificial Arrest of Hemorrhage. Loss of blood being almost always extremely undesirable, surgical inter- ference is indicated even in cases where natural means would probably prove sufficient, though tardy, and, a fortiori, in all more severe cases. The oppor- tunities which a surgeon of to-day has of gaining that coolness in the great emergency of serious hemorrhage which is so conducive to its proper treat- ment, are few ; we rarely see it. Immediate Treatment. Local digital pressure.—The first point is tem- porarily and immediately to arrest the bleeding until more permanent means can be adopted, and for this purpose no rule of such general appli- cability as this can be given—place a finger on the bleeding point. No force is required if the pressure is accurately applied; even main arteries are easily controlled. The surgeon must open the wound, wipe away clot, see the bleeding spot, and put his finger directly on it, or take it between his finger and thumb. In deep stabs, in which this is not possible, the finger may still be used as a plug, especially by the uninitiated ; the educated finger will, in such cases, often feel the point whence blood is gushing and accurately com- press it. Local pressure, when it can be employed, has the advantage of ligature at the point, viz., that it certainly arrests bleeding; it can be more easily kept up than pressure at a distance; and it is the only treatment immediately available in wounds of the great arteries of the trunk and neck. Digital compression of main arteries.—Often it is most convenient and equally efficacious to compress the main artery at a distance. The points at which main arteries may be best commanded are the following: In the upper limb, the ulnar and radial are easily compressed just above the wrist by placing a thumb on each and pressing directly backward against the bone. The brachial at the middle of the arm may be compressed where it lies in front of the insertion of the coraco-brachialis; it is best to place one hand in front of, the other behind the arm, so that two or three fingers of each may meet on each side of the artery and prevent its slipping in or out. The subclavian (third part) may be compressed against the first rib by a thumb or the padded ring of a door-key placed vertically over the vessel in the subclavian triangle. Stand above the patient, place the thumb of the same side as the artery in the triangle whilst the fingers lie over the scapula; and on the top of the thumb place that of the other hand, and press directly downward. Iu the lower limb, the anterior and posterior tibial arteries are easily taken just above the ankle by the fingers and thumb of one hand grasping the ankle from the inner side. The femoral artery can be perfectly controlled by pressure driving it against the brim of the pelvis and front of the hip-joint. Stand by the side of the patient looking toward his feet; place the two thumbs, one on top of the other, on the artery, just below Poupart's liga- ment, and with the hands grasp either side of the limb. In thin people and children the abdominal aorta may be compressed for a short time in the above manner, or by direct pressure of fingers upon it; post-partum hemorrhage has been thus arrested. 356 INJURIES OF ARTERIES. The use of tourniquets.—To relieve the fingers when compression has to be maintained for some time, and also in many cases to check bleeding more completely, tourniquets are employed. Of these, Esmarch's elastic tourniquet is by far the best, and should always be kept in places where accidents are frequent. It is simply eighteen to twenty-four inches of three-quarters inch rubber tubing, and it is applied by placing the mid-point on the far side of the limb, stretching it, and winding it rapidly and rather tightly round above the wound ; it may be tied by a tape at each end. No skill or knowledge of anatomy is required. When used for an exarticulation at the shoulder, the tubing must be tightly coiled twice or thrice round the shoulder, crossing the axilla as high as possible, and the ring must be prevented from slipping by tapes passed through it in front and behind, and held tight by an assistant on the oppo- site side. In amputation at or excision of the hip, apply the tubing in a figure-8 round the groin and pelvis, and prevent the turn round the groin from slipping after removal of the limb by tapes used as above. To render the penis and scrotum bloodless, use a figure-8 of thick drainage tube round their base and the pelvis. For compression of the abdominal aorta, Esmarch places a board behind the patient and a special pad like a door-handle on a stem over the vessel, and then winds an India-rubber bandage several times round both so as to drive the pad backward. Esmarch's tourniquet, applied too tightly, or in several coils one over the other, has produced paralysis of imperfectly covered nerves, such as the ulnar or median ; this is best avoided by using, in the upper limb, instead of the Fio. 141. Petit's screw tourniqurt. a, pad on the band ; c, bridge ; d, screw. tourniquet, a few (four or five) turns of the India-rubber bandage on top of each other. But the chief inconvenience attributed to this instrument is due really to the anaemia of the limb which is usually produced before its appli- cation. Exclusion of blood deprives the vessels of all food, their muscular coat becomes rapidly weak, and yields before the blood-stream when this is readmitted. Consequently, when a part is kept long anaemic, general oozing may cause the loss of more blood than would have been lost had no tourni- LIGATURE—MODE OF APPLICATION. 357 quet been applied. Hot water is the remedy; or elevation and pressure for ten or fifteen minutes. Petit's tourniquet, formerly much used, is shown in Fig. 141, which fully explains its structure. The pad is placed over the main artery, or, prefer- ably, a roller one and a half inches thick is laid longitudinally over the vessel, and fixed by a turn or two of its own end ; this prevents the skin from being drawn up by the band through the slits in the plate. The band is first buckled close to the limb and then the screw is turned quickly, that arte- ries and veins may be compressed as nearly as possible simultaneously and venous congestion avoided. In the absence of special apparatus, tie a handkerchief, with a stone placed in it over the artery, round the limb, and twist it tight with a stick. There are special tourniquets for special vessels—e.g.. Signoroni's or Carte's, which compress the femoral artery, leaving collateral channels and veins open, and Lister's horseshoe clamp for the abdominal aorta. As the ending of this vessel may be in the mid-line, or on the left or right of it, it is essential before applying Lister's tourniquet to feel its pulsation, opposite the fourth lumbar; then place a small soft Turkey sponge over the spot, and screw the pad down upon it with just sufficient force to stop pulsation in the femoral. Death has been caused by injury to intestine. Under this head- ing must be mentioned also Davy's rectal lever for compression of the common iliac. It is a straight round bar of wood which is introduced into the begin- ning of the sigmoid flexure, and so guided that its end shall lie over the common iliac in the angle between the lumbar spine and psoas; by raising the handle, the vessel will then be compressed against the spine. Attempts to place the lever in position have failed ; and there is danger of contusion or even of perforation of the bowel. The Deliberate Treatment of Hemorrhage.—Immediate danger having been averted by one or other of the above means of temporary arrest, the surgeon will have time to consider how best more permanently to check the bleeding. To this end the surgeon places a tolerably enduring barrier in the face of the blood, and thus gives Nature time for the processes described on p. 352, which alone can permanently arrest hemorrhage. There are many methods employed by surgeons with a view to the perma- nent arrest of arterial hemorrhage. These are: (1) Ligature; (2) Torsion; (3) Forcipressure; (4) Acupressure; (5) Local pressure; (6) Pressure at a distance, either digital, by tourniquet, or by extreme flexion ; (7) Cautery; (8) Styptics; (9) Hot water; (10) Cold; (11) Elevation. Of these the first three are employed infinitely more often than the rest. The object which we always have in view is rapid healing of the wound, and those methods which least interfere with this will be the safest and best. 1. Ligature. Mode of application.—Two cases may occur : 1. An artery has to be tied upon the surface of a stump or similar wound. 2. The artery has been wounded in its continuity or divided. In the latter case ligatures must be applied above and below the wound, or to both ends as described in the chapter on " Ligature of Arteries." In the first case the end of the artery must be seized with a pair of artery forceps (Fig. 142) and drawn a little from its sheath if it be of any size; the ligature is then tied firmly round it with a reef-knot. The ligature is left loug or cut short, according to its nature, and the forceps are loosed. The less tissue included with the vessel, the better; but with small arteries, espe- cially in aseptic wounds, the inclusion of a little tissue is not of much impor- tance, and frequently it cannot be avoided when the vessel is retracted. In some cases of this kind it is recommended to pass a threaded needle at some depth through this tissue, round the bleeding point, and tie up all that it 358 INJURIES OF ARTERIES. includes ; or to pass a tenaculum through or near the vessel, and raise it and the surrounding tissues for the ligature; but these plans are clumsy and bad, and should, if possible, be avoided. Fig. 142. Assalini's forceps. The effects and results of ligature.—When a thread is tied tightly round an artery, it is felt to sink a little into the substance of its wall. If the vessel is now laid open, as in Fig. 143, it is found that the ligature has divided the inner and middle coats, retaining in its knot a complete Fig. 143. ring of the tough adventitia; the divided coats are turned in to the lumen of the vessel, and puckered up closely into a short cone. Stasis occurs up to the nearest col- lateral, and, as a rule, an internal clot forms up to this level. The artery contracts upon it, its base becomes infiltrated with cells, and these ultimately form vas- cular connective tissue, exactly as has been described at p. 59. But the formation of an internal clot is not constant, and does not occur in a good many aseptic cases. It was formerly regarded as a great safeguard against hemorrhage, and spots most free from branches were chosen for the ligature of arteries in their continuity in order that movement of the blood should not interfere with the development of a long internal clot. Doubtless The effects of ligature it did act as an elastic buffer, and lessened the force upon an artery. with which the blood was thrown against the end of the artery; and this was a matter of much importance in the days of septic ligatures, which had to cut their way through the vessel as follows. Septic ligature.—Ten or twelve years ago, all vessels on the face of a stump were tied with stout hempen threads; one end was cut off, and the other brought out through the wound ; on the main artery both ends were left. Experience showed that these ligatures "cut through" in five to thirty days, according to the size of the vessel, and the amount of tissue included with it; consequently, after a proper time had elapsed, the threads were tugged at daily to see if they were loose, and in some case a strong pull was ulti- mately required to remove them. Until they came away, the strands of ligatures hung out at the corners of the wounds, affording a poor, but the only, means of drainage provided. As foreign bodies they necessarily pre- vented union ; but, becoming soaked in septic wound fluids, they kept these irritants constantly applied to the very end of the artery, and lower down acted as setons. The piece of outer coat included in the knot was killed by pressure, and was cast off by a process of ulceration and suppuration, like any other septic slough. With a septic suppurative inflammation going on about the end of the artery, tending to destroy its sheath and vascular supply, softening its tissues, preventing organization of the lymph thrown out, and often infecting the internal clot, rendering it soft and friable; and, besides all this, with the daily disturbance of the reparative processes by pulling on the ligatures, is it any wonder that to the impossibility of com- plete primary union, frequent secondary hemorrhage had to be added as a fault of the ligature? Its defects were too manifest to be overlooked, and ASEPTIC LIGATURE AND ITS RESULTS. 359 thoughtful surgeons sought in many ways to overcome them. The hemp ligature prevented union by its simple presence; even when thoroughly waxed, to render it non-absorbent, it served to conduct septic fluids to the end of the artery, and prevented tissues about it/from healing over it; if cut short, either the wound did not heal until the knot and included bit of artery were eliminated, or the wound healed, and an abscess, due to the presence of the septic knot, formed, burst, and cast out the irritant. An ideal ligature should admit of being cut short, should heal in, and should then cause no injurious irritation. It was early seen that the latter result would be best attained by employing a material which would be more or less quickly absorbed, and experiments were made with several animal structures, such as silk, silk-worm gut, and catgut. Every now and again a success wTas recorded, the ligature being unusually clean, and the wound healing rapidly round it; but generally they did not prove satisfactory. The chief reason was that the wounds in which they were applied became septic and suppu- rated, and the nooses round the vessels were consequently rendered strongly irritant, and their absorption or encapsulation by living cells was thus pre- vented ; and even prepared catgut under such conditions would rapidly soften and lose its hold. Aseptic ligature.—The attainment of ideal success in the all-important matter of ligature is, therefore, one of the triumphs of aseptic surgery. Lister, by a beautiful series of experiments and observations, worked out a process by which catgut could be so prepared as to resist the softening influence of the aseptic fluids of the body, and to retain its hold upon an artery long enough to insure, almost certainly, its sound occlusion; ultimately in an aseptic wound it is gradually eroded from the surface by leucocytes which surround it, and themselves develop into fibrous tissue. This " carbolized catgut" was kept in carbolic oil, and was consequently difficult to carry about. More recently Lister has introduced the " chromic sulphurous cat- gut," which is kept in the dry state, and requires simply a few minutes' soaking in some antiseptic lotion to soften it sufficiently to knot well; noth- ing could be more convenient. The essence of the aseptic ligature is that we have in it the minimum of irritation ; the artery is occluded and held by the thread ; usually, though not always, its inner coats are divided, but it is sufficiently injured to cause its vessels to pour out the usual coagulable exudation, rich in leucocytes, which seals the end of the cone into which the vessel is puckered. Being exposed to no further irritation, the lymph quickly becomes vascularized and develops into strong connective tissue. There is, of course, no suppura- tion, the arterial walls are not softened, their blood-supply is interfered with only by the passage of the ligature. The internal clot under these circum- stances seems superfluous and, as a matter of fact, is often absent (Baum- garten); being in no way dependent upon it for successful closure of the vessel, we can, with asepsis, disregard the proximity of collateral branches. The piece of artery included in the ligature is probably killed, but is even less irritant than the catgut; and although in ligature upon the face of a wound the bit of vessel beyond the thread is cut off from all blood supply, yet it probably does not die. Sections made weeks after aseptic ligature show it still present with its lumen full of connective tissue; and a band of the same tissue occupies the place of the ligature and its included adventitia; the end of the vessel beyond the thread seems to derive nourishment from the fluid by which it is surrounded, until fresh communications between its vessels and those of granulation tissue are established. Consequently, we see that an aseptic ligature does not cut through the artery; the portion which is included in the noose is not cast off. Lastly, the wound heals un- 360 INJURIES OF ARTERIES. interruptedly, and complete healing is the only sure guarantee against hemorrhage. If catgut is not well prepared, or if it is used in septic wounds, it softens quickly, its knot loosens, and it may not hold long enough for the occlusion of large arteries; indeed, this has apparently happened with really good catgut in an aseptic wound. Consequently for tying large vessels in their continuity, silk, soaked for twenty-four hours in 1 in 20 carbolic, is very generally used. It heals in as readily as catgut, but is very slow in under- going absorption, if indeed this is possible. After many weeks, a section shows numerous cells, and usually some giant cells round and between the fibres of the ligature—signs of chronic inflammation. In the great majority of cases all goes well; but a few cases of abscess after some weeks and elimi- nation of the noose are on record. The\tendons of the kangaroo's tail, portions of the sciatic nerve of the calf, and other structures rendered aseptic have been and are employed as liga- tures; the kangaroo tendon is more enduring than catgut. With the idea of leaving the vessel-wall still stronger than it is after division of its inner coats, R. Barwell has introduced a flat, ribbon-like liga- ture, about one-eighth inch broad, made by cutting spirally the middle coat of an ox-aorta. The strips are kept dry and soaked fifteen minutes in 1 in 20 carbolic lotion before use; they do not divide the inner coats, but main- tain their hold for a considerable time after they have healed in, which they readily do. After twenty months, the knot and loose ends of a ligature on the cartoid seemed little reduced in thickness and were opaque yellow ; round the vessel, and closely united with its wall, was a thin, tense-looking band, perhaps one-tenth the original ligature; the whole was covered by delicate membranous connective tissue movable over it, and there was no naked-eye sign of irritation. Every now and again we meet with arteries so degenerate, or situate in such soft tissue, that a ligature cuts through them. The slighter cases may be dealt with by using a somewhat thicker ligature than usual and tying less tightly, or by in- cluding a good deal of tissue with a needle; but it may be necessary to resort to other methode—tor- sion, acupressure, cautery, etc. As to the size of the ligature to be ordinarily em- ployed, it must of course be strong enough to resist the strain put upon it in tying; given this, the thinner it is, the less irritation does it cause, and the more slowly does it cut through in septic cases. The chromic catgut ordinarily used is very thin. 2. Torsion is the only rival of the ligature, and apparently deserves to rank equal with it. At Guy's Hospital it is always used instead of the ligature for securing vessels on the face of wounds. There are two ways of doing it—viz., unlimited tor- sion, which is that usually employed, performed by drawing out the vessel from its sheath by a single pair of broad-pointed torsion forceps, and then twisting it round as far as its natural connections will allow, or, as some prefer, until the end comes off; and limited torsion, performed by drawing out the vessel, fixing it by one pair of forceps a quarter or half an inch from the end, and then with another pair twisting the end round till it does not untwist itself. The effect Fig. 144. The effects of torsion on a large artery. (Bryant, on the "Tor- sion of Arteries," etc., Med.- Chir. Trans., vol. ii.) FORCIPRESSURE AND ACUPRESSURE. 361 of torsion is very similar to that of tearing. The inner and middle coats are torn and invaginated more and more into the lumen of the tube as the adventitia is twisted round and round, and the end of the artery assumes a conical shape. The adventitia does not untwist, and, assisted by the invagi- nated coats, opposes ample resistance to the blood wave. The twisted end of the artery is killed and cut off from all blood supply, like the bit beyond the ligature; and doubtless behaves similarly in an aseptic wound. In a septic wound it would become septic and tend to irritate. But if unlimited torsion is done and the end removed, scarcely any dead tissue is left on the end of the artery. This method then obviously has as great advantages over the septic ligature as the aseptic ligature has; only a pair of forceps is re- quired to twist a vessel; but with torsion it is often more difficult to arrest the bleeding from indefinite points at which retracted vessels probably lie. Secondary hemorrhage is said to be very rare after torsion properly done; and Byrant states that he has found no special difficulty in dealing with de- generate arteries, in which cases he seizes as much of the surrounding con- nective tissue as possible, and twists that into a conical cap. 3. Forcipressure means the seizing of the end of an artery with a pair of forceps having serrated blades worked by scissor-handles provided with a catch, so that the instrument can be clamped on and left hanging. When removed after a few minutes, no bleeding will occur from the smaller vessels, the portion gripped having been welded into a mass sufficiently solid to resist the blood-pressure. It is by the use of several of Sir Spencer Wells's forcipressure forceps to clamp vessel after vessel as they are divided, that we are enabled to operate with a dry wound, even when the circulation cannot be controlled, and so effectually to prevent the escape of blood into the peri- toneum in operations opening its cavity. Another use of the forceps is to seize a bleeding point too deep for the easy application of a ligature—e.g., in the palm, high in the axilla, or in a lith- othmy wound. They may be left on for several hours. Formerly small bulldog clips and serrefines (Fig. 145) were sometimes used temporarily to close bleeding vessels. 4. Acupressure was proposed by the late Sir J. Y. Simpson, as a means of avoiding the above-mentioned dis- advantages of the common ligature. To this end Simpson proposed—first, to employ metallic instead of textile sub- stances ; and secondly, to use them in such a way as allows them to be removed at will, so soon as the occlusion of the artery is complete, which may be at the end of 48, 60, or 120 hours, accord- ing to the size of the vessel. The first method of employing simple acupres- Fm. 14' Serrefine. Fig. 146. Fig. 147. First method of acupressure ; shows the outer surface of a flap with the needle passed through it. First method of acupressure, seen from flap surface ; shows the mouth of the artery on the wound-surface, bridged over and compressed. sure (Figs. 146, 147) is to pass a long needle through one of the flaps of a wound, in such a way that it shall compress the bleeding artery, as we fasten 362 INJURIES OF ARTERIES. the stalk of a flower to the coat with a pin. The needle (three to six inches in length, according to the depth of the vessel) may in some cases be made to compress the vessel against a bone. In the second method of acupressure, a small sewing-needle is employed, threaded with a short piece of inelastic iron wire, by which it may be pulled out. A long pin may be substituted. This is dipped down into the tissues on one side, then raised up and made to bridge over the vessel, while com- pressed with the point of the left forefinger. (See Fig. 148.) In the third method, which is practically the harelip suture, the sewing- needle is passed simply behind the vessel, and a noose of fine iron wire passed over the point, brought over the vessel tightly enough to close it, and then Fig. 148. ■Fig. 149. Second method of acupressure Third method of acupressure. secured with a slight twist around the eye end of the needle. When the operator chooses, he can pull out the needle, and then the wire loop follows without resistance. The wire passed through the needle should be distinguished by being twisted, or in some other way1 (Fig. 149). Mr. Wood has successfully employed this mode in bleeding from wounds of the palmar arch, which cannot be controlled by a compress: a harelip pin is passed under the radial or ulnar artery, or both, just above the wrist, and a piece of soft silk or lint, instead of the wire, twisted round it sufficiently tightly to stop the flow of blood through the vessel. The pin may be removed in a day or two if the reparative changes in the wounds have sufficiently advanced to seal up the wounded artery. The inclusion of the ulnar nerve in the acupressure rarely gives rise to more than temporary inconvenience. There is yet a fourth method of acupressure : the point of a needle is stuck into the tissues close to the mouth of the bleeding vessels ; the handle is then carried through half a circle or more, so as to close the mouth by twisting; and the point is then pushed on further into the tissues. There are many other means of using needles, which the surgeon's ingenuity will suggest. When several oozing points are close together, they may be compressed for some hours by a needle and loop of wire. Acupressure controls hemorrhage whilst closure of the divided or wounded artery goes on in the ordinary way. Even in septic wounds the absence of a septic ligature, leading right up to the vessel and preventing union round it, is an immense advantage, and excellent results have been obtained by the method. But it is now used only in exceptional cases, such as that of hemor- rhage from the palm above noted, being more troublesome and less certain than aseptic ligature or torsion. Acupressure seems very applicable to degenerate vessels. 5. Local Pressure follows most naturally upon acupressure. By its means we endeavor to close the end of the vessel and prevent the issue of 1 See Sir J. Y. Simpson's original papers in the Med. Times and Gaz., January, 1864; and Dr. Joseph Hutchison's Prize Essay on Acupressure, Albany, U.S., 1869. PLUGGING AND THE GRADUATED COMPRESS. 363 blood until the vessel is well closed, chiefly by contraction, retraction, and clotting. It is employed to check bleeding from wounded arteries—e.g., temporal or occipital—lying immediately over bones; in cases of vessels (vertebral or deep palmar arch) lying deeply among important structures, which it is important not to wound or disturb ; and, lastly, in cases of hemor- rhage where it is impossible to tie either on account of the impossibility of controlling the bleeding temporarily during the operation (e.g., great vessels at root of neck), or because the bleeding points are many, or cannot be reached and otherwise treated (nose, rectum, vagina). In the latter cases plugging is resorted to ; an India-rubber bag is introduced and blown up, or a fold of muslin is pushed into the cavity and filled with sponges, lint, or wool, or the openings of the cavity are stopped ; blood fills the cavity, and by its pressure prevents further bleeding; the vessels are usually small and the result of this blindly used force satisfactory. In cases of punctured wound the graduated compress is generally used. The results of this treatment as ordinarily employed, in wounds of the deep palmar arch, are often disastrous. The compress is made of circles of lint placed one on top of the other, and fastened by a stitch through their centres; the first circle is about the size of a sixpence, and often made of a bit of cork, the last is as big as half a crown, and the pad is an inch or so thick. To apply it, the fingers are care- fully bandaged, and the hand and forearm fixed on a back splint, whilst the bleeding has been checked by local pressure; but now the brachial is con- trolled, the wound thoroughly dried, the small end of the compress is placed in or over the wound, and pressed down firmly by a bandage passing round it and the splint; lastly, the elbow is strongly flexed, and the forearm and arm connected by a figure-of-8 bandage. It is left undisturbed for two or three days, or longer, unless complications necessitate its removal. When danger of hemorrhage is thought to be over, the bandage is loosened, but the compress is allowed to come away of itself. Too often bleeding recurs, the parts pressed upon slough, the wound gets very foul, and septic inflamma- tion burrows widely among the tendons of the palm and wrist, perhaps invading even the carpal joints. These complications are best prevented by avoiding the compress, using instead, if possible, forcipressure, acupressure, or pressure at a distance. If it must be used, apply it as above, paying attention to the following points: 1. The pressure in even a largish artery is not high, and that in the deep palmar arch is easily overcome by force accurately applied ; but force sufficient to empty the deep arch will certainly empty all vessels super- ficial to it, and therefore, to avoid sloughing, and to permit healing, must not be continued for more than twelve hours; after this time the bandage should be relaxed. 2. As the bleeding comes from a small point, to apply pressure accurately to this, it is necessary that the compress shall have a fine point, and this will reduce the tendency to cause sloughing. 3. In cases in which it is possible that the vessel is only wounded, not divided, put in a knife and divide it completely, unless this would be dangerous to important structures. 4. Render and keep the part aseptic, dusting it with iodoform after disinfection. To meet this and other ends, it is better not to endeavor to insert the compress into the wound, but to plug the latter care- fully from the very bottom with gauze or sponge, and to place a fine-pointed compress on top of this. In some cases it is impossible to apply compression in any way other than by the fingers of the operator and his assistants, relieving each other at regular intervals till bleeding ceases. This is termed " local digital compres- sion," and has often saved life. This is, perhaps, the best place to mention a valuable plan in cases of 364 INJURIES OF ARTERIES. bleeding from canals in bone, that of plugging the canal. Thus a rounded match-handle stuck into the posterior palatine canal is said to have saved life after the operation for cleft palate. In aseptic cases a bit of gauze, wool, or catgut may be pushed tightly into the orifice. 6. Pressure at a Distance.—This is practised upon the main artery above the wound, in order that clotting, etc., may occur whilst the direct current is checked. The pressure may be made by the finger, by a special tourniquet—e. g., Signoroni's—or, at the elbow and knee, by extreme flexion. The method is not suited to deal with severe cases, but may be a useful auxiliary. 7. The Cautery may be used to close even large arteries. When a cau- tery iron is pressed against the open end of such a vessel, it shrivels up into an adherent eschar which will resist the blood-wave stoutly. But such a mass of dead tissue is an excellent absorbent of putrid poisons and products, and consequently, in septic cases, irritation is likely to interfere with the formation of a firm internal clot and sound connective tissue. Secondary hemorrhage is accordingly common after such use of the cautery, and occurs when the sloughs separate, about the end of the first week. It is now never employed upon large vessels, but is found most useful in checking bleeding from small vessels in any soft, lacerable tissue in which ligature or torsion is impossible. The most useful form of cautery is Paquelin's hollow cautery-knife, which is first heated to redness in a spirit flame, and then kept hot by the combus- tion of benzol vapor blown down it by a ball-syringe. This knife is used to perform operations in which avoidance of hemorrhage is important, and those who fear bleeding employ it frequently in spite of the facts that it leaves a surface which must heal by granulation, which is highly absorbent, and upon which it is hard to detect bits of new-growths left behind. When used bright red it cuts almost like a knife, and even small arteries bleed; to check hemorrhage it must be used slowly and dull red or black, and the part to which it is applied should be dried. 8. Styptics are substances which coagulate the blood or induce strong contraction of vessels, or act in both ways. Solid perchloride of iron or the strong liquor on wool or lint, solid alum, or a saturated solution, solid nitrate of silver, the powdered matico-leaf, and turpentine, are the best. The latter is potent, but excites much inflammation ; all interfere with union by first intention, so they should be avoided when this is wished for. Perchloride of iron is the one usually employed; if improperly used it makes a dreadful mess of a part, and renders subsequent treatment difficult. To apply it or any styptic, dry the bleeding point thoroughly, if possible whilst the circu- lation is controlled above, then gently press on the spot a bit of wool well moistened (not wet) with perchloride solution; after two or three minutes relax the pressure, and a little later allow the circulation to go on. Let the wool separate naturally. 9. Hot Water, or an antiseptic lotion so hot that the hand can only just bear it, is probably the best means we have of checking bleeding from small vessels and general oozing. It must be applied with a sponge. It does not prevent primary union. 10. Cold.—Ice or iced water or lotion is applied directly to the bleeding part or to some neighboring part, as the face in epistaxis, when it acts reflexly. It generally acts speedily ; but in hemophilia, cold irrigation is required. It causes strong contraction of the vessels and of the surrounding tissues, and is of value chiefly in general oozing. 11. Elevation of a limb causes marked contraction of its arteries, and is a useful adjunct in all forms of bleeding which are not perfectly controlled. It frequently suffices to stop venous or capillary bleeding. TREATMENT OF PRIMARY HEMORRHAGE. 365 The Effects of Loss of Blood. These are the more intense the larger the quantity lost and the more rapidly it is poured out. Fatal syncope may be quickly induced ; short of this, symptoms of more or less intense shock appear. In acute losses patients not uncommonly lose their sight entirely or partially, and they often com- plain much of thirst. (Edema of extremities is common in bad cases. Dry gangrene may result (p. 86). The quantity of blood which may be lost in repeated small or even con- siderable bleedings is astonishing, the patient being reduced to a state of the most profound weakness and anaemia. The anaemia may be very persistent. Women bear such loss of blood better than men ; young children and old people, on the other hand, suffer severely from slight hemorrhage. Treatment.—In acute cases the patient must be placed on a flat mattress without any pillow ; the limbs, especially the lower ones, should be raised to facilitate the return of blood from them ; and it may be necessary for a time to compress their main arteries, or even to apply Esmarch's bandage to them, in order to supply the brain with blood. Dr. Sainsbury has suggested the use of digitalis and ergotin in these cases, with the idea of slowing and steady- ing the heart's action, and, at the same time, of diminishing the capacity of the vascular system ; and the suggestion would seem to be a very valuable one. In extreme cases, in which life is in great danger, transfusion of blood should be resorted to (see " Minor Operations "). The temperature must be kept up by warm coverings and hot bottles; fluid food should be given frequently by spoonfuls; a little ice may be allowed for thirst; and great restlessness may be met by small doses of opium every three or four hours. In chronic anaemia, the hemorrhage having ceased, warmth, careful feeding —the diet being simple, nutritious, and given in frequent small doses—fresh air, and plenty of sunlight are most important. Some preparation of iron may be administered, and usually it must be a mild one at first. In cases of hemorrhage which it is difficult to restrain by ligature or other- wise—e.g., intra-abdominal—it is necessary to keep the patient recumbent and very quiet, administering opium, if necessary, and to combat shock most cautiously. We must always remember that in internal hemorrhage the patient's best chance lies in a long period of weak heart-action; it is our business to prevent it stopping, if we can, but not to excite it. Stimulants, therefore, must be very carefully used. Primary, Intermediary, and Secondary Hemorrhage. Hemorrhage may occur at the time of infliction of the injury, and is then called primary; or it may come on later, when it is termed secondary. Most surgeons make a third variety—reactionary or intermediary—said, arbitra- rily, to occur within twenty-four hours of the injury, and to be due to recovery of the heart from shock. For purposes of treatment this variety may be considered with primary hemorrhage; the only difference being that in the latter case the wound is open, and the vessel more or less accessible, whilst in the former the wound, as a rule, has to be opened up and clot turned out to expose the artery. Secondary bemorrhage, on the other hand, differs in its etiology and pathology, and, to some extent, in the laws which govern its treatment. Rules in the Treatment of Primary Hemorrhage : 1, If a case is not bleeding when seen, no matter how great the loss of blood may have been immediately after the infliction of the wound, do not endeavor 366 INJURIES OF ARTERIES. to tie, or otherwise deal with, the injured vessel. Dress the wound antiseptic- ally with moderate pressure, and provide for rest. The reason for this rule is that a wound of a comparatively small artery, especially when cut close to its origin, may yield a very large quantity of blood ; but when faintness comes on, hemorrhage will cease, and may not recur; it will be time enough to operate should it do so. Gutbrie quotes a case of ligature of the external iliac for hemorrhage and haematoma, due, it was supposed, to wound of the femoral; the man died of peritonitis, and it was found that a superficial branch of the femoral had been wounded one inch from its origin. 2. The most important rule of all is, always deal with the bleeding point. The slightest thought will show any one who knows with what ease blood finds its way by collateral channels past an obstruction in the arterial system that this is the only safe method. A ligature applied at such a distance from a bleeding point that a branch intervenes between them may perma- nently arrest the bleeding for which it is applied—i. e., firm clotting may close the opening before the diverted stream again finds its way strongly into the original channel; but there is no security that it will do so. When the anastomosis is free, as in the forearm and hand, bleeding may recur immediately after the operation of ligature at a distance; but more commonly the recurrence does not take place for hours or days. 3. When an artery is wounded in its continuity or simply divided (the distal part not being removed) it must be secured above and below the wound. The argument upon which this rule is based is chiefly that upon which the second rests, viz., the ease with which blood finds its way past the obstruction into the main channel below it. We have already mentioned (p. 354) the ill- understood fact that secondary hemorrhage is much more common from the distal end of a divided artery than from the proximal, and that in the lower limb the blood thus escaping is often dark and flows in a continuous stream ; the less completely collateral circulation is established, the more venous will the hemorrhage appear. This fact is a further warning to us to be careful to secure the distal end, which at the time of the operation may, perhaps, not be bleeding. Of course, no branch must intervene between the ligatures and the wound. Formerly the Hunterian operation of ligature at a distance was frequently done in such instances and with extremely bad results. The double obstruction of ligature and wound frequently prevented the reestab- lishment of circulation in the distal parts of the lower limb, and it morti- fied; whilst in the upper limb, where the anastomosis is more free, hemor- rhage from the wound usually occurred. So the Hunterian operation exposed the patient to two great dangers—gangrene if the circulation were not rees- tablished, hemorrhage if it were. The greater ease of the operation at a seat of election doubtless rendered it attractive; but the raison d'etre of ligature at a distance for aneurism is disease of the artery near the seat of dilatation, a condition which does not hold in cases of wound. Further, it is quite pos- sible in operating at a distance to tie a trunk which has no connection with the bleeding vessel; thus in wounds of the upper part of the back of the neck the common carotid has several times been tied in the belief that the occipital was wounded, whereas the vertebral really furnished the blood. The error arose primarily from the surgeon's forgetting that the vertebral does not enter its bony canal below the sixth transverse process; pressure on the cartoid below this point (Chassaignac's tubercle) stopped the bleeding, but the vertebral was compressed as well as the carotid. Another cause of failure of ligature at a distance for wound is high division or unusual distri- bution of the arteries; thus an enlarged median artery, or vas aberrans from the upper part of the brachial or the axillary, opening into the palmar arch CAUSES OF SECONDARY HEMORRHAGE. 367 has kept up hemorrhage from it after ligature of the ulnar, radial, and brachial, necessitating finally ligature at the point. Wherever, therefore, primary hemorrhage is occurring from a wounded artery, the latter must be secured at the bleeding point, both its ends being dealt with when there are two; and these rules are to be departed from only after a determined attempt to follow them has shown the impossibility of doing so—except in the case of the internal maxillary and its branches, and one or two other vessels, which it is practically impossible to reach. To perform the operation when the superficial parts do not gape suffi- ciently to allow the artery to be seen, as in punctured wound, render the part bloodless and control the circulation whenever this is possible ; then introduce a probe or finger into the wound, and taking this as a guide, care- fully divide the structures in the line which will give the freest access to the vessels and do least damage to the muscles or other structures of the part; keep a sharp lookout for any divided vessel, probably covered by clot, until the level of some large known artery of the region is reached; then if no wounded vessel has been discovered, slacken the tourniquet and watch care- fully for any spirt of blood which will guide to the injured spot. The main artery should now be taken by an assistant, as it may be necessary now and again to let a little blood escape as a guide to the operator; and oozing may have to be checked by hot lotion and sponge pressure before going on with the operation after the removal of the elastic band. When found, the bleed- ing vessel is treated according to the above rules by one or other of the methods described at p. 357 et seq. We do not, of course, mean that every case of slight primary hemorrhage requires immediate opening of the wound and tying or twisting of the artery ; elevation, cold, well-applied pressure, etc., will deal with many such, if there is any difficulty in at once picking up the bleeding vessel. Secondary Hemorrhage: Its Pathology and Treatment. Secondary hemorrhage may occur at any time until a wound has healed, though a patient may be regarded as safe from it so long as the wound is everywhere covered with healthy granulations, whilst he is in danger so long as the end of the artery is visible. It was rare before the fourth day, most common about the time of separation of the ligatures in the days of the old hempen thread, and it has become quite a rarity since the practice of aseptic surgery has become general. Skins —It may occur in one sudden and perhaps fatal gush ; but much more commonly, small discharges of blood give warning of what may be expected. The blood may be bright and the stream jetting and forcible, or dark and welling up in a continuous stream as from a spring—in the latter case coming from the distal end (p. 354). Its immediate causes are many, but they may probably be classed in five groups: 1. Certain general conditions under which repair proceeds slowly or is arrested, aud of these the chief are septicaemii and pyaemia. It is, how- ever, very difficult to be sure how much of the arrest is due to the general state and how much to the fermentative processes going on in the wound. 2. Straining, rough transport, rough handling, etc., may mechanically burst open such union as has occurred. 3. Formerly, when the tenaculum was used to pick up vessels, secondary hemorrhage was sometimes attributed to puncture of the artery above the point tied, and another assigned cause was wound of a collateral brauch, which soon ceased to bleed and consequently was not tied. But in either case, if no bleeding occurred until after the intermediary period, it would seem likely that septic inflammation was really 368 INJURIES OF ARTERIES. the cause. Excessive stripping off of the sheath deprives the artery of its blood-supply ; but even if a portion of it died there would almost certainly be no hemorrhage in a subcutaneous injury. Again, when the ligature in- cludes a quantity of tissue besides the artery and has to cut through, septic suppuration is prolonged about the end of the vessel and produces its usual results; hence the necessity for most carefully cleaning an artery before passing the ligature, especially in septic cases. 4. Disease of the arterial coats, atheromatous or calcareous, will, on the one hand, prevent the retrac- tion and contraction which favor healing and render it slow, whilst, on the other, they will cause the ligature to cut through rapidly; naturally, hemor- rhage is a frequent consequence. 5. But the great cause of secondary hemorrhage is excessive inflammation about the end of the artery, which prevents healing and the formation of firm clot, softens the vessel wall, injures its vitality and perhaps causes it to slough by destroying its blood-supply. Such inflammation is practically always of septic origin ; and, consequently, the practice of aseptic surgery has almost banished secondary hemorrhage. Septic cases, however—cases of phagedsena and hospital gangrene, and of casting off septic sloughs—must still occur; and even in aseptic wounds sec- ondary hemorrhage must be regarded as possible from mechanical injury, softening and loosening of a badly tied or ill-prepared catgut ligature, or separation of an atheromatous or calcareous plaque; so we must be ready to meet it. Treatment.—The main rule for our guidance is that given as Rule 2, under " Primary Hemorrhage " (p. 366)—always seek for the bleeding point. Only when this is secured can the condition of the patient be regarded with anything like satisfaction. Ligature at a distance has succeeded and may succeed again in the upper limb, but in the lower almost invariable either the circulation is not reestablished and the distal portion becomes gangre- nous, or it is reestablished and hemorrhage recurs. In the case of a stump, the danger of gangrene from a ligature placed on the main trunk a short distance above is nil; here we have to think only of the danger of recur- rence of hemorrhage, either because a freely anastomosing branch is present between the ligature and the wound, or because the bleeding vessel springs from the trunk above the ligature. This latter danger is, however, suffi- ciently great to render the practice of ligature at a distance for hemorrhage from a stump unjustifiable until the flaps have been separated, clots turned out, and every effort has failed to secure the bleeding point. The greatest difficulty will arise from diffuse suppuration and sloughing of the stump, for neither forceps nor ligature will hold upon the end of the vessel. In these cases, the surgeon may endeavor to arrest the bleeding by pressing a cautery against the end of the artery, but in such a stump there would then be great liability to the recurrence of hemorrhage; it is therefore far better either to remove with knife or scissors so much of the artery and tissues round about it that either ligature or torsion is possible, or to carry a cut upwards along its line, and tie it as low as possible. The latter practice is easiest in cases of circular amputation or of the flap operation, where one angle lies near the line of the bleeding vessel. The opportunity of removing sloughs and ap- plying antiseptics should be taken. Such an operation occupies some time and causes a good deal of shock if the amputation is a high one and the stump in great measure healed ; but nothing short of a conviction that the patient could not endure it should cause the operator to depart from the rule. Under such circumstances we have the authority of Erichsen for tying the common femoral for bleeding from a hip-stump, or the subclavian for hemorrhage from a shoulder-stump. THE TREATMENT OF SECONDARY HEMORRHAGE. 369 In cases of secondary hemorrhage from a wound in which an artery has been tied in its continuity, wounded or divided, we shall often be able to judge from the character of the bleeding (p. 352) whether it comes from the proximal or distal end. In cases of hemorrhage from vessels of the trunk and neck, in which it is impossible temporarily to control the bleeding by digital pressure and at the same time to expose and tie the bleeding point, there is no resource left but pressure by the finger or plug. But in all other cases severe enough to justify operative interference the wound should be opened up, and every endeavor made to secure the bleeding point; and be- fore closing the wound we must make sure that the other end of the artery also has not been bleeding. Should it be impossible to carry out this treat- ment, and milder means are of no avail, the only choice left to the surgeon will be that between ligature at a distance and amputation. In the lower limb the former procedure is so hopeless that the latter is always adopted; in the upper, ligature at a distance is sometimes practised—apparently be- cause the preliminary ligature is not a serious operation, and does not inter- fere with the success of amputation should it fail, there being little danger of gangrene. It will, however, happen but rarely in the upper limb that a bleeding point of any size cannot be found, and it would seem probable that amputation would be required in a case in which the state of the tis- sues prevented the use of a ligature or of torsion either in or close to the wound. The rules of treatment of secondary hemorrhage from a vessel tied or wounded in its continuity or divided are therefore: in almost all cases, en- deavor first to check the bleeding by local measures: should one or more of these fail, and amputation be possible, it will probably prove the soundest treatment, and should be done at the level of the wound or just above it; the occurrence of hemorrhage from a disorganized part may render amputa- tion at once the best treatment. As in primary, so in secondary hemorrhage we have to decide whether or not to interfere in case the bleeding has ceased spontaneously when the patient is seen. Guthrie was strongly in favor of not doing so, and he quotes a case in which, having failed to make a vessel bleed, and having thus lost all guide to the source of hemorrhage, he sent the man back to bed with an orderly to look after him. Two or three recurrent bleedings were promptly checked by pressure on the femoral, and the man ultimately re- covered. Many similar cases might be quoted. Guthrie's case was one of bullet-wound going right through the thigh ; the wound necessary to secure the vessel would probably have been very large, and it is obvious that, if the artery which has bled will not bleed again when the wound is opened up and thoroughly cleared of clot by sponging, the only point gained by the opera- tion will be, that, should the bleeding recur, the wound can then be rapidly opened up and the vessels found and dealt with. One could not but feel very anxious, however, in leaving a patient who had had more than one severe attack of secondary hemorrhage, knowing that bleeding would in all probability recur and perhaps kill or greatly exhaust the patient before it could be arrested. In such a case, especially if the bleeding vessel is prob- ably a main trunk, or one of its branches cut near its origin, we should probably act for the greatest happiness of the greatest number if we at once laid open the wound and endeavored to find the bleeding point; and we should be failing in our duty if, after a second attack, we left the result to chance. But if the bleeding has not been severe, came apparently from a branch distant from the main trunk, and especially if we can remain to watch or leave in charge an assistant competent to arrest bleeding imme- diately, we may, in cases in which access to the vessel is difficult, wait a 24 370 INJURIES OF ARTERIES. while, keeping the patient at perfect rest, the wound as sweet as possible, compressed over the dressing by a bandage which should include the whole limb, the part elevated, and the main current of blood may be for a time diverted by continuous pressure, by the finger or special tourniquet, or by flexion. If, however, even small losses are frequent, or show a tendency to increase in quantity, something radical must be done at once before the patient becomes exhausted. Frequently secondary hemorrhage from an artery injured by stabs and similar wounds will be found due to incomplete division of the artery. Con- sequently in the case of small vessels, such as those of the palm, which commonly suffer in cuts from broken glass, it is well before applying pres- sure (p. 363) to put a lancet into the wound and make sure that the artery is cut across, just as was done in old days after arteriotomy of the temporal. Arterial Hematoma, Diffused and Circumscribed. Pathology.—When a large artery is wounded at some depth from the surface, the track leading to it being narrow, long, and perhap's oblique, blood is often forced into the cellular tissue to a considerable distance, form- ing a diffuse swelling, whilst the opening in the skin becomes closed by clot, and hemorrhage from it perhaps ceases. Sometimes the skin wound heals rapidly. A state of matters exactly similar to this results in cases of sub- cutaneous laceration of an artery by a broken bone or sudden strain. The swelling which forms may be widely diffused or fairly circumscribed to the region of the wound in the artery, and was formerly called a diffused or cir- cumscribed traumatic aneurism. But this term is misleading and very con- fusing, for there is really nothing " aneurismal" in the case; but for the wound or rupture, the artery may be perfectly healthy; and whereas a real aneurism is limited by a sac composed at first of one or more of the dilated coats of the artery, the so-called traumatic aneurism either never acquires a sac, or, when circumscribed, obtains one only by exciting some inflammation of surrounding tissues which leads to their condensation. The only differ- ence, in fact, between the blood-tumor under consideration and that which forms after any severe contusion is that in the former the blood escapes from a considerable artery, in the latter from veins and small vessels. A " trau- matic aneurism " is simply a subcutaneous hemorrhage from a considerable artery, and its relation to and difference from an ordinary haematoma is best expressed by the term arterial hematoma. Symptoms.—These vary according to the size of the vessel wounded and the size and nature of the wound in it, being more serious the larger the ves- sel and the freer the opening; the resistance, also, which the tissues round about can oppose to the diffusion of blood must be taken into account. The first sign, after the pain of the injury, is swelling starting from its seat, and spreading more or less widely round about; it may form rapidly and be very extensive, or slowly, and remain fairly circumscribed. In a serious diffused case, the whole limb swells, partly from hemorrhage, partly from oedema, due to pressure of the confined extravasation on the veins ; the part is pale or dusky, cold and numb, the seat of more or less acute tensive pain; the swelling due to hemorrhage, sometimes enormous, may be dis- tinctly fluctuating, or simply tense and elastic, and does not pit. In such a case, the main artery would almost certainly have been wounded, and pul- sation would be absent in it beyond the injury; immediately over the open- ing in the vessel there may be some thrill, bruit, and expansile pulsation, or, when coagulation has occurred, a general lifting up of the whole mass at each heart-stroke; but in the worst cases these signs may be quite absent. TREATMENT OF ARTERIAL HEMATOMA. 371 They are most plain in large lateral wounds of arteries, least so in small, punctured, or longitudinal incised wounds and in complete division or rup- ture. If not early and properly treated, moist gangrene up to the wound in the artery soon occurs. In other cases, almost always due to wound of arteries smaller than the brachial, the extravasation ceases to spread before danger of gangrene arises, and becomes more or less solid from coagulation at its circumference, whilst its centre remains fluid ; and here thrill, pulsation, and a whizzing bruit are more or less strongly marked. Supposing that increase is arrested, the cen- tral fluid part is encapsuled first by clot, and next, as this is absorbed, by condeused and infiltrated tissues which form a fibroid sac; and we then have a case anatomically resembling an advanced stage of a true aneurism, except that the artery is healthy but for the wound in it. But the haematoma may increase and burst, or inflammation and suppuration may arise about it. Diagnosis.—From an acute deep abscess the diagnosis may be difficult, especially when we have to deal with a haematoma which threatens to sup- purate ; the immediate onset of swelling after an injury, the marked inter- ference with the circulation beyond the wound, the results of aspiration with a fine needle, and perhaps more or less central thrill, bruit, and pulsation must be relied upon as distinguishing the haematoma. When there is no tendency to suppuration about a haematoma, the part would be pale or bluish and cold, and there would usually be no fever. In a doubtful case requir- ing operative interference the surgeon should make an incision, being pre- pared for the worst. It is possible that .a circumscribed arterial haematoma may be mistaken for a rapidly growing cancer. A man may meet with a blow on the thigh, causing pain and swelling. The swelling does not subside; on the contrary, it continues slowly to increase ; evidently infiltrates the tissues of the part; is somewhat elastic, perhaps displays feeble pulsation at parts; punctured with a grooved needle, it yields serum or blood. The case is supposed to he malignant, and amputation hopeless; the patient sinks. After death there is found no cancer, but a great collection of blood, fluid or coagulated, amongst all the deep muscles, and proceeding from an artery that had been ruptured by the blow. An incision would have revealed the mystery. Another point to be remembered is that a true aneurism may suddenly be- come diffused. Here the diagnosis rests upon the history. Treatment.—The only difference between a case of arterial haematoma aud one of arterial hemorrhage is that in the former case the blood escapes into the tissues, in the latter from a free surface; consequently, the treat- ment is that of arterial hemorrhage, the cavity containing the blood being opened freely to permit access to the artery. On no account should the Hunterian operation be done in any diffused haematoma: gangrene would certainly result; but in well-circumscribed cases, in which laying open the sac would be a hazardous or very injurious proceeding, the artery may be tied a short distance above with fair hope of success—for in these cases a kind of sac has formed, and cure will be effected as in ordinary aneurism. Cure is rendered most certain, however, when the wounded artery has been tied above and below the wound or rupture—the state which alone offers security against hemorrhage. In cases seen early, compression of the main trunk above and over the wound might limit extravasation permanently by permitting coagulation of already effused blood. In established circum- scribed cases compression should be tried. But if bloodless treatment fails and the haematoma increases, and in all cases threatening bursting or gan- grene, ligature at the point must be practised. The whole field of surgery does not present a more difficult operation than that of laying open a large 372 INJURIES OF ARTERIES. arterial hematoma, nor one requiring greater judgment, nerve, and dexterity. This is a case in which boldness is better than caution. It was thus described by John Bell in 1800: " Run your bistoury upward and downward, so as to slit up the tumor quickly; plunge your hand suddenly down toward the bottom ; turn out the great clots of blood with your fingers, till, having reached the bottom entirely, you begin to feel the warm jet of blood; and, directed by that, clap your finger upon the Wounded point of the artery: as it has but a point, your finger will cover it fairly, and your feeling the beat- ing of the artery assures you that all is now safe." A needle was then worked round the vessel above and below the wound—what it included be- sides the artery was often somewhat doubtful, though Bell knew the impor- tance of thoroughly cleaning the vessel—a ligature tied in each situation and the finger was then removed from the bleeding point. This was the way in which John Bell successfully treated, for example, an enormous haematoma from wound of the gluteal artery as it issued from the pelvis, and the hemorrhage from which he had no means of controlling. The wound in this case was two feet (!) long, made by two strokes of the bistoury. (Principles of Surgery, 1826, vol. i.) Nowadays we can control the bleeding from most arteries, and can con- sequently operate more deliberately. Only in a few cases is it necessary to adopt the above rapid plan, with pressure of a finger on the wound as the sole means of checking bleeding ; then the surgeon must do his best to in- clude the artery only in the ligature. In the more usual case, the sac is opened freely, clots and blood turned out, and the interior rendered dry. Perhaps the wound in" the artery will now be seen; if not, with a good light on the wound, loosen the tourniquet, and let a little blood escape. Pass a thick probe into the opening, first in one, then in the other direction, clean a channel round the vessel above and below the wound, pass ligatures and tie them. The distal end always gives most trouble. If such an operation is not done aseptically, prolonged suppuration must be expected. In John Bell's case healing took seven months, being delayed by necrosis of the ilium and sacrum. Traumatic Aneurism. This name may be truly applied to cases resulting from punctured wounds, generally of large arteries, which have healed ; but in the course of weeks or months the scar has yielded before the pressure of the blood ; it may be ap- plied also to aneuiism after strain, laceration of the outer coats, or contusion of the vessel, as, for example, of the subclavian after fractured clavicle (p. 246). In these cases there is a sac from the commencement; the essen- tial difference between them and the ordinary aneurism is, that in the former the vessel is healthy except at the dilated spot; in aneurism from disease the artery is affected widely, as a rule. All the symptoms of ordinary aneurism are present. The history of injury and late appearance of symptoms decide the diagnosis. The treatment may be—1, compression of the artery above the sac; 2, ligature above the sac, but as near to it as is convenient; or 3, the old ope- ration of laying open the sac. The latter must be done when the cavity is very large. ANEURISMAL varix and VARICOSE ANEURISM. 373 Aneurismal Varix and Varicose Aneurism. These result either from the simultaneous wound of an artery and vein lying either side by side (int. carotid and jugular) or near each other (brachial and median basilic), or from rupture of a diseased artery into a vein. In some cases the circumference of the wound in the artery adheres di- rectly to that of the wound in the vein, or with only a layer of fascia inter- vening, the opening from the one into the other vessel being so short as to be practically direct. The vein and all veins in the neighborhood are much dilated and thickened, and pulsate strongly. This is the condition in aneu- rismal varix. In other cases, in which perhaps the vessels were originally a little further apart, the inflammatory tissue lining the channel between the vessel yields under the arterial pressure, and the short, narrow canal becomes dilated into a spherical cavity the size of a marble or walnut; or the cavity may be due to a small hemorrhage, which has been quickly circumscribed, between the artery and the vein. This cavity has a fibrous wall, opens at one pole into the artery and at the other into the vein, and pulsates with the artery; the veins of the part are in the same condition as in aneurismal varix. We bave, therefore, an aneurismal varix with the addition of a kind of traumatic aneu- rism or circumscribed arterial haematoma, according to the view taken of the mode of formation of the cavity. This condition has received the meaning- less name of varicose aneurism. In both aneurismal varix and varicose aneurism the artery below the communication is shrunken. Seats and Causes.—These forms of disease have been met with in most places where a large artery and vein lie close, resulting from lancet-punc- tures, sword-thrusts, stabs, etc. They are now rare affections; formerly they were more common, resulting chiefly from bleeding at the bend of the elbow. Symptoms.—The superficial veins are greatly swollen, thickened, and tor- tuous, perhaps almost bursting opposite the opening; they pulsate strongly, a thrill is felt over the opening as the blood rushes into the vein, and a rough or humming bruit, conducted along the veins running toward the trunk, is heard ; the limb below is cold, and more or less weak and wasted, but there is often some oedema and thickening of connective tissue. By suitable pressure it is sometimes possible to empty the vein and feel the opening in the artery. These are the signs of aneurismal varix, and it is said that all are most dis- tinct when the limb is hanging. In varicose aneurism we must add—the presence of a small pulsating tumor, felt through and beneath the dilated vein, and of a blowing murmur differing from that heard in the vein. Treatment.—Aneurismal varix can generally be kept in check by the application of the analogue of an elastic stocking; and to this might be added a small pad pressing directly on the opening into the vein. In some cases about the neck, the bruit has been a source of great annoyance. Wherever the circulation could be controlled, cure might be effected, in cases requiring more relief than pressure gives, by cutting down through the vein on to the opening in the artery, cleaning this upon a probe, and passing a ligature above and below the wound. In varicose aneurism, simultaneous digital compression of the main trunk and of the opening into the vein has been very successful. This failing, the opening into the artery must be cut down upon through the vein and sac and a ligature applied above and below it. 374 INJURIES OF ARTERIES. Diseases of the Arteries. Atrophy and contraction of an artery follow upon diminution of its blood-carrying function, as seen in stumps (p. 354), between arterio-venous communications, etc. A general atrophy is said to occur in high degrees of anaemia and in marasmic conditions. Degeneration : Fatty.—Most commonly this occurs in the products of a chronic arteritis ; but fatty degeneration of the otherwise unaltered intima and media, especially of the former, is often met with. In the intima it is recognized by the appearance of small opaque yellow, sharply circum- scribed patches, streaks, or dots, which appear quite superficial, are not raised, and can be easily scraped away with the point of a knife, leaving the media and outer layers of the intima intact. Groups of these spots are com- mon at the base of the aorta even in young people. Microscopically, we find fatty degeneration beginning in the spindle and branched subendothelial cells of the intima, the droplets appearing later between the fibres and lamellae. The change must be distinguished from atheroma, due to fatty degeneration of inflammatory products in the deeper layers of the intima. In the media fatty degeneration is not recognizable macroscopically ; it predisposes to rup- ture or formation of aneurism, and is often associated with calcification. Fatty degeneration occurs in vessels of all sizes, may be acute or chronic; general—due to various forms of poisoning, anaemia, marasmus—or quite local and of doubtful etiology. The breaking down of a patch destroying the intima may lead to a dissecting aneurism; or, if the coats are all affected, rupture may result. Birch-Hirschfeld regards this as the cause of many spontaneous hemorrhages from small vessels into internal organs. Calcareous degeneration, though less common, is still frequently met with as a senile change. Its special seat is the muscular coat, and the first sign of it is the appearance of calcareous opaque rings, taking the line of the cir- cular fibres (annular calcification). Sooner or later the rings blend, convert- ing the artery into a rigid tube (tubular calcification) like a pipe-stem. Ultimately, the earthy salts may infiltrate the intima and adventitia; but usually these coats remain sufficiently healthy to prevent thrombosis (intima), and to give such toughness (adventitia) to the vessel as will pre- vent cracking and allow the application of a ligature. In high degrees a thread cuts through as it is tied. Calcification generally prevents dila- tation. Tubular calcification is most frequent in the tibial arteries of the aged, being the great predisponent to gangrene of the parts supplied ; it occurs also in the forearm and arm vessels, and is not infrequent in the intra-abdo- minal vessels—e.g., large uterine arteries. Atheromatous plaques very often calcify, producing the appearance of alligator-hide, and seen chiefly in the aorta and larger vessels. Amyloid degeneration has been described (p. 83). INFLAMMATION OF ARTERIES. Acute arteritis may be due to mechanical or other injury of the whole vessel from without, to spread of inflammation to it from surrounding parts (periarteritis), to the impaction in its lumen of an embolus mechanically or infectively irritating, or to the formation in the vessel of a clot (endarteritis) which may cause varying degrees of irritation according as it disappears, organizes, or softens. The effects of inflammation—the dilatation of the vasa vasorum, loss of polish of intima, and shedding of epithelium, formation chronic arteritis. 375 of lymph on the injured surface and its development into granulation and firm connective tissue closing the vessel—have been described under " Liga- ture " (p. 357); as also the widespread softening or even sloughing of the arterial tissues, in cases of severe and usually septic irritation. It is this ulceration or sloughing occurring at a seat of ligature or other injury, or where an artery is laid bare by some spreading inflammation, especially hospital gangrene (p. 155), that leads to hemorrhage. Chronic arteritis (arteriosclerosis, endarteritis deformans, atheroma).— Chronic inflammation of arteries arises from many causes. The changes induced vary much in naked-eye appearance, according as they occur in large or small vessels, are diffuse or circumscribed, and are or are not combined with various degenerative processes. The commonest and most important form is that usually called atheroma, which affects chiefly the larger vessels—aorta, coronary, iliac, femoral. The changes begin in the deeper layers of the intima, where it is in contact with the muscular coat. Here, in the earliest stage, round cells collect and often become oval, spindle or branched ; the matrix may be homogeneous or fibrillated. The new cells may be wholly converted into fibrous tissue nour- ished by a few capillaries; or, the food-supply proving insufficient, as it usually does, the cells undergo fatty degeneration, and this begins furthest from the endothelium. By this process a cavity full of a yellowish-white fluid, containing numerous fatty and earthy granules and cholesterine crystals, may be developed in the intima (atheromatous abscess); and from the naked-eye resemblance of this stuff to the contents of sebaceous cysts, the morbid process has been called atheromatous degeneration. But much more commonly no such fluid forms. As the cells and fibres undergo fatty degeneration, earthy salts are deposited in such quantity that a calcareous plate results. To the naked eye the muscular coat may appear normal or slightly thickened ; the microscope, however, early shows collections of round cells, fibroid patches, and fatty degeneration of fibres. In advanced cases the adventitia is thickened and condensed. When the above processes occur in a circumscribed area, we notice first a swelling projecting into the lumen of the vessel. At first it is low, smooth, and of gray gelatinous aspect on section—rarely seen; should it develop into fibrous tissue the surface becomes puckered and irregular, and the edge of the patch may be one sixteenth of an inch high and abrupt; should it, on the other hand, degenerate into fluid, the patch becomes soft, markedly yellow, fine openings form in the intima, the contents of the cavity escape into the blood-stream, the openings enlarge and blend, and ultimately the muscularis is exposed at the bottom of a degeneration ulcer (p. 67) upon which fibrin is usually deposited. In earlier stages, endothelium is generally demonstrable over the plaque, and there is no tendency to coagu- lation upon it. When calcareous plates form they are hard, more or less circular, and irregular on the surface, which is often bare or covered with fibrin. On laying open a vessel—e. g., the aorta—affected by atheroma, only one or two patches may be found; or the whole interior may be covered by them, and then, if a length of artery be taken, almost all the above stages may be seen. Thus we have dense fibroid patches, yellow patches of fatty degeneration, a few perhaps containing fluid, numerous calcareous plates covered hy endothelium or fibrin, or bare, with here and there an " ulcer " due to the bursting of an atheromatous abscess or to the separation of a calcareous plate. In an advanced case, the middle and external coats will be fibroid, and the vessel will consequently be found to have lost much of its elasticity and to have become dilated uniformly or partially, and often 376 INJURIES OF ARTERIES. lengthened and tortuous under the blood-pressure. Much calcification renders the lumen very unyielding. When, however, chronic arteritis affects the whole circumference of a smaller vessel, it generally causes narrowing of the lumen instead of dilata- tion ; for in them elasticity is greater and longer preserved, the arterial pressure is less, and relatively the effect of thickening the intima is greater. Actual closure may result, and this is most likely to occur where the branch leaves the main trunk, the disease being most advanced here; thus at the base of the aorta, if there is atheroma anywhere, a ring will be found round the orifice of the coronary arteries. Thrombosis may complete the closure of a narrowed vessel. Fatty degeneration, softening, or necrosis of parts supplied, result from such changes. Etiology.—The variety from which the above description has been chiefly taken—the common atheroma or arteritis deformans—is a disease of the latter half of life, though it may be met with in a marked degree between thirty and forty, especially in alcoholic subjects. Its great cause seems to be strain, as is shown by many circumstances—e. g., its special seats of election, viz., the aortic arch, thoracic and abdominal aorta, the iliacs and vessels of the legs, the coronary and cerebral arteries—all vessels in which the blood pressure is high ; its rarity in the pulmonary circulation, unless the right heart is hypertrophied, then its frequency ; its connection with Bright's disease and its high-tension pulse ; its greater frequency iu men, especially among those of laborious occupations and among athletes. Syphilis is a distinct cause of chronic endarteritis, which differs in many ways from the above. Whereas atheroma is usually widely distributed and affects the larger arteries, syphilis affects single vessels, and often only limited portions of them or small branches, and it occurs in young people, even infants. It is best known in the vessels of the brain and trunk of the internal carotid —partly because these vessels are most open to observation, partly, perhaps, because of the anatomical peculiarities of the cerebral arteries (perivascular sheath, Lancereaux). Other vessels certainly suffer. Thus in a child that died of intraventricular hemorrhage, and in whom miliary gummata of the choroid were noted, I found two prominent fibrous patches in the arch of the aorta. The tendency of the new growth is to raise the endothelium from the membrana fenestrata, and greatly to narrow or obliterate the lumen. Ac- cording to its age we find the deposit almost cartilaginous in its hardness, simply fibroid or cellular, involving only the intima or the whole thickness of the wall, and generally forming circumscribed nodules or rings upon the vessel. It shows little tendency to calcify. Friedlander, however, holds that syphilitic endarteritis cannot be diagnosed by its naked eye any more than by its microscopic characters. Sometimes distinct and characteristic gummata form in the middle or external coats of arteries, though this is much more common in veins, especially the portal. The special causes of the endarteritis obliterans described at p. 87 are unknown. There is no primary tubercular arteritis, but the walls of small vessels, in the sheaths of which tubercles have formed, are often infiltrated, and bacilli may thus find their way into the circulation (p. 96). The dangers of chronic arteritis are: general or localized dilatation of the artery, from the combined effects of loss of elasticity and high blood-pressure, or from heightened blood-pressure behind an obstructing ring—sometimes seen in syphilis of cerebral arteries ; actual rupture or erosion of the intima and admission of blood between the arterial tissues (dissecting aneurism); diminution or obliteration of the lumen by the new growth or by thrombosis, with softening or necrosis of the part supplied. cirsoid aneurism or arterial varix. 377 CIRSOID ANEURISM (ARTERIAL VARlx). In this disease arteries, generally of medium or small size, and their branches become dilated, lengthened, and very tortuous; their walls are thin, and saccular dilatations form here and there. Capillaries and even veins dilate similarly. The ultimate result is the formation of one or more ill-defined swellings having large tortuous vessels running to them from all sides; they are often of bluish color, and are spongy and compressible to the touch, pulsate distinctly, and yield a systolic bruit. These arterial varices may arise spontaneously, but frequently follow an injury, supposed by some to paralyze the vasomotor nerves. They rarely occur in connection with large arteries, and are most common in connection with the secondary branches of the external carotid (temporal occipital, facial). The scalp is more often affected than any other part. These growths are distinguished clinically from true aneurisms by their spongy, indefinite feel and less forcible pulsation, and by the presence round about of tortuous supplying arteries; but when they are out of reach of the fingers, their differential diagnosis may be impossible. Pathologically, they differ from naevi in the size and nature of the vessels of which they are com- posed, and in the fact that they are not congenital though often appearing during the period of youth. Fig. 150 represents this disease. Mr. Storcks tied the common carotid artery, producing a marked decrease in the tumor; and the patient was sub- Fjg. 150. Cirsoid aneurism. sequently treated by Sir W. Fergusson with the needle and ligature, em- ployed as for the cure of varicose veins. Treatment.—Excision, when possible, is the most certain mode of cure; to avoid bleeding, cut wide of the growth. When impossible, ligature of the tortuous supplying vessels has been done with scant success; or they may be acupressed between two needles and threads, like a varicose vein, and di- vided subcutaneously; success has attended the cutting through of the growth 378 INJURIES of arteries. in several directions by the galvanocautery; and, lastly, the main supplying artery—e. g., one or both common carotids—has been tied, but the results are not satisfactory. True Aneurism. The word aneurism has been used, as we have seen, very loosely and im- properly to designate a number of conditions bearing only a very superficial resemblance to the real thing. Thus: 1. "Traumatic aneurism" is often synonymous with arterial hematoma, diffuse or circumscribed (p. 370). 2. " Varicose aneurism," and " aneurismal varix" indicate simply a direct com- munication between an artery and a vein, or almost direct, the communica- tion in the first case being by means of a small arterial hsematoma between the two vessels. 3. "Cirsoid aneurism" or "aneurism by anastomosis" is best described as an arterial varix; arteries do dilate here, but uniformly and over considerable lengths—not in such a way that the dilatation of any artery produces a circumscribed, tumor-like swelling. The tumor is formed by the aggregation of enlarged arteries. Definition.—A true aneurism is formed by the more or less abrupt, uni- form or one-sided dilatation of a circumscribed length of artery, so that a definite tumor-like swelling results. The term dilatation is employed in con- tradistinction, to indicate the comparatively slight general enlargement of long tracts of vessel, such as often arises from endarteritis deformans, or from the passage of more blood than usual through vessels—e. g., those round the enlarging pregnant uterus or a rapidly growing tumor, or those by means of which collateral circulation is being established. Varieties of True Aneurism.—Shape. In some cases the whole cir- cumference of the artery yields tolerably uniformly in all directions; if the Fig 151. Au incipient aneurism of the arch of the aorta. The portion of artery represented is slit up, so as to show the cut edges, with the atheromatous deposit between the coats of the vessel. yielding is gradual, the swelling of the artery will be fusiform, but if it almost suddenly reaches its maximum the enlargement may be cylindriform or globose. These varieties occur chiefly in the ascending aorta. In other much more common cases only a small portion of the circumference of the vessels yields, or, if the dilatation affects the whole circumference, it takes place very unequally, so that a sac-like swelling projects upon one side: this is the sacculur aneurism. Usually, it communicates with the artery by an TRUE ANEURISM—MORBID ANATOMY. 379 opening (mouth) situate in a more or less markedly constricted neck; the mouth may be very small in proportion to the sac, or it may occupy its widest part. AVhen the artery has yielded in all directions, but very un- equally, there are of course two openings into the sac at its base. When situate upon arched vessels, saccular aneurisms usually spring from the con- vex side. Very irregular tumors may arise by the blending of two or more neigh- boring saccular aneurisms, by the saccular dilatation of fusiform aneurisms, by dilatation of branches springing from aneurismal sacs, and by excessive yielding of the less supported parts of old sacs. Rarely, and probably upon the bursting of an " atheromatous abscess," blood finds its way into the substance of the middle coat of an artery and separates the inner from the outer coat for a greater or less distance. Ulti- mately the blood may burst through the intima into the artery again, or through the adventitia when the aneurism becomes diffuse. This is the dis- secting aneurism, and is met with only in the aorta, though it may extend thence into one or more primary branches. The separation of the coats may be very extensive. Other varieties have been founded upon the presence or absence of all three coats. The distinction is of little importance. It is only in some fusi- form aneurisms, and perhaps in the smallest saccular, that all three coats are found continuous. According to their etiology, aneurisms are divided into traumatic (p. 372) and spontaneous. One traumatic variety—the hernial aneurism—seems worth special mention, though it is rare. It is due to division of the external coat by injury, permitting the protrusion through it of the internal. Morbid Anatomy.—Fusiform and dissecting aneurisms do not reach any great size, but saccular aneurisms may be as large as a child's or even an adult's head. A large aneurism usually springs from a large artery. The commonest aneurisms are those very small ones which occur upon the arteries of the brain and lungs, and are classed as miliary: surgery has little or noth- ing to do with them. In all cases a true aneurism has a sac, at first formed by dilatation of one or more of the arterial tissues ; and within the sac are the contents—blood, fluid or coagulated, according to circumstances. As regards the sac-wall, it may consist of all three coats in fusiform and small saccular cases. At the commencement fibroid patches often form gaps in the media; these enlarge, and in considerable saccular aneurisms muscular tissue usually stops short near the mouth of the sac, but patches of it may be found here and there in the wall. The lining of the sac will usually appear continuous with the in- tima, and may closely resemble it in appearance, being occasionally smooth and shining, but usually presenting numerous fatty and calcereous patches when the vessels are atheromatous; and the outer covering of the aneurism will similarly be continuous with the adventitia. But in all large aneurisms distinction of coats in the wall of the sac is impossible ; there is but one coat, consisting of fibrous tissue, and this is almost entirely of new formation. For the coustant pressure of the sac upon surrounding parts causes atrophy and absorption of their essential elements, whilst their fibrous tissue, thick- ened by inflammatory tissue, blends with the enlarging sac-wall. Even bone and cartilage disappear under this pressure; but as they resist longer than other tissues, their bare eroded surfaces often project into the interior of the cavity of the aneurism. As a rule, the sac contains more or less clot, together with fluid, moving blood. The clot is of the kind known as laminated, and presents on section an onion-like appearance. The oldest layers next the sac are firm, dry, and 380 INJURIES OF ARTERIES yellow-white, the more recent become softer, moister, and redder; and, post- mortem, we find the interior of the cavity full of ordinary dark clot. When deposit of clot has ceased some time, the inner layer may be firm, smooth, and polished. The cause of the lamination is uncertain ;, as a rule, the clot undergoes little or no organization. Histology and Etiology.—The question of dilatation of an artery is evidently one in which the factors are: 1, the strain thrown upon the vessel by the blood-pressure, the sole dilating force to which it is exposed ; and 2, the resistance which the walls can oppose to such pressure. We may assume that normally the two are so adapted that no dilatation shall occur. Varia- tion from the normal may occur in either direction—the arterial pressure may be raised or the resistance of the wall diminished ; frequently causes of both kinds act. Increased pressure.—Perhaps the purest instance of dilatation of a healthy vessel is that sometimes met with in the first part of the aorta when there is a congenital contraction of the vessel at the point of junction with the arterial duct. Cases of dilatation about a point of ligature or of impaction of an embolus are by no means pure. High arterial tension from Bright's disease or other cause is a powerful factor in the production of aneurism. Diminished arterial resistance.—But, practically, aneurisms result from changes in the arterial tissues which weaken their resisting power, blood- pressure being normal. These changes are of an inflammatory, degenerative, or traumatic nature. We already know that inflammation may commence in the intima and extend outward (endarteritis), in the adventitia and ex- tend inward (periarteritis), or it may begin in the media (mesarteritis) ; and there is no doubt that the resisting power of an artery can be sufficiently destroyed to insure its dilatation by inflammation starting in either coat, as the following remarks show. Formerly, atheroma (p. 375) was regarded as the state sublying the great majority of spontaneous aneurisms. But to this view there are many objec- tions, of which the following may be mentioned. Atheroma is very common, aneurism uncommon; atheroma is a disease of advanced life, aneurism occurs chiefly in the prime of life (thirty to fifty) ; atheroma is equally com- mon in the two sexes, aneurism much more frequent (9 to 1) in the males, especially of the laboring class; atheroma is very common in Germany, yet aneurism is rare ; lastly, in many cases of aneurism there is neither local nor general evidence of atheroma. But in advanced life, and earlier when marked atheroma is found, there can be no doubt that this chronic endarte- ritis is frequently the cause of aneurism. It is almost necessarily so from the completeness with which it destroys the arterial elasticity, leaving the vessel slowly but surely to yield before the blood-pressure. The disease is by no means confined to the intima, however; the media shows frequent fibroid foci, and the adventitia signs of infiltration (p. 375), and to the former Koster attributes the chief weakening of the wall. An atheromatous ulcer naturally detracts much from its strength; without the presence of such a process as this, it would hardly be possible to account for cases of dissecting aneurism. Koster and Kraft regard a mesarteritis as the essential lesion in the pro- duction of aneurism; the vessel dilates, they say, because the muscular coat is replaced by a fibroid patch. When, in the investigation of commencing aneurisms, the middle coat is examined, foci of round cells or fibroid tissue are always frequent. This mesarteritis may exist in middle-aged people without change in the intima other than puckering from contraction of the fibroid media; whilst in older people such patches frequently correspond to atheromatous patches of the intima. These, Koster and Kraft believe to be TRUE ANEURISM—HISTOLOGY AND ETIOLOGY. 381 secondary to the changes in the media, which constrict the vasa vasorum. So atheroma, instead of being a primary endarteritis, would be secondary to mesarteritis, and its degenerative changes would be due to mechanical con- striction of the vasa vasorum, which do actually send branches into young inflammatory foci in the intima; and mesarteritis would replace endarteritis as the primary and perhaps sole lesion leading to aneurism. But Orth dis- putes the constancy of the relation between the patches in the media and intima, and points out that vessels having no vasa vasorum may suffer from atheroma. Moreover, it does not seem rational to endeavor to connect dila- tation of a vessel with disease of a single coat; doubtless the thickness of an artery, which must lose its elasticity and contractility before dilatation can occur, varies in different vessels and different people; whereas loss of the muscular coat's contractility may allow a small cerebral artery to dilate, it is unlikely that this will result in the aorta, in which muscle is, compara- tively, so poorly represented. Charcot (Lectures on Senile Diseases, Syd. Soc.) describes a diffuse periar- teritis of cerebral vessels leading to miliary aneurisms, which are the ordinary source of cerebral hemorrhage. The disease affects the small arteries of the brain-substance, which are remarkable for richness in muscular elements and relative poverty in elastic tissue. The first sign of disease is cell-infiltration of the lymphatic sheath, and then of the adven- titia ; next, conversion of the cells into fibroid tissue, which, probably, constricts the vasa vasorum. Anyway, secondary as regards time to this fibroid thickening of the, normally, very thin adventitia, the muscular cells atrophy, and disappear without undergoing previous fatty degeneration. And now, the chief resisting tissue of the cerebral artery being destroyed, bulgings of all shapes occur, unless the fibroid adventitia, lymphatic sheath, and intima blend and form so thick and firm a covering as to preserve the balance between dilating force and resistance. Changes in the intima may finally occur, but it is obvious that the disease is totally different from athe- roma or endarteritis deformans, to which disease the spontaneous rupture of cerebral vessels has generally been attributed. Aneurisms of the large vessels at the base of the brain sometimes coexist with miliary aneurisms, and are said by Charcot to owe their origin to a similar periarteritis. Lastly, cases of aneurism of vessels of trunk and limbs coincident with cere- bral aneurisms have also been recorded; and Charcot suggests that the pathology of many of the aneurisms met with in surgical practice may be that above given. True atheroma may coexist with this periarteritis. Inflammation round about an artery may, by spreading to its coats and by depriving them of their normal support, lead to its dilatation. The frequent small aneurisms on pulmonary and bronchial vessels in tubercular cavities are the best examples of this. Large vessels are very resistant; they may slough from exposure in septic wounds, very rarely they have ulcerated into closed abscesses, especially in the neck (Liston) ; but they do not dilate under such circumstances. Of simple degenerative processes likely to predispose to aneurism we may mention atrophy of the arterial coats, fatty degeneration of the media, and perhaps calcification of the same from its rendering the artery more subject to injury. The last pathological state believed to be the starting-point of aneurism is that of rupture of one or two of its coats, healthy or diseased, by violence. Usually it is the intima and media which suffer, but the hernial aneurism, due to protrusion of the intima through the external coat, has been described (p. 379). Just as we are often in doubt as to which of the above pathological condi- 382 INJURIES OF ARTERIES. tions has led to the aneurism, so we frequently fail to discover the exciting causes of this disease. A history of distinct injury of the part or of a sense of something giving way in it during violent effort is common in cases of aneurism. It is, consequently, thought that the part played by traumatism in the produc- tion of aneurism is considerable, causing, when slight, separation of the fibres of the media or cracking of a diseased intima, whilst such violence as over-extension of the knee until the posterior ligament cracks will be found to have ruptured the two inner coats of the popliteal (Richerand). When the vessel is diseased, less force will suffice, and thus are to be accounted for rare cases of aneurism of the femoral forming a few days after its compres- sion for popliteal aneurism, and still rarer cases of acute dilatation during sleep, attributed by Billroth and Marcacci to rupture of the intima. Strain acts upon a vessel either in the line of its long axis, or, when exerted by the blood, at right angles to its inner surface; probably the heightened blood-pressure during a sudden violent effort in people unused to hard work often produces yielding of a weak spot of artery. With strain as a cause it seems possible to explain, in part at least, the greater frequency of aneurism in men, and among laborers ; in England and America than in Germany, athletic exercises and feats of strength being more generally prac- tised ; and the relatively much greater frequency with which the popliteal among arteries of limbs, and the arch of the aorta among vessels of the trunk, are affected, for the former is fixed by small branches and subject to violent stretchings in kicking, etc., and the latter must feel the effect of all exten- sive movements of the neck and upper limbs. Pointing in the same direction is the fact that aneurisms of the aorta are more frequent the nearer the heart—i. e., the higher the blood-pressure. It may be said that many people go about with vessels which are so diseased that extra strain w7ould cause them to dilate, but they are still able to bear the pressure normal to them; in such, sudden strong efforts are dangerous. There are many aneurisms which cannot be accounted for by primary arterial disease and injury or strain. The most frequent cause of these is perhaps embolism; to this, probably, are due most cases of aneurism in chil- dren and young people, in whom it is very rare and generally coexists with heart disease. The embolus is usually a fragment of fibrinous or calcareous vegetation in simple endocarditis, some fragment from a valve in malignant endocarditis, or a bit of a calcareous plate from a larger artery. These may actually wound the intima, or by their irritation excite more or less arteritis —even suppurative, very similar to that proceeding from a septic wound. Pressure above the blocked spot is only momentarily increased (Roy). The characteristic symptoms of embolism of a large artery are sudden vio- lent pain in a limb, numbness, coldness, loss of pulse, and tendency to gan- grene (p. 88) in distal parts of it, together with tenderness and swelling about the affected artery. A boy under Dr. Green, at Charing Cross Hospital, suffered for months from a very remittent temperature and occasional rigors, which, taken with aortic disease, led to the diagnosis of endocarditis maligna. One day he complained of great pain in one forearm, and the ulnar pulse, previously felt, was missed at the wrist. Some weeks later he had severe pain in the arm, and the radial pulse became very small. Post-mortem, I found two small saccular aneurisms—one upon the ulnar, just where the vessel was narrowed by the giving off of the anterior interosseous; the other upon the brachial, above the origin of the superior profunda. Both were filled with clot, as also was the artery, for some distance above and below them. The explanation given of'aneurism from embolism probably holds good for rare cases of aneurism just above a seat of ligature. (Broca, Sur les Anevrismes, Paris, 1866, p. 41.) TRUE ANEURISM—SYMPTOMS. 383 About syphilis as a cause of aneurism there has been much dispute, syphilis of the larger arteries not being well known. A history of syphilis is very frequently obtainable. Besides its well-known endarteritis of small vessels (p. 117), it probably produces gummata and diffuse infiltration of the media and adventitia, leading to local or general loss of elasticity and weakening. The argument that iodide of potassium has sometimes appeared to do good in the treatment of aneurisms is not worth much to prove their syphilitic origin. Chronic alcoholism seems to cause vascular degeneration directly or by ex- citing the heart. Any other condition inducing cachexia—e. g., malaria, old age—may act similarly; and the strength of the arteries suffers with general or local wasting. Situation.—The most common situation of aneurisms is the aorta, near the heart; but if aneurisms of the aorta are excluded, we find that of all the arteries of the limbs, the popliteal is the most frequently affected. Thus, out of 179 cases of spontaneous aneurism collected by Lisfranc (not including any of the aorta), there were 59 of the popliteal artery; 26 of the femoral in the groin, and 18 in the femoral at other parts; 16 of the carotid; 16 of the subclavian ; 14 of the axillary; 5 of the external iliac; 4 of the innom- inati; 3 of the brachial, common iliac, and anterior tibial, respectively; 2 of the gluteal, internal iliac, and temporal respectively; and 1 of the ulnar, perineal, internal carotid, radial, and palmar arch respectively. Number.—As a rule, only one aneurism develops; but two are often met with—e. g., one of each popliteal, of the popliteal and femoral on the same side, or of a limb-artery and of the aorta. Rarely, more than two aneurisms are present; and as many as sixty-three have been noted in one person. These remarks refer to aneurisms of considerable size—not to miliary cerebral or pulmonary dilatations. Before commencing the treatment of an aneurism, the surgeon should never neglect to examine the heart and the whole arterial system. Symptoms.—In the development of an aneurism in the neck or limbs, the first sign noticed is often an unusual pulsation and perhaps movement of the whole part communicated from the aneurism. Next, a swelling appears and enlarges more or less rapidly; it is circumscribed to the eye and still more so to the touch, lies in the course of a large trunk, is tense, elastic, or fluctuating, and pulsates synchronously with the pulse; sometimes a marked thrill is felt with each systole. The distinctive point about the pulsation of aneurism is that it is expansile—due, not to the pushing forward of the whole sac as if it were a solid mass, but to the driving of blood into the sac, distending it and forcing its walls asunder. This peculiarity is easily recog- nized if a finger can be placed fairly on either side of the sac, but it is diffi- cult to be sure of it when we can only lay two fingers slightly separated upon its superficial surface. On ausculting the swelling, whilst taking care not to use such pressure as would develop a bruit in a normal artery, a blowing murmur synchronous with the pulse will usually be heard. In aneurisms of the head and neck the patient may be greatly troubled, and sleep prevented by hearing the bruit. If the main artery be compressed between the swelling and the heart, pulsation and bruit will cease, the tumor will become smaller and more flac- cid, especially if direct pressure be made upon it. On removing pressure from the artery, the swelling suddenly regains its full size—often with a thrill—and pulsation and bruit return. The pulse beyond the tumor is often smaller than that on the sound side and delayed; the sphygmograph shows deficiency in the second or dicrotic elevation. The above signs are common to all aneurisms which do not contain much ' 384 INJURIES OF ARTERIES. clot, though they may be undiscoverable on account of inaccessibility of the sac. But as the clot accumulates in the sac the aneurism assumes more and more the characters of a solid tumor—it feels firm, does not fluctuate, does not pulsate expansilely, but rises and falls as a whole, or perhaps exhibits no movement, the artery being obliterated opposite the mouth of the sac. There will then be no bruit, and little or no change of volume on compress- ing the main artery above. We now come to the pressure-symptoms, which vary with the site (i. e., with the relations) of the tumor and in intensity directly with the rate of its develop- ment ; for when its enlargement is slow, structures in contact with it may stretch, slip aside, or otherwise adapt themselves to the altered circumstances, which is not possible when they are suddenly pressed upon. There is noth- ing peculiar in the pressure-symptoms of aneurisms; they act simply as tumors. In aneurisms which present upon the surface, pressure-symptoms are noted to complete the case, not because they are required to diagnose or localize the disease ; but in internal aneurisms—especially intra-thoracic— we rely largely upon pressure-symptoms to recognize their presence and fix their sites. An accurate knowledge of anatomy is essential for these purposes. Iuquiry must first be made as to the manner in which the various structures in the neighborhood of the affected vessel discharge their functions; then the aneurism must be of such size and so placed as to produce the symptoms complained of. Frequently, however, an aneurism may reach a large size in certain directions without pressing upon any important parts. The commonest pressure-symptoms are due to pressure on nerves: motor, sensory, or sympathetic. Spasm and paralysis from irritative and destructive pressure, respectively, on motor nerves, are uncommon ; they are best seen in laryngeal muscles from pressure of aortic aneurisms on the recurrent laryngeal. Very severe neuralgia and perhaps hyperesthesia are the first results of pressure on sensory nerves ; anesthesia may follow. These symp- toms are well seen when aortic aneurisms press on intercostal nerves or upon those going to the lower limb; but still more often these swellings cause a fixed, constant burning or boring pain, with sense of weakness from erosion of the vertebrae. The results of pressure on the sympathetic are best known in the head and neck (p. 44). Veins are commonly pressed upon, perhaps obliterated, and afford impor- tant indications; they become swollen and varicose behind the obstruction, then more or less marked oedema of the area whence they draw their blood results, and rarely even moist gangrene may ensue. Arteries may be pressed upon by aneurisms of other vessels, but symptoms are rare. A sac may press upon the vessel whence it springs and lead to the complete cure of the disease. No special remarks are needed upon the symptoms which result from pressure on the trachea, bronchi, lung, oesophagus, bile-duct, etc. Progress and Terminations.—Sometimes, though comparatively rarely, an aneurism remains stationary for long periods, or undergoes spontaneous cure (see below); but in the great majority of untreated cases aneurisms tend either slowly or rapidly toward rupture. The sac enlarges most in the directions of least resistance (usually toward free surface), adhering to and causing the absorption of all structures with which it comes in contact (p. 379). In the limbs usually, and sometimes in the trunk, it presents beneath the skin and distends it. Inflammation succeeds; the skin becomes red, then livid and vesicated, and sloughs. When the edge of the slough sepa- rates, a fatal bleeding ensues, sometimes in a gush enough to destroy life at once; but more frequently the blood oozes away slowly, or hemorrhage" occur at intervals and clot blocks the opening between times. Sometimes TRUE ANEURISM—COMPLICATIONS. 385 rupture takes place into the areolar tissue of the limb or part in which the aneurism is situate—in other words, the aneurism becomes diffuse. Aneu- risms of central vessels frequently open into mucous canals (alimentary, re- spiratory), or serous cavities—by a small, ulcerated opening in the former, by a crack or fissure in the latter case. Occasionally aneurisms burst into large veins which have become adherent to the sac, a varicose aneurism re- sulting; and those of the first part of the aorta may open into the heart itself. Signs of perforation.—Sudden, severe pain, rapidly followed by collapse, is the usual sign of the rupture of an internal aneurism; special symptoms may indicate the direction in which it has burst—e.g., haemoptysis, asphyxia, haematemesis, escape of blood per anum. The collapse varies with the in- tensity of the pain, and especially with the quantity of blood lost in a given time. When an external aneurism becomes diffuse, pain and collapse may be very marked ; and sometimes with only a slight rupture there is high fever with septic symptoms. Local symptoms are generally prominent; the limb swells more or less diffusely ; the circumscribed aneurismal tumor disappears; pulsation is often entirely lost—at least until the arterial haema- toma becomes limited by the pressure of the tissues; pulsation is absent in the main arteries beyond the rupture, and the signs of venous obstruction— coldness, dilatation of subcutaneous veins, oedema, and perhaps moist gan- grene—appear in the distal portion of the limb. We have, in fact, an arterial haematoma (p. 370), which may be circumscribed or diffuse, and lead to rup- ture through the skin, with or without suppuration, or to gangrene. Spontaneous Cure.—In a small number of cases, aneurism ends in spon- taneous recovery, usually by the more or less gradual deposition of laminated clot, but sometimes by the more rapid formation of ordinary clot. The local conditions favoring the formation of clot are: a rough sac-wall and stagnation of blood in contact with it. Stagnation or languid circulation of blood obtains (1) in saccular aneurisms with small mouths, whilst it cannot occur in fusiform aneurisms, through which the main current rushes; and saccular dilatations from which large vessels spring are also unfavorable to clot formation. As a rule, no clot, other than a thin layer upon calcareous plates, forms in fusiform aneurisms; but Holmes speaks of the arrest of this variety by clotting until only a narrow channel is left through which blood passes. In saccular aneurisms clot-formation goes on until the whole sac is full of onion-like layers, and the artery is usually obliterated opposite its seat by fibrous tissue; then the solid mass slowly shrinks. (2) In a few lucky cases, a portion of clot has been detached from the interior of the sac by some accidental violence, and has effected a cure by blocking up the opening out of the aneurism, or by embolism of the main trunk beyond the aneurism. (3) The artery has become obliterated by accidental pressure of aneurism upon it, above or below the mouth, under the resisting tension of a strong aponeurosis; or by the pressure of blood escaping from it on its bursting into the cellular tissue. (4) Inflammation about the sac may lead to primary thrombosis of the artery at the mouth of the sac and secondary clotting in the sac; or if the latter suppurates, healing by granulation will occur under favorable circumstances. Complications.—Before rupture can occur the following complications may arise: Cellulitis and suppuration about the sac are rare. They may occur around aneurisms in loose connective tissue, which have been increasing rapidly; but usually they appear after the application of a ligature near the sac (e. g., of subclavian for axillary aneurism) or after manipulation or other injury of the swelling. The signs are ordinary. Should the inflammation end in 2o 386 INJURIES OF ARTERIES. suppuration, there is much risk that when the abscess is opened or bursts, the contents of the sac, broken down and altered in appearance by admix- ture with inflammatory products, will escape with the pus, and either at once or after some days be followed by hemorrhage from the main artery. This, however, does not happen in the majority of cases, the artery appa- rently becoming thrombosed at the mouth of the sac before the latter opens. Suppuration of the sac must not be confounded with ulceration of an artery into an unopened abscess—a very rare occurrence. Gangrene of distal parts may result from the pressure of a rapidly enlarg- ing sac upon the veins, but even one of the venae cavse may thus be completely obliterated without gangrene resulting; usually it arises from diffusion of the aneurism. Coagulation may spread widely along the main trunk leaving the sac, and, blocking the mouths of branches most important for collateral circulation, cause mortification. Diagnosis.—An aneurism may be met with in four states: (1) with con- tents chiefly fluid, in which it may be termed typical; (2) solid, or almost so ; (3) diffused ; and (4) suppurating. 1. In its typical state, aneurism is characterized chiefly by its forcible expansile pulsation, its bruit, and the distinct diminution in size that follows gentle pressure on the sac, whilst the main artery is compressed above. In this state it may be confused with fluid swellings—cystic tumors, hydatids, large bursae, and especially chronic abscesses—lying immediately upon great vessels and receiving a communicated pulsation. Points in the history of such cases may be of value, especially as showing absence of pulsation in early stages; the swellings are often less firm and circumscribed than aneu- risms ; their pulsation is hardly ever expansile and forcible, they can often be drawn aside from the vessel, when pulsation and bruit cease ; if the vessel can be compressed on the proximal side of the growth, the swelling, though soft and fluctuating, undergoes no diminution in size, nor does it increase with a sensation of thrill when pressure is removed from the artery. Much more difficult than the above may be the diagnosis from pulsating sarcomata, which almost always spring from bones. These growths pulsate expansilely, and are the seats of a humming or whizzing bruit; compression of the artery above checks both these signs, and may cause diminution in the size of the mass. Usually these growths present in such situations that they cannot be aneurismal—i. e., they are not in the lines of great arteries; but the greatest difficulty has arisen when the tumor has presented where it could not be well examined and in the vicinity of an artery—e. g., in the iliac fossa or region of the great sciatic notch. Mistakes have been made by the best surgeons in such cases. Prolonged and careful observation should always precede treatment. 2. When the aneurism is solid or almost so, it is liable to be mistaken for a tumor in the line of a great vessel, for it has lost in great part or entirely its characteristic signs. In the more solid cases pulsation is absent, or, if present, consists in a rising and falling of the whole mass. The history is here of the utmost importance, and if this does not render diagnosis possible, the patient must be kept at rest and treated for aneurism in some bloodless way, whilst the swelling is carefully watched. Amputation has been per- formed for consolidated aneurism causing pain by pressure on a nerve and regarded as a malignant tumor; it would seem that even short observation must have prevented such an error. The diagnosis of a solid tumor over an artery from an aneurism rests chiefly upon the ability to move the tumor away from the artery and deprive it of its aneurismal signs ; its pulsation is, of course, not expansile at any time. The shape of the mass may be characteristic, as in unilateral TREATMENT OF TRUE ANEURISM. 387 enlargement of the thyroid, in which the isthmus may often be plainly traced into the swelling. 3. When an aneurism has become diffused, and especially when this acci- dent is accompanied by fever, loss of pulsation, and redness and vesication from threatened bursting through the skin, the diagnosis from deep abscess has to be made ; and aneurisms have several times been opened in error. Again, the history is of chief importance; and even if the existence of an aneurism had not been recognized, the suddenness of the onset and the early obstruction to both arterial and venous circulations should arouse suspicion. Exploratory puncture is apparently not conclusive, as inflammation is often excited about the haematoma ; so in doubtful cases, with gangrene threaten- ing, an exploratory incisiqn must be made, everything being ready for further treatment. 4. When suppuration has occurred its signs are plain and usual, whether it happen before or after ligature. The chief difficulty would lie in recog- nizing as a suppurating aneurism one which had ceased to pulsate on account of periarteritis (p. 385). Prognosis.—This must be regarded as bad if treatment is not adopted or cannot be. Yet old, feeble people, living quiet lives, may go on for many years with stationary aneurisms, and finally die of something else. Treatment of True Aneurism. This may be either general or local. General treatment is directed toward : (1) diminishing the frequency and force of the heart-beats, and (2) increasing the tendency of the blood to form fibrin. Very little is known on the subject of formation of fibrin, Schmidt's views being disputed by Hammarsten. But observation has shown that fibrin forms more or less quickly and in varying amounts in different physiological and pathological states—e. g., pregnancy and sthenic inflammation ; we may therefore hope to influence its development, and it is thought that a dry, albuminous diet and the administration of iodide of potassium (grs. x to xxx) favor coagulation in aneurisms. Mr. J. Hutch- inson values highly acetate of lead pushed till it causes the lead-line, consti- pation, and colic, and he would similarly push ergot; by other surgeons/ these drugs are little used. The first indication is fulfilled by keeping the patient as nearly as possible at absolute rest, upon a starvation diet. The patient must be instructed to avoid every unnecessary movement and all mental excitement; the bowels should act easily, but no drastic purgatives should be given, as they cause circulatory excitement; if he is strong and plethoric and the aneurism pulsates forcibly, bleedings of three to four ounces may occasionally be em- ployed ; and his diet must be gradually lowered to something like this: Breakfast, bread and butter, 2 oz.; dinner, bread and meat, of each, 2 oz.; tea, bread and butter, 2 oz.; and milk or water, 6 oz. per diem (Tufnell); no stimulants. Tobacco may be allowed. In patients already feeble and anaemic, most surgeons allow a fuller diet, highly nutritious and easily digestible; but fluids are limited and stimulants disallowed. Iron is often administered in such cases. In the absence of all accurate knowledge, the general treatment of aneu- rism is highly empirical, and but little reliance is placed upon it. Alone it is used only in inaccessible central aneurisms. When local treatment can be employed, a moderate diet with little fluid and no stimulant is usually prescribed.- 388 INJURIES OF ARTERIES. Local Treatment.—Of this there are many varieties; but all that are employed under ordinary circumstances act in imitation of nature, inducing either the deposit of laminated fibrin or the more rapid coagulation en masse of the blood in the sac. With regard to these two modes of cure, it was stated by Broca, and has been repeated since, that the rapid coagulation of the blood in the sac excited much irritation, and was to be regarded as a potent cause of suppuration ; but suppuration of popliteal and femoral aneu- risms after treatment by Esmarch's bandage is scarcely known; so it is probable that the frequent occurrence of suppuration referred to by Broca, was due, not to the coagulation, but to the methods of inducing it (direct pressure, injection of coagulants, etc.). Laminated fibrin, once formed, is stable and little prone to organization ; clot, on the other hand, is at first easily broken down and washed away, but is more easily organized. The local methods of treatment are fhe following: 1. Compression (a) of the sac; (b) of the main artery on the proximal; (c) on the distal; or (d) on both sides of the sac. 2. Ligature (a) of the vessels entering or leaving the sac after laying this open ; (b) of the main artery on the proximal; (c) on the distal side of the sac. 3. Amputation. 4. Manipulation. 5. Electrol- ysis. 6. Introduction of foreign bodies into the sac. 7. Injection of coagu- lants into the sac 8. The injection of ergotin in the tissues over the sac. 9. Ice. 1. Compression.—This simple and very obvious mode of treatment was employed long since by Guattani and others, with some success; but it was usually applied immediately on the sac, was imperfect and violent, and usually failed—causing sloughing, suppuration, or rupture. Pressure on the sac is now employed but rarely, and chiefly in the endeavor to limit the advance of an aneurism which cannot otherwise be treated; thus a well-padded cap is sometimes fitted over a subclavian aneurism. The flexion method often acts partly by direct pressure. Compression of the main artery on the proximal side of the sac was revived and perfected by the Dublin surgeons, Hutton, Cusack, Bellingham, and Tufnell, who pointed out that a cure, very similar to that resulting from the Hunterian operation, might be obtained if the main artery were compressed in an efficient manner. To this end they introduced suitable instruments, and formulated rules for their use. Vanzetti next showed that the fingers of relays of assistants were effective compressors in many cases where instru- ments either could not be applied or were not borne; and thus arose the two varieties of compression—instrumental and digital. Instrumental compression is used almost solely on the lower limb, in which aneurisms are so much more frequent than in any other external part. The instruments employed are: Signoroni's tourniquet (Fig. 152)—an arc of steel, with a joint in the middle, and a screw by which the extremities of the instru- ment are pressed together; or Carte's circular tourniquets (Fig. 153), one of which envelops the whole pelvis firmly in a well-padded saddle, and acts on the lower end of the external iliac, whilst the other forms a circle of steel round the thigh, just below the groin, and has a wide pad behind for the limb to rest upon, and a screw-compressor playing through its anterior arch to act upon the femoral. By working these two tourniquets alternately, com- pression can be borne for a much longer period than when pressure is made at one spot only; but perhaps the chief merit of Carte's inventions is that the use of India-rubber bands, to connect the compressor and its bearings with the fixed part of the instrument, renders the pressure elastic and more like that of the finger. Carte's tourniquets have consequently replaced all others in the treatment of aneurisms of the lower limb. The advantages of two spots of pressure may, however, be obtained with Signoroni's tourniquet by proximal instrumental COMPRESSION. 389 using the double pad (Fig. 152, B). Lister's tourniquet has been used to compress the aorta and iliac aneurisms. For compression of the femoral at the groin, the use of a four pound round- ended weight, which can be lowered on to the artery at pleasure, is excellent. By lowering a weight on to the dorsum of an assistant's thumb in digital com- pression, his endurance (fifteen minutes) can be at least doubled. Sometimes Fig. 152. A, Signoroni's tourniquet. B, double pad. The hinder pad in A should be large and concave, to rest behind the pelvis. a curved needle may be passed beneath the artery, which can^be pressed against it, with a cork and ligature. The conduct of compression.—The skin pressed upon should be shaved if necessary, and well powdered with French chalk. The artery and not the vein should be compressed. The pressure should be just sufficient to check pulsation in the sac, and in digital compression the assistants should work Fig. 153. Carte's circular tourniquet for the external iliac at the groin. two and two—one compressing, the other with a hand on the sac. When a change is made, the fresh assistant should, when possible, compress a point of the vessel below or above that which is being compressed ; and the retiring assistant should not relax pressure until the fresh one has the artery comfort- ably under control. Carte's tourniquets must be used similarly : the spots 390 INJURIES OF ARTERIES. upon which their compressors are to act should be marked, and both should not be up at once. In many cases they, or the weight-compressor, may be left to the management of an intelligent patient. If he cannot feel the aneu- rism as he lies, he should know the number of turns necessary to check pulsation, and the sac should be frequently felt by an attendant. Compres- sion may be continuous for twelve to twenty-four hours or longer ; or it may be discontinuous, kept up for a few hours at a time for many days, weeks, or months. Often a determined attempt to cure rapidly is made at first—i. e., the artery is completely and continuously compressed for many hours together in the hope of inducing coagulation ; should it fail, it may be repeated in a few days or the discontinuous plan may be adopted. When the patient bears the pressure illy morphia may be given hypodermically, or he may be lightly chloroformed during the whole period of compression. The cure may be complete and the sac solid within six hours, or twice as many weeks may be spent over a case in which the sac is slowly diminishing and hardening under discontinuous treatment. In rapid cases pressure should be continued for a few hours after solidifi- cation, lest the clot break down before the circulation; a tourniquet applied on the main artery is the best means. The mode of cure is either by the sudden coagulation (unusual) of the con- tents of the sac (rapid method), or by the deposit of laminated fibrin. The more complete the control of the circulation, the more perfect the stagnation of the blood in the sac, the greater the chance of cure by coagulation; but when collateral supply is free, and blood trickles constantly into and out of the aneurism, cure, if it result, will be by the slow method of laying down layers of fibrin ; and this is the usual result of digital and instrumental compres- sion. In either case the sac shrinks to a small size and may be reduced to a mere nodule of fibrous tissue upon an obliterated artery. As to obliteration of the artery, Broca states that of 17 cured cases it was closed in 8, narrowed in 7, and almost natural in 2. Obliteration is satisfactory, for the artery is weak at the spot.. The special advantages of this method are: That it can be discontinued at once if need be; that it avoids all the dangers connected with an open wound, especially septic disease and secondary hemorrhage, and that patients are more willing to submit to it. Should it fail, ligature may still be resorted to, and a short preliminary compression has probably the advantage of opening up the collateral circulation somewhat, thus rendering gangrene less likely after ligature. Statistics, according to Holmes (Lancet, May 1, 1875), show—"to any one who trusts implicitly in figures"—that previous compression is unfavorable, the mortality and failures after secondary liga- ture being higher than after primary. But there is perhaps some error here, for, as C. J. Symonds points out (" Surgical Treatment of Aneurism," Guy's Hospital Reports, vol. xxv.), a confirmatory result derived from the Guy's statistics is certainly accidental, most of the deaths being due to wound diseases, and among cases in which compression had been practised for only a few hours. It is, however, conceivable that long compression might render the collateral circulation so free as to interfere with cure after ligature; and the difficulty of tying an artery at a spot which has long been compressed is considerably increased. The objections urged against compression are : that some patients cannot bear the pain—which may be met by amesthesia; that some cannot bear the pressure without sloughing—generally overcome by using the finger; and the somewhat doubtful one that, should it fail, ligature will be less likely to succeed. COMPRESSION BY ESMARCH'S BANDAGE. 391 Results of proximal compression.—Its success is variously stated. Dealing with popliteal aneurisms only, Hutchinson gives 52.1 and Holmes 53.2 per cent, of cures; whilst of all cases at Guy's (fifteen years), Symonds gives 56.89; and of 138 cases, Konig says 78.3 were cured. Sometimes the sac may harden once or twice before cure is ultimately attained. As to unfavor- able results, we have most commonly simple failure to induce solidification of the sac. Sloughing of the skin, development of a fresh aneurism at the point of pressure, suppuration or rupture of the sac, and gangrene of the limb, are all rare accidents. Distal compression may be tried when proximal is impossible; it is not nearly so valuable a method. When distal pressure is applied, the sac is kept distended under the full arterial pressure, and if any branches other than the main trunk arise from it, blood will move through it pretty briskly. If the collateral circulation is free, it is advisable to combine distal with proximal compression. There remain two methods of compression which are of more limited application than the digital and instrumental spoken of above, viz.: com- pression by Esmarch's India rubber bandage, and by forced flexion of the limb. Compression by Esmarch's bandage was introduced by Dr. W. Reid, Royal Navy, in 1875, as a ready means of completely controlling flow through a peripheral aneurism, and of obtaining that perfect stagnation in the sac which was pointed out by Dr. Wm. Murray, of Newcastle, as essential to the rapid cure by coagulation. (The Rapid Cure of Aneurism by Pressure, 1871.) At the Congress in 1881, Pearce Gould read a paper on this method, from which the following points are taken. Method.—With the limb horizontal an elastic bandage is applied firmly from the extremity up to the aneurism, then lightly over the sac so as not to empty it, and again firmly for a sufficient distance up the limb to control entirely the blood-supply to the sac. This, the plan adopted by Reid, has been variously modified. Thinking expression of all the blood from the limb below the sac to be useless, and possibly harmful, if the vessels into which it is forced are diseased, some surgeons have begun their bandaging only a short distance below the aneurism, a few turns being enough to keep the blood at rest in this direction. If a sufficient length of limb can be bandaged above the sac to prevent the entry of blood, that is all that is necessary ; but if there is little room here, either the elastic tourniquet must be used alone to control the circulation, or it may be applied over the highest turn of the bandage, or several turns of the bandage, one on top of the other, may. be made as high as possible round the part. In some cases —subclavian, axillary, inguinal—digital or instrumental compression of the main trunk must be used proximally to take off the effect of blood being pumped straight into the sac, whilst the elastic bandage applied up to the aneurism will prevent the establishment of collateral circulation. If the region of the sac is left uncovered, blood from the compressed parts (for all is not at once driven out) is gradually forced into this area, distending the sac and giving rise to numerous capillary ecchymoses. If the arterial circu- lation is not completely controlled, the results of this treatment would prob- ably be disastrous. It is usually necessary to keep the bandage applied for one and a half hours; in twenty-nine successful cases the time varied from a half hour to three and a half hours. Great pain is caused, and morphia, or, preferably, chloroform must be given; ether excites the heart, and is liable to cause bronchial trouble. Before removal of the bandage the main artery should be controlled, in order that the newly formed clot may not be exposed to the direct shock of 392 INJURIES OF ARTERIES. the heart-force; either digital or instrumental compression may be used,and it should be kept up for six to twelve hours. When the bandage is taken off, the aneurism may be quite solid, and remain so; or there may be some pulsation which disappears after a few hours' compression; or the pulsation may increase till all hardening has disappeared; or, lastly, no change for the better may have resulted. Failure of a first attempt does not show that the treatment should be aban- doned, but it is discouraging; for of successful cases 67.6 per cent, yielded to one application, 17.6 per cent, to two applications, and 14.6 per cent, to three. Mode of cure.—This treatment is an excellent example of the rapid method, which acts by causing complete or almost complete stagnation of blood in the sac, thus leaving it to coagulate. Coagulation of the contents of the sac is the first step toward cure, and from the sac, clotting extends into the artery and occludes it; the cure is completed by conversion of the arterial clot into fibrous tissue, thus obliterating the vessel and shutting off the sac from its communication with the blood. An examination of the reports or specimens of the few cases that have died after this treatment leads Gould to state that the contents of the sac become dry, discolored, partially absorbed, and but little or not at all organized. He thinks that this is because the sac is dense and but slightly vascular, less capable of pouring out lymph than the artery. The mass of the clot also must be taken into account. Among the causes of failure of the method are the following: Stasis is not obtained, or is not maintained long enough to allow the clot to extend into the artery and acquire some firmness. Conditions of the sac and of the blood which do not favor coagulation ; of the latter we know nothing, but among the former must rank the fusiform shape or a wide mouth and presence of endothelium. When the clot has formed, exposure to the direct heart-force and other unknown influences may cause it to disappear without embolism or other ill effects; or the arterial clot may fail to organize on account of advanced arterial disease. The following are the chief objections that have been raised to the treat- ment : (1) That expression of blood from the whole lower limb would so raise the general arterial tension as to act injuriously upon a diseased heart or artery. But the rise of arterial pressure from this proceeding is moment- ary ; reflex dilatation of arterioles and veins accommodates the extra blood at once, and there may be even a fall of pressure. Still, caution is advisable under the above conditions. (2) That syncope might result from the great congestion of the limb on removal of the bandage; but the patient is hori- zontal, a tourniquet controls the main artery, and there should be a clot in it lower down. (3) That gangrene, referable to rupture of small vessels, is very liable to occur. Of sixty-five aneurisms of the main artery of the lower limb thus treated, gangrene occurred in two, accounted for in one by com- pression of the popliteal vein by the solid sac, and in the other, apparently, by the presence of continued thrombosis of the arteries of the leg. (4) That rupture of the sac is likely to result; and care must certainly be taken to give it such support by the bandage as is permissible, and to prevent its dis- tention by an uncontrolled artery. Rupture occurred in one of seventy-two cases, and in one the sac was larger immediately after treatment. (5) In the upper limb paralysis may result, especially if the elastic tube is used. The advantages of treatment by the elastic bandage are: that it occupies but a few hours; that its success is great (about fifty per cent, of all cases); that combined with the elastic tube, or other form of tourniquet or with digital compression, it is very widely applicable—the abdominal aorta and PROXIMAL LIGATURE OR HUNTERIAN OPERATION. 393 the axillary falling within its province; and that, in case of failure, it inter- feres with no treatment which it may subsequently be necessary to employ. Continued forced flexion of the knee or elbow stops the pulse at the ankle or wrist by producing a kink in the artery. An aneurism situate in the bend of the joint would be subjected to continuous pressure. The method has been used chiefly for popliteal aneurisms. The limb must be bandaged to the knee, gradually flexed as fully as possible, and so fixed for several hours, whilst the patient is quieted by morphia. Digital compression may be used as an aid. The chief accidents are rupture and gangrene. The method is fairly successful, and may be tried also in circumscribed arterial haematomata. 2. Ligature.—This is really the most perfect means of compressing an artery, a wound being necessary to its application. The dangers of a wound have been so much reduced by antiseptics that some surgeons now regard ligature of the superficial femoral as the best and easiest treatment for all concerned of popliteal aneurism. But even now ligature has very decided dangers, whilst compression is comparatively safe; its proper field is, there- fore, that left by failure, or unsuitability of compression. Thus compression is unsuitable, and ligature or other treatment must be employed, when the skin sloughs easily, when the teguments are inflamed at the point for pres- sure, when the aneurism is suppurating, or is increasing rapidly and threatens to burst or has burst, or when the limb is much swollen from venous obstruc- tion and gangrene threatens or is present; and if during compression such conditions arise, it should be abandoned. Lastly, in certain central aneurisms pressure cannot be employed. Proximal Ligature or Hunterian Operation.—When possible the ligature should always be placed between the sac and the heart, the principles laid down by John Hunter being obeyed. These were that the ligature should be applied far enough from the sac for the vessel to be healthy, yet not so far away that many or large collateral branches shall intervene be- tween it and the sac. The Hunterian operation was a very great improve- ment upon the old operation (that of Antyllus—see below), of opening the sac and tying the vessels entering and leaving, but its province must be clearly understood. Proximal ligature at a distance is done in aneurism ; first, because the old operation yielded such bad results, partly on account of its difficulty and imperfect performance, partly from the frequently dis- eased state of the vessels in the neighborhood of the sac, and in great measure, doubtless, from the effect of sepsis in the necessarily large and irregular wound ; secondly, because in the case of aneurism the gradual establishment of collateral circulation, after tying at a distance, provides that slow flow of blood through the sac which is necessary for the deposit of laminated fibrin; and, thirdly, because with fairly healthy vessels and in ordinary cases, in which the aneurism is circumscribed and not so large as to interfere seriously with return of blood by the veins, this establishment of collateral circulation in parts beyond the aneurism may be counted upon. The aneurism is, of course, always an obstruction to the circulation in the limb—one might a priori think it a greater obstruction than a transverse division, or a liga- ture in continuity of the main artery; but experience has amply shown that it is not so (doubtless because its gradual development allows collateral branches to enlarge and counterbalance advancing obstruction in the main trunk), and that a second obstruction (ligature) may in most cases be safely inserted higher up. These considerations show, once again, how entirely in- applicable ligature at a distance is to the arrest of hemorrhage, in which the establishment of collateral circulation probably brings recurrence of bleed- ing, whilst its non-establishment means death of the part. When to the 394 INJURIES OF ARTERIES. Fig. 154. obstruction of a wound that due to the pressure of a recent arterial haema- toma—diffuse or circumscribed—is added, ligature at a distance is sure to cause gangrene. If, however, a haematoma does not of itself induce mortifi- cation, but becomes surrounded by a capsule of inflammatory tissue, whilst collateral circulation is developed, it becomes amenable to the ordinary treat- ment of aneurism ; but it may with perfect propriety, and with greater certainty of cure, be treated by ligature at the spot, for the vessel is presumably healthy. For the methods of tying arteries in their continuity at seats of election, see "Ligature of Arteries." After-treatment. — The patient should be placed in bed, with his limb in an easy posi- tion, well wrapped up in cotton-wool to pre- serve its temperature, and slightly raised to favor venous return. Neither pressure nor cold may be employed should swelling occur, and hot bottles, if placed in the bed, must not touch the limb lest they induce sloughing. After the operation the temperature of the limb falls several degrees; but in a few hours it may rise two or three degrees higher than the opposite limb, because the blood is forced to circulate through the superficial capilla- ries, and its rapid passage is permitted by very full dilatation of the vessels, due partly to the direct, partly probably to the reflex, action of prolonged anaemia. Subsequently it sinks again rather below the natural standard. The sac should from day to day become pro- gressively harder and smaller. In the course of three or four weeks it should be quite solid and considerably shrunken. Then, all being sound at the seat of ligature, the patient may be allowed to get about. The mode of cure after ligature is usually by the deposit of laminated fibrin ; clot ex- tends into the artery, which becomes obliter- ated opposite the sac by fibrous tissue. The vessel is, of course, obliterated in the usual way from the seat of ligature to the nearest branches, but remains pervious between the knot and the sac (Fig. 154). The latter slowly shrinks by drying, or break- ing down and absorption of its contents; the most superficial layers probably organize. Complications after Ligature, and their Treatment. — The course of an aneurism after ligature is not always smooth. Instead of solidifying, the contents may remain fluid, and the sac may even enlarge under the pres- sure of regurgitant blood supply, necessitating compression, incision of the sac, etc., or large collateral branches may open into the sac or artery above it, but below the ligature, continued or recurrent pulsation, sooner or later, being the result. The latter may rarely occur from early slipping of a catgut knot. Both these complications must be met by still further diminishing the blood-supply to the sac, by vertical elevation of the limb, compression of An aneurism of the common femoral artery, for which the external iliac was tied by Sir B. Brodie. The ligature is seen embedded in lymph; the coagulum in the artery above and below it; and the laminated coagula in the aneurism. St. George's Hospital Museum. DISTAL LIGATURE. INCISION OF THE SAC. 395 the main trunk above the ligature or below the sac, forced flexion, bandag- ing the limb firmly up to the sac and then over a soft pad placed upon the latter, or the cautious use of Esmarch's bandage. These failing, the choice lies between opening the sac and amputation, when this is possible. Suppuration of the sac (p. 385) occurs much more often after ligature close to the sac than under any other circumstances—i. e., it is most common in the neck, axilla, and groin. Probably antiseptics have greatly diminished the liability to it. Before doing anything, make sure that suppuration has occurred. Then the choice of treatment is between incision of the sac and amputation, when this is possible; and of these, free antiseptic incision should first be tried. If there has been no recurrent pulsation, this may be done at once, but under other circumstances it may be well to wait, in the hope that occlusion may occur. If, however, general or local symptoms necessitate action, and hemorrhage result, either immediately or later, the vessel must be secured or compressed from the sac. Erichsen states that attempts to ligature have hitherto failed, the vessel being softened, and recommends the cautery as preferable. Plugging is the last resource in central, amputation in peripheral aneurisms. If not opened, the sac will burst through the skin or some mucous or serous surface; this may or may not be followed by hemorrhage. Gangrene.—This is generally moist, and may result from many causes after ligature—e. g., failure of collateral circulation from arterial disease, spreading arterial thrombosis, cardiac weakness or loss of blood (p. 85), ob- struction to the venous circulation by pressure of the sac upon the main and other veins, or wound of the main vein or its inclusion in the ligature, diffu- sion of the aneurism, or the supervention of inflammatory oedema. The imperfectly nourished tissues slough readily from heat or cold. Gangrene usually appears from the third to the tenth day unless impending before operation. If the aneurism is doing well, and the gangrene is limited and unaccom- panied by much general disturbance, we may allow a line of demarcation to form. If, however, mortification is spreading, high amputation must be done, if possible at a point at which the circulation is satisfactory and there is no oedema. When gangrene is threatening from pressure of the sac or diffusion, the effect of incision and removal of some or all the contents of the sac, with ligature at the point if necessary, should be tried before amputation. Dif- fuse inflammations must be treated by fomentations and elevation. Distal Ligature, or Brasdor's Operation. — When a ligature cannot be proximally applied, as in aneurisms of the innominate and roots of carotid and subclavian, distal ligature may be done. . In some cases of aneurism of the arch of the aorta ligature of the left carotid, in others of the right caro- tid and subclavian, has been done with advantage. When ligature of the carotid and subclavian is thought desirable, it is best to tie them on separate occasions. When one of these vessels springs from the sac of an innominate or carotid aneurism, the mode of action of ligature is obvious ; but in other cases in which good has resulted this is not evident, and there is no reliable means of selecting suitable cases. A moderate inflammation round the sac, starting from the wound, may sometimes have caused clotting. Ixuisiox of the Sac or Operation of Axtyllus.—This operation may be employed after failure of proximal ligature, and in some cases of diffused or suppurating aneurism instead of amputation. In the particular case of aneurism of the axillary, the results of ligature of the subclavian being very unsatisfactory (twelve deaths in twenty-one cases, Poland), Syme revived this operation, hemorrhage being controlled by the finger of an assistant 396 INJURIES OF ARTERIES. placed upon the subclavian through an incision above the clavicle. This mode of commanding arteries is well worthy of note. The operation is the same as that described by John Bell for arterial haema- toma. It is difficult in proportion as bleeding is difficult to check, and as the sac is large and irregular. In the limbs, if Esmarch's band is used, the smaller vessels are often missed. After securing the larger, plug the sac with sponge, elevate the limb, and remove the tourniquet. After ten or fifteen minutes, the consecutive hyperaemia is over ; then lower the limb and secure the small vessels (Konig). 3. Amputation may be required at once in certain cases of failure of the ligature, of diffusion, of suppuration, and of gangrene; incision of the sac and ligature at the spot is generally the only alternative. Sir W. Fergusson recommended amputation at the shoulder after distal pressure had failed in aneurism of the subclavian, the object being to obtain not only the effect of distal ligature, but also the shrinking of all vessels con- cerned in the supply of the lower limb. 4. Manipulation.—In two cases of aneurism of the right subclavian artery, Sir W. Fergusson, instead of trying the hopeless operation of liga- ture between the tumor and the heart, or the doubtful one of ligature on the distal side, endeavored to block up the artery, by fibrin squeezed from the sac. He first emptied the sac by pressure with his thumb, then squeezed and rubbed the opposed surfaces against each other, so as to force some of the fibrin into the artery. The effect in each case was immediate and strik- ing. In the first case there was giddiness; and, after one or two repetitions of the manipulation, all circulation in the vessel and its branches below was arrested, and the tumor became smaller and firmer. Finally, after muscular exertion, it burst into the brachial plexus, and the patient died seven months after the first manipulation. In the second case (in which all pulsation had ceased in the arteries below for some months before the manipulation) there was partial hemiplegia, rendering it probable that a plug of fibrin had been carried to the brain; but the tumor became gradually less, and the man was alive and well two years afterwards. Manipulation has been little used, but may occasionally prove useful; embolism of the brain is its chief danger when used in aneurism at the root of the neck. 5. Electrolysis.—The greatest confusion appears to have prevailed in the application of electricity to the treatment of aneurism ; so that in spite of a long list of cases the best method is scarcely determined. Cells of all sizes and kinds, numerous or few, strong or weak, have been employed ; both poles have been inserted or only one pole ; and the length of the operation has varied greatly- But the great fault from a scientific point of view lies in the absence of all measurement of the strength of current actually used. This measurement is easily made by the insertion in the circuit of a galvano- meter, which is now made by Gaiffe, to indicate the strength of current in amperes and'milliamperes—the ampere being the unit of strength of current. This should always be used. When two needles are placed in fluid blood, a tolerably firm clot occurs round the positive, whilst a large soft frothy mass forms round the negative, and the weight of the clot formed is proportional to the strength of current (i. e., quantity of electricity passing in unit of time) and the duration of its flow. The soft mixture of gas and clot round the negative needle is of little value in the cure of aneurism; sometimes the sac has become tympanitic, chiefly from hydrogen liberated here. The firm clot on the positive needle is the consolidating agent; we want as much as possible of this formed. The positive needle, unless made of gold or platinum, is dissolved, but this INTRODUCTION OF FOREIGN BODIES INTO THE SAC. 397 is an advantage, especially in the case of steel needles, the iron salts causing firm clotting. De Watteville (Medical Electricity, second edition, p. 200) recommends the introduction into the sac of four to eight needles, insulated to near the points, and connected with the positive pole of a battery, whilst the negative pole is represented by a plate electrode at least 8 X 16 cm., placed anywhere on the body, a layer of modeller's clay being inserted between it and the skin to prevent burning and vesication. He would use a measured current strength of twenty to thirty milliamperes per needle, and would allow the current to flow for half an hour at the first sitting, longer at subsequent ones, which may be held once a week. Large elements are necessary to supply quantity of electricity, whilst many in series are required to give the electromotive force necessary to overcome the great external resistance of the epidermis; a battery of zinc-carbon elements in bichromate of potash (Stdhrer's) is most convenient, and twenty-four to thirty elements will be required. The non-insertion of the medical pole suggested by Bastian is generally objected to, as causing so much waste of force in overcoming ex- ternal resistance that little is left for electrolysis of blood, and little clot forms. De Watteville, however, states that a sufficient current is easily ob- tained. Most operators insert a needle attached to either pole, thus reducing the external resistance greatly, and increasing the strength of current (from a given battery) and the quantity of clot. The disadvantage is the forma- tion of loose stuff and hydrogen at the negative pole. Little pain is caused. The needles must be withdrawn by gentle rotation, the punctures closed by collodion, and ice applied. The results of each operation are usually not marked. Embolism has never occurred, though there seems ample ground to fear it. Sloughing round the needles results when these have not been properly insulated or introduced beyond their points. In a few cases cure seems to have resulted ; in others, delayed prog- ress in one direction, too often accompanied by advance in another. 6. Introduction of Foreign Bodies into the Sac.—In desperate cases of central aneurism, the sac has been punctured with a very fine canula, through which several feet of fine iron wire, silvered copper wire, watch springs which curl up as they enter, or horsebair, have been passed, in the hope that they may induce coagulation. The plan has been tried in three cases of thoracic aneurism, but all have proved fatal. C. H. Moore (Med. Chir. Trans., vol. xlviu) many years ago introduced twenty-six yards of wire into the sac of such an aneurism. The patient died of inflammation of the sac and pericarditis, and clots like those found on the wire in the sac were found swept into many arteries. Quite lately Bacelli (quoted in Brit. Med. Journ., 1885, vol. i. page 1256) similarly introduced seven 50-cm. watch springs; death from exhaustion occurred in two days, and little clot had formed. A year ago, Loreta, of Bologna, freely opened the abdomen of a man with a large aneurism of the abdominal aorta high up, intending to tie off the sac or to empty, invert, and sew it up; but as this was impossible, he passed two metres of' silvered copper wire into the sac, and touched the puncture with pure carbolic acid. The man recovered well, and the aneurism quickly became solid and shrank to the size of a walnut. Apparently cured, and in excellent health, he left the hospital in two months, but ninety-two days after the operation he suddenly died from rupture of the aorta just where the lower wall of the sac joined it. The sac was quite filled with fibrin (Brit. Med. Journ., 1885, vol. i. pages 745, 955). This is the best result yet ob- tained by the method. Sometimes six or eight fine gilt needles have been thrust close together into 398 INJURIES OF ARTERIES. an aneurism and left for one or three days; coagulation starts upon them, and spreads till the sac is full. 7. The Injection of Coagulants.—Of these ,perchloride of iron is the most important; but it should not be used unless the circulation can be con- trolled, the danger of embolism is so great. In aneurisms so situate that flow of blood through them can be arrested, some more reliable mode of treatment can probably be employed. In cases in which operation is undesirable and compression fails to induce coagulation, the needle of a Pravaz's syringe may be passed into the sac from some distance, and liq. ferri perchlor. injected, drop by drop, by a turn of its screw-piston every half minute. Compression for some hours should be continued. Under these conditions the injection of Schmidt's " blood-ferment" has been unsuccessfully tried. 8. The injection of ergotin in the tissues over the sac was recom- mended by v. Langenbeck, on the supposition that it would cause contraction of the sac ; but in an aneurism of any size the fibroid condition of the media precludes such a hope. Bonjean's fluid extract, in one-half to three grain doses, was used. If the injections act at all, it is probably by exciting moderate inflammation round the sac. 9. Ice constantly applied to the surface of an aneurism is recommended by J. Hutchinson in combination with absolute rest and large doses of pot. iod., plumb, acetate, and ergot; sloughing must be guarded against. The methods five to nine, inclusive, are very uncertain, and are generally used faute de mieux; sometimes they form adjuvants to better plans. In cases of multiple aneurism, or of two aneurisms—one central, one peripheral— no cutting operation should be done for the peripheral, if it can be avoided. But when there are two popliteal aneurisms, as is not uncommon, or a femoral and popliteal on the same side, the usual treatment may be followed. N;evus, Angeioma, or Vascular Tumor. There are two varieties—capillary and cavernous (see page 136, where their nature, clinical signs, and seats are given). Naevi are so commonly noticed at birth, or shortly after, that some regard them as invariably congenital; it must be admitted, however, that some of these growths, usually deep, are first noticed later, and even in adult life. They often affect, more than one child of a family. Their causes are un- known ; they are sometimes attributed to maternal impressions. Cutaneous and subcutaneous naevi may occur at any point of the surface, are most common upon the head and face, then upon the trunk, least so on the lower limbs. It is with these that we almost always have to deal; but naevi of the lips, gums, tongue, and rectum occur, and may be very trouble- some, or even fatal, from hemorrhage. Naevi of internal organs cause no symptoms. Diagnosis.—A mother's mark cannot be mistaken for anything else; and often the skin is purple from dilated small vessels over subcutaneous growths, or its translucency allows a bluish color to show through. A fatty tumor is almost the only growth a subcutaneous naevus could be taken for; but congenital lipomata are rare, not spongy and compressible, and do not swell when the child strains or cries. Naevus and lipoma may be combined—nevo- lipoma. When discovered after the first years of life, the diagnosis is often doubtful if the skin over them is opaque and normal. Naevi of mucous membranes are usually characterized by their purple or scarlet, obviously vascular, aspect. In the rectum this may not be very MODES OF TREATING NJEVUS. 399 evident, when viewed through the speculum ; the chief diagnostic point here is occasional hemorrhage, commencing in early childhood. Course.—Mother's marks (chiefly port wine stains) may be widespread at birth, and remain stationary, or, starting as slightly raised scarlet points, may Bpread rapidly or slowly ; often they heal centrally, whilst spreading periph- erally, a white scar tissue replacing that of the naevus; many are thus ultimately cured. Subcutaneous naevi do not usually spread far or fast, but they do sometimes grow rapidly, attain a large size, and recur again and again after removal; they often involve the skin over them, but not the deeper parts. These growths may also undergo a fibroid change, or cysts may develop in them by obstruction or dilatation of veins; rarely, when irritated, they inflame, ulcerate, and bleed. Naturally, the latter complica- tion arises most easily on mucous surfaces. Treatment.—When a superficial nevus shows central scar-tissue and shrinking, it may usually be left to itself, or treated by the constant pressure of an ivory or sheet-lead pad and elastic band, or of contractile collodion. Freezing by ice will sometimes check the growth of a capillary naevus. Vaccination, by punctures all over the surface to produce a confluent vesicle, is rarely successful in obliterating the vessels. The most generally useful treatment is that by caustics. Nitric acid is usually chosen, but its action is very superficial; to apply it, oil the skin around, almost to the naevus, and then rub on the acid with a pointed glass rod or a match-stick. Ethylate of sodium is preferable, and should be well rubbed in with a pointed match; it softens the epidermis rapidly, and the surface becomes red-black, as the fluid causes coagulation in the vessels. When the scab separates, in either case, the granulation tissue may be abnormally purple at some points, neces- sitating a fresh application. A small caidery may be used. For diffuse port wine stains, scarification (B. Squire) with closely set knives may do some good, by substituting superficial scar-tissue of white color for the dilated vessels. The same result may be attained by inserting superficially in the skin a num- ber of fine needles, and connecting them alternately with either pole (De Watteville); no contraction results. Subcutaneous nevi may be treated in many ways; but if stationary, and not disfiguring or discomforting, treatment will be unnecessary. Seton.—Silk threads, simple or steeped in liq. ferri perchlor., are dragged, by a proportionately small needle, in various directions through the growth; they are withdrawn when suppuration has set in, and fresh ones inserted as may be necessary. A good deal of scarring results, but general symptoms are usually slight. Injection.—Many irritant and coagulant fluids are introduced by a hy- podermic syringe into subcutaneous nsevi, but the plan is dangerous, unless circulation through the growths can be completely controlled, for pulmonary embolism has proved fatal. Therefore, before injecting, pass stout harelip pins crosswise beneath the growth, and tie a silk ligature tightly beneath these. Two or three drops should now be distributed in the tumor by screw- ing down the piston. The chief fluids used are—neutral liq. ferri perchlor., pure carbolic acid, solution of tannin (3J ad gj), tr. iodi (Coates). If much fluid is injected, sloughing will occur. After ten or fifteen minutes remove the pins and ligature. Ignipuncture, with Paquelin's or other pointed cautery, is often useful where scarring is not of much moment. As many punctures as possible should be made from one centre; sloughing occurs round the punctures, and the resulting scar is larger than one expects. Electrolysis, in moderately skilful hands, is the best method for obliter- ating naevi of the face and other places where a scar disfigures; if the skin 400 INJURIES OF ARTERIES. is involved, a scar must result in the process of cure, but it is said that gal- vanic cicatrices do not contract. In small naevi, either introduce only the negative pole, closing the circuit with a plate electrode on the surface, or pass a needle from each pole into the mass. In large growths, several needles should be inserted and con- nected with opposite poles alternately; needles of opposite polarity must not touch. It is best to begin with a few cells, say five or six Leclanche elements, and watch the effect with the finger, the object being to solidify the tumor, but to stop short of causing sloughing. As the number of needles and size of the growth increase, add to the cells; fifteen of Stohrer's battery are usually enough even for large masses (De Watteville). Subcutaneous discission, with a fine knife or cataract needle, followed by pressure, and repeated if necessary, is successful in some cases. Extirpation.—This is often the best treatment, when flaps to cover any loss of skin can be made, for the wound heals readily, and the scar is narrow and regular. Bleeding should be controlled by the needles and ligature, as above, the skin reflected—any involved being sacrificed—and the growth dissected out right down to the pins; care must be taken to go wide of the diseased tissue, as it is from this alone that bleeding is to be feared. Remove the needles and ligature; probably no bleeding follows; bring the cut to- gether, and dress antiseptically, with uniform pressure. Healing by first intention is usual. Ligature. — This was formerly much employed in the treatment of cav- ernous nsevi, to avoid bleeding—subcutaneous when the skin was healthy, but when it was involved, the ligatures were caused to lie in suitable cuts in the skin, or beneath reflected flaps. Waxed silk or hemp was passed with a slightly curved Liston's needle (Fig. 43) beneath and round the growth, drawn as tight as possible, and tied in a bow, so that as the noose cut through and became loose, it might again be tightened. The necessity for this tight- ening is an objection which might be obviated by using strong elastic; but no method which kept a considerable septic slough in contact with living tissues, especially without free drainage, as in the subcutaneous method, can be regarded as good. In the latter treatment, not uncommonly, either the skin sloughs or the naevus is nourished through it and continues to grow. It is always difficult to in- clude enough tissue in the ligature to destroy the naevus and to avoid healthy parts. The surgeon's ingenuity will suggest how best to pass the threads, but the following methods may be mentioned: To tie a small round naevus subcutaneously, the simplest plan is to pass an unarmed needle under the skin half-way round the tumor, and then through the skin; now thread and withdraw it, leaving an end of ligature at each hole. Next pass the unarmed needle from hole to hole, on the opposite side of the growth, thread it with the end left at the hole of exit, and withdraw. The thread now includes the whole mass, and must be tightly tied. \ In larger growths, which most surgeons tie in two portions, after passing a double ligature through beneath its centre, John Wood uses the ingenious knot shown in Fig. 155. The loop beneath the mass is first passed, then the ligature ends are caused to include opposite Fig. 155. Wood's subcutaneous ligature for nievus. HAEMOPHILIA OR HEMORRHAGIC DIATHESIS. 401 halves of the growth—as in the first method—and before knotting they are passed through the projecting loop, one from before back, the other from behind forward. If successful, pus and sloughs escape by the punctures along the threads, the naevus shrinks, and only two small spots of scar remain. Strangulation of a naevus and involved skin over it may be effected by the following among other knots: Fig. 156, due to Sir W. Fergusson, is performed by passing a double thread beneath the growth, and dividing the loop left at the hole of exit. Thread the needle with one of these ends and pass it under the growth at right angles to the double thread. The needle is now unthreaded and the other divided end put in the eye, that it may be withdrawn with the needle. Suitable grooves are now cut in the skin, and the threads drawn tight and knotted. John Wood accomplishes entire strangulation of skin and tumor by a single thread, in the manner shown in Fig. 157. One loop is first carried Fig. 156. Fergusson's ligature for naevus, including Wood's ligature for naevi, including skin. skin. beneath the mass, and then the other, and in withdrawing the needle from the second it must travel along the free end. In four or five days the strangulated parts are sloughy, and if not sepa- rated the ligature must be tightened. As the wound granulates, watch for any recurrence (marked by redness deeper than that of granulations), and destroy it by nitric acid or ethylate of sodium (p. 383). Haemophilia or Hemorrhagic Diathesis. This rare condition is characterized by an abnormal tendency to bleed from small vessels and capillaries; the slightest scratch oozes for hours or days, and extraction of a tooth has frequently caused death. Etiology.—The bleedings may be spontaneous, from the mucosse of the nose, lung, bowel, kidney, or uterus, into the connective tissue of the skin and other parts, or into the cavities of joints; or they may be traumatic, oc- curring from even the slightest breech of surface or in response to slight contusions. The morbid state is always congenital and very often heredit- ary through several generations; and here the curious fact appears that, although men are much more commonly (11 to 1, Legg) and more severely affected by haemophilia than are women, they usually do not hand down the 26 Fig. 157. 402 INJURIES OF ARTERIES. tendency to bleed to their children ; but the women of " bleeder " families, though as a rule they do not themselves exhibit the diathesis, almost always hand it down to the male children they bear to healthy men, and their female children may in turn do the same. The women of these families are said to be very fertile. It has been said that many bleeders have been re- markable for the delicacy of their skin and plainness of the subcutaneous vessels; but there is really nothing in the naked-eye appearance of a bleeder to distinguish him. Pathology.—Nothing abnormal has been proved to exist, either in the blood or vessels, but it is probable that the latter are at fault. The tissues in bad cases seem to inflame and slough with abnormal readiness. Post-mortem, recent hemorrhages and traces of former hemorrhages into connective tissue or joints, are the only positive signs. Symptoms.—There is not usually any hemorrhage connected with the separation of the umbilical cord, but often bleedings occur during the first year of life from vaccination, lancing of gums, etc. Sometimes none occurs until the period of second dentition ; cases said to begin later than this are held by Legg to be untrustworthy. It has been noticed at University Col- lege Hospital, where several bleeders attend, that pathological breaches of surface—e. g., phthisical cavities, typhoid ulcers, and ulcers formed by sepa- ration of sloughs—are not nearly so liable to bleed as wounds and con- tusions. Spontaneous hemorrhages, especially from the nose, are sometimes pre- ceded by sense of fulness of the head and malaise. Subcutaneous hemor- rhages may be mere ecchymoses, diffuse bloody infiltrations, or circumscribed haematomata; they are most frequent in the popliteal space, inside the thigh and over the lower ribs. At first they are accompanied by a little fever. Lastly, the larger joints, especially the knee, are liable suddenly to swell and become hot and painful, with more or less fever; this is believed to be due to hemorrhage into the joint, and may occur spontaneously or after an injury. This state may last a long time, recovery being interrupted by fre- quent relapses; and fresh attacks are always liable to occur. Fifty per cent, of bleeders die before the age of eight, and more than eighty-five per cent, before twenty-one (Grandidier). Treatment.—There is no treatment of the diathesis known; it is sometimes said to become less marked with age. The acute or chronic anaemia result- ing from hemorrhage must be treated as directed at p. 365. As to the treatment of hemorrhages: interstitial hemorrhages will require absolute rest and the application of cold to the part. Epistaxis must be met by ordinary means. In hemorrhages from mucous surfaces which cannot be directly acted on, reliance must be placed upon styptics, of which acetate of lead and opium, gallic acid and turpentine in small doses, seem the most hopeful. Ergotin has not proved of service. Hemorrhage of wounds has been treated by all the recognized methods— even by that of inflicting another wound to tie a main artery at a distance! Experience at University College (Erichsen) has shown that the most satis- factory method, when it can be adopted, is constant iced irrigation, coupled with rest and elevation of the part. Perhaps, if a wound were seen early, and rendered aseptic, a permanent antiseptic dressing might successfully be made the means of applying constant pressure; but under septic conditions, inflammation, sloughing, and fresh hemorrhage in removing the dressings are frequent. Styptics produce much the same results; the cautery is better, but the separation of septic sloughs is a source of danger. In the special case of bleeding from the socket of a tooth, this should be carefully wiped out, plugged from the bottom with a fine strip of lint, and pressure just suffi- INJURIES AND DISEASES OF THE VEINS. 403 cient to check the bleeding made upon the plug by the teeth of the other jaw and a piece of gutta-percha moulded to them. The jaws must be fixed together by a four-tail bandage. It is a rule never to perform any operation that can be avoided on such patients; extract no teeth, open no abscesses. When operations cannot be avoided, endeavor to use Paquelin's cautery or the elastic ligature. The swollen joints will require absolute rest and cold at first; then moist warmth to aid absorption ; finally a Martin's bandage may be worn. Rest must be prolonged and great care exercised in beginning to use the joint again. CHAPTER XXX. INJUEIES AND DISEASES OF THE VEINS. Wounds of Veins. Signs.—Venous hemorrhage is recognized by the dark color of the escap- ing blood, and by the steady, slightly forcible character of the stream. The blood " wells up," as it is said ; sometimes it escapes in a steady curling jet an inch or less high, and when an obstruction to flow is placed above the wound—like the fillet in venesection—the blood may be projected two or three inches. It usually comes from the lower or distal end only. As a rule it is not dangerous, but may be so when coming from a large trunk, or from a varicose vein in which all valves are incompetent and blood consequently escapes, not only from the distal end, but also from the proxi- mal—from the right auricle—with force proportionate to the vertical height of the auricle above the wound. Treatment.—Elevation or light local pressure and the removal of any obstruction at once stop venous bleeding—facts which should be known to everyone with varicose veins; a firm bandage over the dressing is usually all that is necessary. If a vein is seen bleeding in a wound, tie it like an artery with catgut or silk. When a large vein, like the axillary, is punctured dur- ing an operation, the vein around the opening may be picked up and tied; but if it is widely opened, the vein should be tied above and below the wound just like an artery. It may be difficult or impossible to do this, and we must then rely on forcipressure—leaving the clip on for several hours; or plugging or unremitting digital pressure on the point must be employed. The latter practice was resorted to " in tbe case of his Excellency William, Prince of Orange, who, in his hurt by the Spanish boy, as my Lord Bacon relates, when the internal jugular was opened, could find no way to stop the flux of blood, till the orifice of the w7ound was hard compressed by men's thumbs, succeeding for their ease one after the other, for the space of forty-eight hours, when it was hereby stanched." (Turner's Art of Surgery, vol. i. p. Gangrene does not result from obstruction of a main vein by ligature if the arterial circulation is unimpaired, the intercommunication of veins being so free; but, frequently, compensation is imperfect and cyanosis, oedema, and chronic thickening of connective tissue occur. Ligature or wound and sub- 404 INJURIES AND DISEASES OF THE VEINS. sequent thrombosis of the main vein at the same time that the main artery is tied, is a most serious complication, almost if not quite certain to lead to gangrene in the lower limb. Air in Veins.—The entrance of large quantities of air into a vein is a most dangerous accident, that has sometimes occurred during the extirpation of tumors from the neck or axilla, where the effect of inspiration upon the blood in the veins is most marked. With a deep inspiration the great veins of these regions may become empty and collapsed, and such inspirations were common, after prolonged holding of the breath, during operations in the days before chloroform. Further, the jugular, subclavian, and axillary veins are closely related to the dense fascise of the part, and cannot collapse when the fascise are rendered tense and drawn away from the sublying vein. If wounded when thus canalized or held open, a sort of bubbling, sucking noise is suddenly heard, the patient instantly faints, and generally dies soon after- ward. On examination, the right side of the heart is found distended with frothy blood, which cannot be pumped through the lungs in any quantity; and it is this which kills, not the blocking of fine pulmonary vessels by air- emboli. When possible, veins in this region should be tied before division; and an inadvertent wound, followed by the above-mentioned noise and symp- toms, must be instantly compressed. The patient, if faint, should be kept recumbent with the head low, and well plied with brandy. Artificial respi- ration should be kept up, in the hope that it may aid the pulmonary circu- lation and bring more blood to the heart. The air has no noxious properties in itself, and if introduced slowly does no harm. Thrombosis. As "thrombi" (intra-vitam clots) are much commoner in veins than else- where, and as these clots are the most frequent source of emboli, thrombosis and embolism are most conveniently mentioned in this place. Conditions Leading to Thrombosis.—Our knowledge of these is very imperfect. The most important point known is—that so long as blood, mov- ing or stationary, is in contact with healthy living vessel-wall, it does not coagulate; and experiment and observation have shown that it is upon in- tegrity of the endothelium that its fluidity depends. Injure the endothelium, push bodies bare of endothelium (wire, horsehair) into the blood, or draw it into a basin, and coagulation will commence. Naturally, prolonged contact with an abnormal surface is favorable to coagulation, so we get a second common factor in the process—rest. But rest is not essential; abnormal endothelium probably is. If we add that the blood in some states of body, pathological and physiological, tends more strongly to coagulate than in others, and that the existence of such a state will predispose to thrombosis, we have probably stated all that is known upon the subject. It seems probable, however, that cases of spontaneous thrombosis accom- panied by symptoms of phlebitis (see acute phlebitis), as also those occurring in pyaemia at a distance from any wound (p. 161), are in some way connected with the action of organisms. Abnormality of endothelium may be produced in many ways; by injury of any kind acting from without, as seen in the various methods of checking hemorrhage, and in contusion (p. 351) ; by pressure of new growths, aneu- risms, etc.; by extension of some septic or infective inflammation to the wall; by primary diseases of the vessel-wall, mostly of an inflammatory nature—e. g., arterio-sclerosis, atheroma, and corresponding processes in veins—which lead to tortuosity and dilatation, or to marked narrowing of the vessel, as well as to an irregular abnormal surface. Primary disease is much more often a THROMBOSIS OF VEINS. 405 cause of thrombosis in arteries than in veins. Foreign bodies, bare of endo- thelium, may enter vessels—e. g., clots, tumors, parasites, calcareous plates; and wire, horsehair, etc., may be purposely introduced (p. 397). Stagnation of the blood, or a tendency to it, may be due to local causes, as ligature or other pressure, or dilatation of the vessel by aneurism, varix, or gravity; or to cardiac weakness, low vascular tone, and prolonged recum- bency, which act generally. Now, slow circulation means imperfect nourish- ment of the tissues, and, among them, of the endothelium ; so stagnation of blood must be regarded as acting partly by causing abnormality of endo- thelium. The above causes frequently act together. Seats of Thrombosis.—Thrombi are uncommon in the heart, but occur upon inflamed foci and in parts which in marasmic states do not empty themselves completely. In the arteries the speed of the circulation is greatly opposed to clotting, as is seen in aneurism, in which the effect of stopping or impeding the flow is also shown ; but extensive thrombi do form, and not rarely, upon abnormal arterial surfaces. In the capillaries clotting probably does not occur during life ; they consist of endothelium only, and are most likely dead if they cannot inhibit clotting. The veins with their feeble cir- culation are the seat of spontaneous thrombosis, and in them clots most easily extend. Varieties of Thrombi.—Two kinds of clot—the red, uniform, and the pale, laminated—are found in vessels, according as the blood which coagu- lates is still or moving: the former we have met in the " internal coagulum " (p. 352) between a wound and the first collateral, and in the " rapid cure " of aneurism ; the latter, in the ordinary cure of aneurism. If a small crystal of salt is placed near a vein in a frog's foot beneath a microscope, a pale clot will form beneath the eye (Zahn) as the irritant causes change of the venous endothelium, either on one side or all round according to the situation and size of the crystal; it is due to the successive adhesion of white corpuscles and deposit of fibrin upon the injured surface, and may be partial or totally obstructing. Once formed, a clot tends to grow, for it acts like a foreign body to blood. In certain cases in which the opposing influences are weak, thrombi spread rapidly from vessel to vessel (usually veins) and reach a great length—continued thrombi; they extend chiefly in a central direction, and are checked most often by the quicker circulation in some larger vessel, into the lumen of which their upper end may project. There is then much danger that it will be broken off and become an embolus. Fate of Thrombi.—1. Resolution. This in recent red clot occurs easily, as we have seen in cure of aneurism by Esmarch's bandage; what becomes of the constituents of the clot is unknown; no symptoms accompany its disappearance. 2. Organization is a frequent result, described at p. 353. The vessels of the new connective tissue may, especially in veins, become so largely dilated as to form a free communication between the upper and lower part, more or less completely compensating for the obstruction. Thus is ex- plained the improvement or recovery after months from the cedematous swelling known as white leg (phlegmasia dolens). 3. Softening of two kinds —simple and infective—occurs. In each the clot breaks down centrally into & puriform fluid, consisting almost entirely of granular debris: in the latter case some of the granules stain deeply with aniline colors and are micro- cocci ; in the former no organisms are present. As the softening approaches the ends of the thrombus, progressive clotting occurs, but ultimately this may tail, or some force bursts the partition and the contents of the central cavity escape into the circulation. In a simple case no harm comes: the clot is canalized if both ends open, and circulation goes on through it. In an in- 406 INJURIES AND DISEASES OF.THE VEINS. fective case the entry of portions of clot and organism into the circulation will be accompanied by symptoms of pyaemia (p. 161). More frequently an abscess forms round the vein, the softened focus bursts into it, and both are discharged externally. Almost always a clot undergoing puriform softening has its peripheral end upon a septic wound or infective inflammation—e. g., acute necrosis; rarely this is not the case, but a septic wound is present at a distance; very rarely no wound by which cocci might have entered is dis- coverable. Calcification is rare, except in the prostatic plexus, in which concretions, often very numerous, are usually present after twenty. Such masses are Fig. 158. Phleboliths in veins of neck. called phleboliths. Fig. 158 represents an extraordinary case of phleboliths, in which Sir W. Fergusson removed the concretions with a knife. Changes in Thrombosed Vessels.—A thrombus usually excites more or less inflammation, which results in the adhesion of the wall to them and their organization. Sometimes, especially in arteries, a clot above a ligature will remain non-adherent for many months. When infective softening occurs, acute phlebitis or arteritis is excited, and it may be suppurative. Thrombosis of Veins.—The feeble circulation in veins and their thin and flaccid walls render them more liable than other vessels to thrombosis from injury (p. 236), pressure, extension of inflammation from surrounding parts; stagnation of blood occurs in them and new growths penetrate them most easily. Clots forming in states of exhaustion, and apparently in great measure due to feebleness of circulation, are called marasmic; in phthisis and malignant disease they are common complications, and form usually in the most dependent veins—profunda and internal iliac—whence they extend to the femoral and common iliac; they occur also in the heart and cerebral sinuses. Signs.—These are: 1. Evidence of obstruction to the venous circulation in the shape of cyanosis or more or less sudden oedema, varying in amount with the magnitude of the veins affected and the freedom of their anasto- moses ; it is best seen in white leg after labor due to thrombosis of the common embolism and the nature of emboli. 407 iliac vein, probably starting in a vein from the uterus. The swelling may be so tense that it does not " pit;" and if it continue long, thickening of the con- nective tissue is sure to occur. 2. The discovery of a cord-like hardening of the vein where superficial. 3. Signs of more or less phlebitis and periphle- bitis, varying in intensity with the infective or non-infective nature of the clot. Treatment.—Perfect rest must be insisted upon until the thrombus has resolved, or until it is probable that it is securely fixed to the vessel-wall, and manipulation of it should be avoided, lest a portion be detached and embo- lism occur. Phlebitis, if present, must be treated as recommended at p. 409. In certain cases of infective softening of clots in limb-veins, especially such as start from infective osteomyelitis, amputation after symptoms of pyaemia have manifested themselves seems to have sometimes saved life. Persistent oedema must be treated by douching, friction, and massage, and the constant application of a Martin's rubber bandage as tight as can be borne. Embolism. Embolism means the impaction in a vessel of some solid particle or frag- ment which has gained access to the blood. The solid particles are emboli, and they vary much in nature, size, and source. Usually they are furnished by thrombi in veins: either large clots, perhaps several inches long, are mechanically loosened, or fragments are swept off from parietal thrombi or the ends of clots projecting from collateral into main veins, or clots undergo simple or infective softening and break down. Thrombi on inflamed cardiac valves are common sources of emboli; those in aneurisms and on calcareous plates in arteries much less frequent. Cells of malignant growths (p. 127) often form emboli, and much commoner still are the vegetable parasites; rarely animal parasites enter the circulation ; fragments of calcareous plates in arteries, minute drops of fat from fractures (p. 236) and contusions, air, which has entered veins, and other substances, may similarly become impacted in vessels. An embolus is stopped by the first vessel which is too small to allow it to pass; if from the systemic veins it is usually in the pulmonary arteries or their capillaries; if from the radicles of the portal system, in the artery-like ramifications of the portal vein in the liver; and if from the left heart or systemic arteries, in the finer branches of these arteries or their capillaries. Commonly the impaction takes place where some sudden narrowing of the vessel occurs owing to the giving off of a branch (p. 382). If the arrested particle is hard and irregular and does not block the channel, thrombosis occurs round it until occlusion is complete. The local effects of embolism are: (1) obstruction of the circulation through the occluded vessel; (2) more or less irritation according as the embolus is infective or non-infective. For the results of obstruction of arteries of different sizes, with and without anastomosing branches, see p. 42. If the embolus is non-infective and admits of absorption, this may rarely be its fate; more commonly it will be organized; but, though simple, it may so injure an artery as to give rise to an aneurism. When infective (e. g., in malignant endocar- ditis) acute arteritis and dilatation are more likely to occur; and suppurative arteritis and periarteritis are common (p. 161). The general effects of embolism vary with the functions of the part supplied by the blocked artery; thus apoplexy and death may result from embolism of a large cerebral artery. The results of pulmonary embolism are given at p. 235; and those of embolism of a systemic artery at pp. 87 and 382. 408 injuries and diseases of the veins. Inflammation of Veins : Phlebitis. Causes.—By far the most frequent is thrombosis. The presence of a thrombus in a vein probably always excites inflammation of the vessel-wall— more or less intense according as the clot is more or less irritant (p. 406). The causes of thrombosis therefore come to be causes of phlebitis, and among them none is so common as injury. The commonest form of phlebitis is the traumatic. In this a vein is cut across or otherwise injured, it collapses, and a clot forms in it up to the next pair of valves. If the wound become septic, either through the open end of the vessel or through its wall if it have been tied, the thrombus (septic traumatic) is invaded by infective organisms, probably carried by migrating leucocytes, becomes more or less markedly irritant, often undergoes infective puriform softening, and tends to spread (p. 406), induc- ing symptoms of acute spreading phlebitis, to which may be added at any moment those of acute embolic pyaemia from the entry into the circulation of portions of the infective clot (p. 161). As an irritant clot spreads, or when one forms at a distance from a wound, the walls of the containing vein always become swollen, soft, and grayish or yellowish, from inflammatory infiltration, and often dotted with fine hemorrhages; and the connective tissue round the vessel suffers similarly, and more or less severely—at times being only hyperaemic and infiltrated, at others suppurating diffusely or at certain spots, giving rise to abscesses in which the vein lies bare or into which it opens. In subcutaneous and aseptic wounds of veins a little inflammation of the vein-walls is induced for repair, but is quite localized ; and the thrombosis, though sometimes continued, often fails even to obstruct the vessel. In non-traumatic cases, phlebitis may arise by extension from surrounding parts, the seats of infective inflammation. The adventitia is first affected, and the morbid infiltration with its cause spreads inwards until the intima is reached and sufficiently altered to induce clotting upon it; the clot then becomes infected and irritant, and thus exactly the same results—up to peri- phlebitic suppuration and infective puriform softening of the clot—may be produced by infection from without as by infection from within. An excel- lent example of this is found in the not uncommon thrombosis of the petrosal and lateral sinuses, and often of other veins communicating with these, which arises in suppurative otitis media and ends in infective softening of the clot and pyaemia or meningitis from infection of surrounding parts. Again, in acute infective osteomyelitis ending in pyaemia, veins containing puriform clots are found leading from the unopened abscess (p. 281). But a suppura- tive inflammation is not necessary to induce thrombo-phlebitis, which occurs, rarely, it is true, in veins leading from catarrhal mucous membranes—e.g., of the bladder in cystitis; the thrombosis may be continued to the iliac veins, and may prove infective when the cystitis is putrid. At first sight it seems strange that thrombosis of considerable vessels, especially veins, is not more common in acute inflammation. But an expla- nation is probably to be found in the facts that the intima must be altered to induce thrombosis by infection from without; that this coat is nourished from the lumen of the vessel itself, and that the vasa vasorum normally penetrate only the adventitia—an arrangement rendering the two inner coats little prone to inflame. The adventitia alone is often affected. In a number of cases no cause is discoverable: there has been no injury, no previous inflammation. Such cases are styled idiopathic, and occur mostly in varicose saphena veins. Occasionally in these cases the irritant in the clot, whatever its nature may be, is sufficient to induce softening of the clot and suppuration around the vein, perhaps at several spots. In other much rarer varicose veins. 409 instances, death with symptoms of acute septicsemia may occur, although no wouud and no puriform softening of the clot is found. In these cases an 'irritant thrombosis is probably the primary event, but we are in the dark as to its etiology. Sir J. Paget has noticed that recurrent phlebitis, usually of the internal saphenous, is apt to occur in gouty people. Symptoms.—When the affected veins are superficial, as they usually are in the idiopathic variety, a firm, tender cord, obviously a thrombosed vein, is felt, and over it the skin is swollen and reddened in a broad, ill-defined band. The affected vein is frequently varicose, and its tortuosity is very evident. There may be much spontaneous pain, or only a dull aching, increased by movement. Abscess is recognized by increasing localized red- ness, oedema and tenderness of skin, and progressive softening; but clots in varicose dilatations fluctuate most perfectly. The general symptoms are usually slight, but may be of very severe septic type, and even fatal. When a deep vein is affected, as is usual in septic cases and may be in idiopathic, with the exception of perhaps some tenderness and pain along its course, the local signs of inflammation are wanting. The diagnosis will rest upon the occurrence of oedema in the area drained by the thrombosed trunk. When this is small, nothing is usually known of it until, in septic wounds, its presence is inferred from the occurrence of symptoms of embolic pysemia, or, in simple cases, from the phenomena of embolism. The results of simple thrombo-phlebitis may be quick disappearance of all symptoms, or obliteration of the vein and chronic thickening around it; oedema, permanent or lasting many months, and disappearing as vessels open up through the organized clot; and simple embolism is its great danger. In the case of septic and infective phlebitis, the formation and opening of a periphlebitic abscess must be regarded as favorable; septicsemia and infect- ive embolism are the dangers. Treatment.—The first point is by absolute rest and avoidance of all manipulation to reduce the chance of displacement of the clot and embolism to a minimum. A case of phlebitis should not be allowed to walk at all if it can possibly be avoided. With regard to the inflammation, belladonna and glycerine freely applied, and assiduous fomentation are the best remedies. If one or more abscesses form, they should be opened aseptically. The only satisfactory treatment of septic phlebitis is prophylactic, by antiseptics ; once the disease has started, it is impossible to apply antiseptics to its seat. Rarely, after signs of septic embolism have occurred, life seems to be saved by amputation well above the wound or focus of inflammation : and similar treatment may be proper in idiopathic and septic traumatic osteomyelitis. Persistent oedema must be treated as directed at p. 407, after all danger of shifting of the clot is over; if very marked, the prognosis as to complete recovery is not good. Varicose Veins. Causes.—(1) Heightened intravenous pressure, due (a) to obstruction to the return of blood to the right auricle by pressure on veins, thrombosis, or obstructive lung or heart disease; (b) to gravity. This does not affect the driving force of the circulation in any way, but it increases the pressure upon the vein-wall in proportion to the height of the column of blood count- ing from the top of the head. In the lower limb gravity is a very important moment, for it dilates the veins, and if allowed to act continuously renders the dilatation permanent, (c) To the forcing of too large a quantity of 410 INJURIES AND DISEASES OF THE VEINS. blood into veins, as when in severe, sustained muscular effort the blood in the deep veins is squeezed into the saphenae faster than these trunks can empty themselves (Gay). Varicose aneurism and aneurismal varix afford other examples. (2) Impaired strength of wall due (a) to periphlebitis, (b) to fatigue of muscle and nerve in general from overwork, heat, etc.; (c) to congenital deficiency; for, though varicose veins are not congenital, the tendency to them is distinctly hereditary. Some inherent defect seems to be the only possible explanation of cases which occur often without any obvious obstruction in apparently healthy young people, (d) To lack of support. Several causes often act together. The disease is fairly common after fifteen or sixteen, and becomes still commoner up to middle life, then the tendency to it declines. As would be expected, it is commoner in tall than in short people, in the weak and seden- tary than in the strong and active, and especially in those (laundresses, shop assistants) who have much standing, as opposed to walking, to do. In women, the pressure of the pregnant uterus on the iliac veins is a frequent cause. Seats.—Chiefly the legs (especially internal saphena), the spermatic cords (varicocele), labia majora, and the rectum (piles); but pressure will produce varix anywhere. Probably the explanations given of the greater frequency with which the left spermatic and internal saphenous veins are affected, viz., the opening at right angles into the renal of the former, the pressure of a loaded rectum in the latter, are insufficient. Morbid Anatomy.—As a result of the above causes, veins dilate, and at first the dilatation is easily recovered from, if the causes are removed ; but if they continue or are often repeated, the dilatation becomes permanent, and the vein-wall thickens by development of fibroid tissue in the media. The vein not only widens but also lengthens and bends upon itself, assuming a tortuous or serpentine form. Dilatation is most marked upon the convex- ities of bends, immediately above valves, and where subcutaneous join deep veins—i. e., in the popliteal space and groin. At such spots dilatation often exceeds hypertrophy, and large thin-walled cavities, covered by atrophied skin, occur. They may rupture, or the septa between contiguous sacs or bends may be perforated, when a multilocular cavity results. If a number of contiguous veins are affected and this intercommunication is carried to any great extent, an ill-defined spongy swelling, consisting of a kind of cavernous tissue, is produced. As dilatation proceeds, the valves become incompetent, and the assist- ance which muscular contraction gives to the venous circulation is then an- nulled. All the veins of the lower limb are never equally varicose; the superficial veins suffer earlier than the deep, being less supported ; sometimes the in- ternal, sometimes the external saphenous vein is chiefly affected; now the main trunk is the prominent object, now its branches; in some cases one or two masses of cavernous structure, coarse or fine, are alone present. Transudation of fluid and escape of corpuscles is increased, sometimes so much as to cause some oedema of the foot and leg: and commonly more or less chronic thickening of connective tissue results, so that when a vein is empty, the finger detects a hard-edged groove. Symptoms.—Often with very marked varix of leg veins there are no symptoms; sometimes there is sense of weight, aching, and slight oedema, especially after standing or much exercise; but quite a small patch of small dilated veins may be the source of much pain and tenderness. In special parts, special symptoms arise, and naturally, piles more often than vari- cocele give rise to inconvenience. In the upright position dilated veins are treatment of varix. 411 seen and felt as tense, compressible, rounded, tortuous cords, often irregular from the presence of sac-like pouches, over wbich the skin may be quite thin and bluish. The grooves felt when the limb is raised are characteristic. Spongy masses caused by twists or by dilatation of neighboring vessels and their inter-communication are common; also purplish swellings in the skin in which small vessels are numerous. Complications are chiefly the effects of stasis and malnutrition. Pig- mentation of legs from escape of red corpuscles is common. The tissues are more or less edematous and thickened, their resistance is much lowered, and obstinate catarrh of mucous membranes or eczema of skin is excited by slight injuries; ulcers form easily, are difficult to cure, and tend to recur after healing (p. 72); varicose veins are the usual seat of thrombosis often accom- panied by phlebitis, perhaps ending in abscess (p. 409); calcification of thrombi may lead to phleboliths (p. 406) ; lastly, a thin spot may burst and give rise to the most profuse hemorrhage, as there may be no valves between the aperture and the heart. Treatment may be palliative or radical. The first point is to remove any cause, any constricting band, compressing tumor, or dropsical effusion, con- stipation and overloaded bowels, excessive use of a part, prolonged standing, lack of exercise, and general or cardiac feebleness; with regard to catarrh or eczema, it should be cured as soon as possible, for it injures the vessel- walls and keeps the veins abnormally full. When upright, the patient should have the dilated veins supported by an elastic stocking or a well- applied Martin's rubber-bandage, or the effect of gravity may be lessened in varicocele by wearing a suspensory bandage and shortening the column of blood. When lying, it is an excellent plan, if the legs are affected, to have the foot of the bed decidedly raised. Friction with a flesh-brush in the course of the blood is strongly recommended by Mr. Vincent, and a cold douche night and morning is certainly beneficial. Under such treatment early stages of varix may subside; mere removal of the cause is often sufficient, as is seen in women after labor. In other cases the above measures will keep patients quite comfortable. Fig. 159. Twisted sutures applied for varicose veins. But if the patient suffers much from weight or pain in the part, or from obstinate or frequently recurrent eczema or ulceration, or is in danger of hemorrhage from rupture of a sac, radical measures must be resorted to. There are many methods of operating. Varicose trunks are best treated by H. Lee's operation. The surgeon pinches up the vein between his finger and thumb and passes needles behind it at selected points; on the skin along the vein bits of bougie or drainage tube are laid opposite the pins, and figure- of-8 sutures are made over them round the ends of the pins, the points of which are cut off. The pins are inserted in pairs about three-quarters of an 412 INJURIES AND DISEASES OF NERVES. inch apart, and between each pair the vein is now divided with a very sharp tenotome passed beneath it. The pins are left in till the vein feels throm- bosed, or until slight ulceration is caused. Instead of protecting the skin, Sir W. Fergusson used to divide it over the vein and place the ligature in the groove, thus occluding the vein more certainly and avoiding the pain of pressure on the skin. The little wounds are rather long healing. Prof. John Wood employs subcutaneous acupressure as follows: he first, with needle and thread, draws a wire loop across behind the vein, then passes a special pin (Fig. 160) through the same openings, between the vein Fig. 160. Wood's method of treating varicose veins. and the skin. The wire loop is then slipped over the pin and its ends crossed and twisted round the shaft. By daily twisting of the pin on its axis, the vein may be completely cut through, or, at any time, the pins may be with- drawn and the wire loop afterward. The method is more painful than Lee's, and, one would think, more dangerous. Should these methods fail or be unsuitable, the most radical one of dissecting out the veins is left. The great length of the incisions is a serious objection in many cases. Ulcers and eczema should be quite healed, and the operation done with scrupulous antiseptic precautions. Indeed, these should never be omitted in operations upon veins, no matter how slight, for the danger is that of septic-thrombo-phlebitis, and a death from an operation on varicose veins is a great surgical misfortune. Purple masses of small veins may be best treated like nsevi, by the cautery, electrolysis, or excision. After these operations preventive treatment should be employed, for the disease is very likely to appear in other veins. CHAPTER XXXI. INJUKIES AND DISEASES OF NEEVES. Injuries of nerves may be divided into (1) those which do not, and (2) those which do interrupt their conducting power. This depends upon the integrity of the axis cylinders—delicate structures which may be destroyed, even though the physical continuity of the nerve is maintained by its con- nective tissue. But the nature of the violence which causes the injury is also of importance, and is the usual basis for the classification of injuries. INJURIES OF NERVES—WOUNDS. 413 Compression is a frequent cause of nervous symptoms. In its slighter forms it causes a part to " go to sleep;" thus after pressure on the sciatic in sitting the leg tingles, and feels numb and powerless, recovering completely in a few minutes. This pressure is slight and indirect; but Weir Mitchell has shown that direct pressure of ten pounds on the square inch applied by a mercurial column breaks up the medullary sheaths, and interrupts motor impulses for a short time—a result sometimes seen in the so-called " Sunday- morning" paralyses of the musculo-spiral or ulna after sleeping with the arm under the head or body, or resting on a sharpish edge—e. g., the top of a chair; and the paralysis may now last so long as to indicate destruction of the axis cylinders. Sensation, too, may disappear, but it is always preserved longer than motion, the perceptive centres being excited by much slighter stimuli than the muscles. Similar paralyses are not uncommon from the pressure of crutches (crutch-palsy). Nerves are not infrequently paralyzed as a result of pinching with forceps during operations, and sometimes they are ligated by mistake, the result being paralysis as complete as after section. Even the more severe cases of this kind usually recover after some months, for the ends of the nerve are together, though its physiological continuity is gone. Frequently nerves are exposed to constant pressure from more or less slowly growing tumors, aneurisms, etc. Up to a certain point they stretch or slip aside, and adapt themselves to altered circumstances; beyond this, they atrophy. As the limit is reached, neuralgia frequently results, and the involvement of nerves in tumors, laying bare in aneurisms, or compression against or in some resisting structure (e. g., callus) excites much pain. Contusion.—The ulnar nerve is frequently struck where it lies between the inner epicondyle and the olecranon; but most of the force usually falls on the bones. The result is some local pain with tingling and numbness of the two inner fingers. Rarely, sufficient force acts on the ulnar or other nerve to cause more or less lasting paralysis. Occasionally fragments in fractures and heads of dislocated bones contuse nerves sufficiently to cause symptoms; the musculo-spiral at the middle of the arm and the ulnar at the elbow most often suffer. Strain.—Deliberate stretching with the finger and thumb of a large nerve does not cause paralysis; but in dislocations and fractures, especially such as result from machinery accidents, paralysis is a rare occurrence. In sim- ple injuries it may be taken as certain that laceration has not broken the physical continuity of any large nerves. Dislocation of the ulnar from be- hiud the epicondyle, with subsequent paralysis, has happened in fighting. As to treatment of the above injuries, any source of pressure should be re- moved where possible. A nerve may be dissected out from scar-tissue; or when it is compressed by fibroid tissue in or around it, stretching may restore its functions. The tendency in all injuries due to the above causes is toward recovery, though this may not be complete for many months. The operation of suturing the ends is therefore unnecessary, at least until it is certain that physiological continuity will not be reestablished. To prevent wasting of muscles, warmth, massage, and electricity must be regularly employed. The chief danger in all the above cases is that chronic neuritis (q. v.) may ensue. Wounds.—We have incised, punctured, contused, and lacerated wounds, causing complete or partial division of nerves. Nerve-trunks are commonly divided by wounds from sharp instruments, glass, etc., such as are very common about the fingers, hand, and wrist. Having but little elasticity, their ends do not separate more than an eighth 414 INJURIES AND DISEASES OF NERVES. of an inch, if so much; but if union does not take place, they are slowly drawn apart to a distance of two to three centimetres or more, by such movements of the limb as would stretch the nerve-trunk. The surfaces of section are rather swollen and look frayed out, the nerve fibres shortening less than the neurilemmata which contain some elastic tissue. In amputa- tions, the retracted muscles often leave the nerve ends hanging out on the face of the stump. A pointed instrument will do little or much damage in its passage through a nerve, according to its size and the nature of its edges; division of a few fibres or of the whole nerve may result. Contusions rarely destroy the continuity of nerves, even when they tear skin, pulpify muscle, and crush bones; but a nerve may be so crushed that it subsequently sloughs. This sometimes happens from gunshot violence, but, as a rule, the nerve is partially or completely torn through. Nerves move out of the way of shot much less often than vessels (Fisher). When lacerated thus or in the tearing off of a part, the irregular ends hang long on the surface of the wound, and ecchymoses from stretching are found in its sheath much higher up. Results of Section of Nerves. Degeneration and Regeneration.— Ceteris paribus, partial section or interruption of the physiological continuity only of a nerve is more favorable than complete section, as the ends are held together. Speaking of complete division, the most favorable case for union and restoration of function is that of a clean-cut transverse section with the ends immediately sewn together, and the wound aseptic. Then the usual round-celled exudation (nerve-callus) infiltrates the cut ends, causing them to swell up, and also fills up the gap between them. In a few days the callus becomes firm, holds the ends together, and appears as a fusiform swelling upon the nerve-cord. Exceptionally, divided nerves unite without suture; usually the ends separate an inch or more and both swell up into firm knobs, perhaps twice as wide as the nerve. Subsequently the distal portion of the nerve with its knob becomes gray, atrophied, hard to find and to separate from the sur- rounding connective tissue; the central end remains swollen, tender, and often spontaneously painful. Histology.—Axis cylinders, being long drawn-out processes of cells, natu- rally degenerate when cut off from their parent cells. The motor nerves spring from anterior cornual cells in the cord, the sensory fibres are con- nected with the ganglia on the posterior roots; consequently, sections of spinal nerves below the latter ganglia result in speedy degeneration of the peripheral portion simultaneously along its whole length ; whilst, with the exception of a few fibrils, (probably recurrent), the central end remains sound. The peripheral degeneration occurs almost always, if not always, in man, and is permanent unless physical union with the central end occurs; then regeneration is probable. The dates at which the following degenerative changes occur vary some- what in different animals. First, the nuclei of the primitive sheath swell, multiply, and protoplasm accumulates around them and elsewhere in the sheath, and at the same time the medullary sheath breaks up into larger and smaller drops of myelin. In four or five days these, changes are well marked, and the axis cylinders are interrupted at many points; they ulti- mately disappear. The granular protoplasm, containing fat drops, increases at the expense of the myelin until the primitive sheaths, containing proto- plasm and several nuclei, alone remain (middle of third month). Ulti- mately, in the absence of regeneration, a fibrous cord results. Regeneration occurs as follows: both ends swell and unite as above early and late symptoms of section. 415 described. The infiltrating cells become vascularized, undergo the usual changes of granulation-tissue, and form a provisional callus, through which regeneration of the nerve takes place by growth of the axis cylinders in the central ends. There is no sign of this until the middle of the fourth week or later; then it would seem that new fibres spring from the central axis cylinders at nodes close above the section. A cylinder may split into two new fibres, and these divide further, or a small brush of fibres may at once form. They grow down into and between the old primitive sheaths, passing very sinuously through the callus. At first pale, the new fibres acquire ulti- mately a medullary sheath with nodes of Ranvier; these are doubtless furnished by connective-tissue elements, whilst the axis cylinders, as in normal development (Balfour), grow out from the centre (Ranvier, Neu- mann, Eichhorst). The whole process may be complete in three months in animals, but in man a year or longer is usually required. It is more rapid in the young than the old, and is uncertain if the ends are not in contact; it may occur, however, if they are brought within one-half inch by suture. Provided the ends are brought together, the excision of a piece makes no difference. Sensation returns long before motion. From experiments on animals, some writers support a healing of nerve without degeneration of the peripheral end; the fibres are said to become connected by processes of the connective-tissue cells, and union is complete in three weeks. Gluck succeeded in transplanting an excised piece of a rabbit's nerve into the sciatic of a hen; but the experiment has failed in man (Albert). This early union is very rare, even in animals. It is some- times called " primary." Early symptoms of section.—It is not always easy to detect the division of a nerve of mixed or pure function. We should expect section of a nerve to annul its function ; and so, doubtless, it does, but the annulment may be concealed, especially as regards sensation. Section of any sensory nerve gives an area of maximum insensitiveness, which is limited in relation to the entire area of distribution of the nerve. From this central region feeling increases as we pass outwards, a fact explained chiefly by the anastomoses, coarse and microscopic, which nerves enter into. The tactile corpuscles at the margins of two contiguous sensory arese seem to be supplied almost equally by the nerve of each. Moreover, the vibrations set up by tactile impressions upon an anaesthetic part may extend to neighboring tactile cor- puscles of which the nerve-supply is normal. This indirect, together with the former direct, sensation, constitutes the sensibilite supplee of Letievant. It varies greatly in different people, and, together with the area of the maximum anaesthesia, must be determined by a careful examination soon after any injury of a sensory nerve ; later, fresh injury or neuritis may have caused much change. For this examination, blindfold the patient, and sup- port thoroughly the suspected part that it may not move as a whole; then lightly go over the whole surface with a needle, find the most insensitive area and pass outward from this until feeling is acute as on the normal side. It is necessary to try the same spots several times, as patients often think they feel without really doing so. Usually the loss of sensation after section of a pure sensory or mixed nerve is such as to leave no doubt as to the nature of the injury. As regards motion, we can usually detect with ease which muscles are paralyzed after section of a motor nerve; but it may be difficult or impossible to do so when other muscles can produce, though less strongly, the movements of those paralyzed. Later effects of section.—When a purely motor nerve—e. g., facial—is cut, rapid wasting of the muscles results. The superficial parts may suffer secondarily from loss of that hypersemia which attends the contraction of 416 INJURIES AND DISEASES OF NERVES. muscles, but otherwise they remain unchanged. If a growing part is deprived of motion, development of all its tissues will be imperfect. The effect of section of a purely sensory nerve is best seen in the fifth. It was thought that intracranial division of this nerve produced keratitis, panoph- thalmitis, and ulcers on mucous membranes; but these lesions are now regarded as due to neglected, because unfelt, injuries. In spinal nerves we have not only motor and sensory, but also numerous vasomotor fibres. Active hypersemia, which might a priori have been expected from section of such nerves, has not been noted; but soon the skin supplied by the divided nerve becomes bluish from passive congestion, lax, cold, prone to chilblains, bullous eruptions, and slowly spreading ulcerations, which may extend to the bones of a part, or destroy the ends of fingers and show no tendency to heal. Sometimes, especially upon the fingers and toes, and after contused or lacerated and often incomplete divisions of nerves, the skin becomes thin, tense, shiny, hairless, and the seat of intense neuralgic pain (causalgia), a condition known as " glossy skin " (Paget). Hair may grow excessively, sweat may be diminished or increased on such parts, nails become curved, opaque, furrowed, and brittle. Changes in muscles are even more marked. These atrophy much more quickly than when merely kept at rest, and more quickly after an irritant lesion of nerve than after simple section. The fibres lose their cross-stria- tion, degenerate and shrink, whilst their nuclei multiply, the interstitial con- nective tissue increases pari passu (sclerosis), and sometimes becomes so loaded with fat that the shrinking of muscle is concealed. Adaptive shortening of unopposed muscles, whether paralyzed or not, is common and leads to deformity. Bones of paralyzed parts atrophy or fail in development. Joints become stiff and painful, and it is said that in cases of irritant lesion and neuritis, they (e. g., finger-joints) may suffer as in ataxy (p. 332). How far these changes are due to vasomoter disturbance and lack of exer- cise, how far to some " trophic " influence of the central nervous system, it is impossible to say. Regeneration of a nerve stops them all. Reaction to Electricity of Nerve and Muscle after Injury of Nerve.—Pressure and other slight injuries usually have no effect; but when the physiological continuity of a motor nerve is interrupted, very character- istic changes occur, grouped together by Erb under the name of reaction of degeneration. The peripheral end of the nerve under these circumstances rapidly loses excitability and conducting power as its fibres degenerate; both are gone by the end of the second week, or rather earlier. If, however, regeneration (p. 414) takes place, these properties reappear, first in the more central, then in the more peripheral part, and conducting power is said to return first (Erb). Excitability reappears as the new fibres acquire medullary sheaths. To faradism muscles behave just like the nerves—i. e., they rapidly fail to respond to the stimulus; but to the slowly interrupted constant current they react differently. To tbis stimulus during the first week the excitability diminishes, but then it rises until currents which have no effect on normal muscles cause strong contractions of those paralyzed, and the contractions differ from normal twitchings in being slow and drawn out. This state last9 perhaps six or eight weeks, and then excitability gradually disappears unless regeneration occurs. After four months the paralyzed muscles will not usually react to any form of electricity. They behave to mechanical stimuli just as to the galvanic. It is obvious that these signs are of great importance in investigating the nature of an injury of some standing, from the point of view of both diagnosis and prognosis. DISEASES OF NERVES—NEURITIS. 417 Treatment.—Complete section of a nerve is always, when possible, to be treated by suture of the ends, no matter whether the injury be recent or old, provided, of course, that in the latter case spontaneous recovery is not cer- tainly occurring, and it rarely does without suture. Suture of a nerve is performed with the finest catgut and a small round sewing needle, which will injure but few fibres in passing through the central end. Trim tbe ends till they fit accurately, then pass a suture of support through them about 1 cm. from the section, and two or more sutures of ap- position close to the cut surfaces. Treat the wound most carefully, and fix the limb so as to take off all tension from the nerve. In old cases, and whenever a search for an end is necessary, apply Esmarch's bandage, make a free incision, cut down upon the upper end, which often will have been felt or discovered by its tenderness, and then seek for the lower end: finding this is the first difficulty. Now cut off all or part of the bulbous ends, according to the distance between the ends, and sew them together. In some cases no position of the limb, even when coupled with stretching of the nerve, will allow of their apposition. Successes are, how- ever, recorded when a gap of quite half an inch has been left; and though transplantation has not yet succeeded in man, Tillmanns has obtained a suc- cess by cutting half through the central end a few centimetres above the division, splitting it in a downward direction, twisting the freed portion through 180°, and sewing it to the lower end. Extreme flexion of a limb may be necessary to take off strain for some weeks after such an operation; it may be gradually relaxed as soon as re- turning sensation is noted. Then the wasting must be treated (p. 413). Recovery may not occur for a year or even longer and be quite rapid then, or it may be very gradual. Failure must not be accepted and suture repeated until after a year has elapsed. Even then the effect of dissecting the nerve out of the surrounding scar-tissue, or of simply stretching it, should first be tried. Diseases of Nerves. Besides the usual results of nerve injuries above mentioned, neuritis may ensue; neuralgia and sometimes spasmodic affections start from such lesions, and very rarely tetanus appears, or epilepsy with an aura starting from the scar. Neuritis may be traumatic or non-traumatic; acute or chronic from the first, or the former may pass into the latter. Causes.—Mechanical injuries, especially contusions, lacerations without complete division, or impaction of foreign bodies; but even quite trivial sub- cutaneous injuries, slight strains or constant pressure, may induce neuritis, and severe ones are even more likely to do so. Cold is apparently a very frequent cause, as is most often seen in Bell's palsy (facial) and in sciatica. Extension of inflammation from surrounding parts is common; there is no better example than paralysis of the seventh, from inflammation of the middle ear. Syphilis, leprosy, and malaria are non-traumatic causes. Chronic traumatic neuritis occurs only with a special predisposition (Erb). Morbid Anatomy and Pathology.—In acute cases all stages may be found, from more or less marked hyperaemia of the sheath up to purulent infiltration and sloughing of the nerve; usually the trunk is swollen uniformly, or presents fusiform enlargements due to a coagulable exudation of pinkish- yellow color. The perineurium suffers most, but the medullary substance of Schwann is more or less broken up, and also a few of the axis-cylinders; the nuclei of the primitive sheath are said to multiply, and infiltrating leucocytes are numerous. The nerve is softer than normal. 27 418 INJURIES AND DISEASES OF NERVES. Chronic cases are characterized by increase of fibroid tissue, causing uniform or localized swellings of the nerve and its adhesion to the surrounding tissues, whilst the compressed nerve fibres atrophy in greater or less numbers. Such nerves are often gray and very tough, and they may be thin rather than thick. Either form of neuritis may therefore suspend or destroy the conducting power of more or fewer nerve fibres, and lead to the usual degeneration changes in their peripheral portions. Sometimes neuritis (ascending) extends rapidly or gradually, continuously or by jumps, toward the centre, the symptoms spreading with the disease. Branches higher up, other nerves, and even the cerebro-spinal centres, may then be attacked. The whole pathology is very obscure, the nature of the cause which leads to a centripetally spreading inflammation starting perhaps from a very slight contusion or strain, and affecting nerves only, is quite unknown. The pro- cess has almost a mysterious aspect. Symptoms.—Acute neuritis is very rare. It is said to begin not uncom- monly with a rigor, high fever, and delirium; intense pain radiating along the affected trunk to its ramifications, and occasionally into neighboring nerves; some redness and oedema of the skin over it when superficial, and great tenderness, usually preventing the discovery of swelling of the nerves; muscular twitching is uncommon, but tonic contraction occurs; the symp- toms and result vary with the intensity and outcome of the inflammation; usually the acute symptoms subside, and chronic neuritis remains. This is characterized by more or less constant, dull pain of a tearing, boring, or aching kind, increased by motion or pressure, ultimately associated with some ansesthesia; no paralysis, but paresis and wasting, rarely fibrillar con- tractions. Proportionate to the number of fibres destroyed by the pressure is the peripheral degeneration: this is never entirely absent, and its results (p. 415) may be very marked. Especially do the finger-joints suffer in neu- ritis of the great trunks of the upper limb. The difficulty in these chronic cases is to eliminate disease of central origin, unless one can feel a tender, thick, perhaps irregular, cord. Treatment.—In acute neuritis ice or belladonna fomentations should be applied along the nerve, and the pain subdued by morphia; this failing to relieve, a free incision down to the nerve and into its perineurium is recom- mended. In chronic neuritis the general health must be seen to (see " Neu- ralgia "), and syphilis or malaria must be treated; any local cause must, if possible, be removed. Free blistering over the nerve is very useful, also warm baths, and electricity to the muscles. In all cases give physical and physiological rest if possible. Stretching the nerve should always be tried if other treatment fails. Neuralgia.—This is really the name of a symptom, of pain, which is usually intermittent or markedly remittent in character, now dying away, now shooting with intensity along the nerve. It may affect a single branch or all the branches of a nerve or several nerves, but it seldom occurs on both sides, and is never symmetrical (Fagge). " Tender points " develop sooner orj later, and are fairly constant for the different nerves, occurring at spots where they enter or leave bony canals or pierce fascise. Pressure or even a draught on these spots may bring on an attack, but usually the onset is spontaneous. The pain may be accompanied by twitching or spasm, vaso- motor, secretory and trophic changes. The skin may be tender, especially during an attack; but Erb says careful examination will always show rela- tive ansesthesia. Proportionately, the general health seems little affected. Etiology and Pathology.—Fagge makes two forms : one, reflex, due to irritation of a nerve, which is not itself the seat of the pain, as in trifacial trifacial neuralgia—TIC—SCIATICA. 419 neuralgia from a diseased tooth; the other due to some morbid process in the trunk of the nerve, as in sciatica. But in the majority of cases it is said that no change is discoverable in the affected nerve; so if there is one mor- bid state sublying neuralgia it is unknown. Very likely there is a group of central origin. Injuries, especially contusions and crushes, are sometimes the starting- points of neuralgia, which begins after any wound has healed ; in some of these cases pressure on a filament in the scar, in others a traumatic neuritis, is the immediate cause. Pressure of new growths (especially cancers), aneu- risms, callus, fragments of bones, or even of dilated veins, extension of in- flammation from surrounding parts, impaction of foreign bodies, and especi- ally exposure to cold and wet, are causes of the second variety, and demand that in all cases the whole length of a nerve, if possible, shall be carefully examined for a source of irritation. Causes of the reflex variety are caries of teeth with its complications, exostoses of fangs, ulcerations, and involve- ment of peripheral filaments in scars and inflammatory tissue (e. g., orchi- tis). Besides these" local causes there may be a neurotic family history, hysteria may be present, the patient may be suffering from nervous or gen- eral exhaustion or anaemia, or may have suffered from syphilis or malaria. In the latter case the attacks are probably periodic. Varieties.—The fifth is one of the commonest seats. Tic douloureux is the most severe form known. It consists of sudden, extremely severe fits of pain in the area of one or more of the branches of the fifth, lasting a few seconds to a minute, and ceasing as suddenly as they begin : the paroxysms occur with varying frequency, and are less marked or absent at night; there may be remissions of days or months. The general effects upon mind and body of such pain, often brought on by movements of the jaws, can be easily imagined. The patients are almost always over forty. The causes are quite unknown, but Tomes says the teeth, though they may be tender, are never at fault. A milder form, paroxysmal, but with less marked remissions, is often due to the teeth, and occurs in young and old, especially when they are depressed by illness, fatigue,"or want of food. A meal often relieves at once. In all slighter forms of neuralgia of any branch of the fifth, have the teeth thor- oughly examined. Sciatica.—The great sciatic nerve is that most often attacked next to the fifth. The pain is unlike that of tic, being much more constant and duller; its seat usually seems to be the back of the thigh, but it may extend down to the foot. After a time the limb feels cool, is wasted, its muscles are flaccid, and there is some anaesthesia. The nerve is tender. The patients are chiefly men from twenty to forty, or older. Treatment.—The general causes must be looked for and met by appro- priate treatment, and a liberal diet with little or no stimulant is almost always valuable. Anstie laid stress upon the value of fat, especially ol. morrhuae. Any local cause must, if possible, be removed. With regard to drug- treatment : iron in simple anaemia, quinine, and arsenic in malarious and other obstinate cases, strychnia in nervous exhaustion and atonic dyspepsia may be tried. Phosphorus (gr. Ta^th 4tis horis) in ol. morrhuae has been strongly recommended ; it acts within three days if at all. Great care must be taken to prevent a patient from seeking relief in chronic alcoholism or morphinism. Except in the most severe and hopeless cases morph., gr. y^th to ith twice a day, will usually give ease. The patient should never himself use the syringe. 420 INJURIES AND DISEASES OF NERVES. As a local application the liniment of aconite or aconitia ointment often relieves, and counter-irritation may do so in the less severe cases. When treatment such as the above has failed, and even when, as is usually the case, the cause of the disease is unknown, two operations, nerve-stretching and neurectomy, remain. Nerve-stretching.—This operation has been employed upon many nerves in very various morbid states, but in none with anything like the success it has met with in neuralgia. Of 222 cases, 143 are said to have been cured, 62 improved, and 17 unrelieved; its mortality is very slight (Omboni). It is thus performed upon the sciatic: a 3-inch cut is made above the middle of the thigh through the fascia, the biceps and semitendinosus are separated, and the semimembranosus is drawn in with the latter muscle. The nerve is now seen; its connective tissue sheath is opened, and the trunk is taken between the forefinger and thumb and pulled with such force as the arm alone will give, first from the cord and then toward the cord, in the line of the nerve. Some surgeons cut down on the nerve midway between the trochanter and tuber ischii, where it is covered by the gluteus maximus alone (its lower fibres must be cut), and lies outside the hamstrings. The results are no better, and the wound is more difficult to keep aseptic. But before cutting the skin it is well to try this bloodless method: with the patient on his back fully flex the hip and then slowly straighten the knee. This may tear some fibres of the hamstrings, and stretches the sciatic strongly. The branches of the fifth in the face are reached by short cuts made at right angles to a line extending from the supraorbital notch, which can be felt, to the interval between the bicuspid teeth. The infraorbital nerve issues just below the margin of the orbit, the mental midway between the alveolar and lower borders of the jaw, perhaps a little beyond the above line. A blunt hook is used to stretch small nerves like these, and less force must be used. The result of stretching is laceration of the medullary sheaths and of more or fewer axis-cylinders at the spot stretched, followed by peripheral degener- ation and regeneration. Fibroid matting in and around a nerve is likely to be broken down; and Marshall suggests that it may paralyze the nervi nervorum (sensory nerves of nerves) discovered by Horsley. Clinically large nerves, like the sciatic, are not paralyzed; but a small one like the facial is. Neurectomy is practised chiefly on the superior maxillary and branches of the inferior in cases in which pain recurs as the effect of stretching passes off; it cannot, however, like stretching, affect the central part of a nerve. At least half an inch should be removed to prevent regeneration, which usually occurs after simple section. The inferior dental may be reached by trephining the lower jaw. The lingual can be felt beneath the mucous membrane below and behind the last lower molar. The superior maxillary may be cut behind Meckel's ganglion by trephining the front and back walls of the antrum, and tracing back the infraorbital in its canal. For the operation and results see T. Chavasse, Trans. Med.-Chir. Soc, 1884, p. 145. Spasmodic Tic.—This consists in the sudden involuntary contraction at longer or shorter intervals of one or several muscles; sometimes the twitch- ings are almost incessant and interfere with sleep. When the face is affected the eyes may be suddenly closed at some important juncture. The seat and nature of the disease are unknown, but it sometimes dates from an injury. After years, perhaps, the spasms may shift to another part. Medicinal treatment is useless. Stretching of the facial may relieve his- varieties and etiology of tetanus. 421 trionic spasm, but rarely cures (Godlee, Trans. Clin. Soc, 1882). In a case of perpetual spasm of the arm muscles, dating from a blow on the neck from a falling spar, in which the brachial plexus had been stretched both below and above the clavicle without effect, J. H. Morgan began to divide the nerves of the arm, one by one, or their motor branches, but spasms then ap- peared in the leg of the same side as well as in the arm, a result which Dr. Ferrier had feared. Neuroma.—Tumors of nerve tissue are very rare (p. 135) ; " neuroma" usually means an encapsuled tumor growing from the connective tissue of nerves, a fibroma, myxoma, or sarcoma, roundish or fusiform, compressing or stretching the nerve fibres. Such masses should be removed if they give rise to symptoms or are growing; much care should be taken not to pinch or bruise the nerve fibres, or months of neuralgia and palsy may follow the operation." If necessary a piece of nerve with a small tumor might be ex- cised, and the ends sutured. Tetanus. Definition. — Tetanus is a disease manifested by tonic or continuous spasm and rigidity of the muscles of voluntary motion. It is divided into idiopathic, or that which arises without wound ; and the traumatic, or that which is caused by a wound; the latter is by far the com- moner, but the occasional absence of wound seems established. Trismus in- fantum or neonatorum, which attacks children soon after birth, is frequently made a distinct species, but without reason. Etiology. — Traumatic tetanus is especially liable to follow lacerated, poisoned, and punctured wounds of the hands and feet, gunshot wound in particular; wounds in which nerves are exposed, or pus or foreign bodies confined under fasciae. Frequently a nerve twig has been found partially divided by the cutting instrument, or irritated by a foreign body, etc. It is said to have been caused by a contusion with a schoolmaster's ferule, but this is doubted ; it very rarely follows clean-cut incisions. The doctrine that wounds of the extremities are more liable to cause tetanus than wounds of the head, neck, or trunk is perhaps to be explained by the more frequent occurrence of injury to the extremities. The period at which it may come on after an injury i3 very uncertain. Sometimes it occurs very quickly; sometimes during the inflammatory stage; often not till the wound is nearly healed ; most commonly from four to fourteen days from the injury. Trismus neonatorum is prone to arise during the first nine days after birth; it seems to bear relation to the separation of the umbilical cord, and there* fore would rank as a form of traumatic tetanus. The tetanus arising after abortion may perhaps also be looked upon as traumatic. Causes favoring the occurrence of traumatic tetanus are exposure to cold and damp, fatigue, privations. Cold and damp take especial effect in tropi- cal countries where the alternation from the heat of the day to the cold of the night is very sudden and extreme. In military campaigns all the above- mentioned predisposing causes are likely to obtain, and it is during such that cases of tetanus are most frequent, occasionally appearing like an epidemic. Tetanus is rarely absent from certain hospitals in India; and occasionally, after absence for years, small epidemics of two or three cases occur in hos- pitals in temperate climates. These considerations and points in its patho- logical course cause many to regard tetanus as probably an infective disease; some have stated that it is contagious. Of idiopathic tetanus cold and damp are the most efficient known causes. It is chiefly met with in tropical climates. Malaria appears to give rise to an intermittent form of tetanus. 422 INJURIES AND DISEASES OF NERVES. Men are more subject to tetanus than women; the young and middle-aged more than the aged. Symptoms of Tetanus.—The patient first complains of stiffness and pain about the neck and jaws, as if from a cold, flexion of the neck is imperfect, and a finger in the mouth will feel the edges of the masseters; his voice is husky ; it is difficult for him to put out his tongue, and his countenance ex- hibits a painful smile, because the corners of the mouth are drawn outward by incipient spasm of the facial muscles; the alse nasi are drawn out, the naso- labial furrows deepened; the eyelids are half-closed but the eye muscles are rarely affected; the pupils are contracted. Next, the muscles of mastication and deglutition become rigid, so that there is great difficulty in opening the mouth and swallowing, especially liquids. The jaws may now become firmly clenched (trismus or lock-jaw). The tongue is rarely rigid ; saliva flows from the mouth because the patient is unable to swallow it. To these symptoms succeed a fixed pain at the point of the stomach shooting to the back, and a convulsive difficulty of breathing, indicating that the diaphragm and mus- cles of the glottis are affected ; and the spasm now extends tothe muscles of the trunk and limbs, rendering them completely fixed and rigid. Various positions of the body are assumed in this spasm. The term opisthotonos de- scribes an arching backward of the neck and trunk, more or less of which is usual; emprosthotonos a curving forward, pleurosthotonos a lateral curvature, both of which are rare. The muscles of the extremities are not, as a rule, affected to so great an extent as those of the trunk, neck, face, and jaws; their distal portions scarcely ever suffer. In the lower limbs extension predominates over flexion; in the upper, if affected, flexion prevails over extension. The abdomen feels remarkably hard; there is obstinate constipation ; frequently difficult mic- turition from spasm of the perineal muscles. This spasm never ceases en- tirely ; but it occasionally has a lull, and then comes on again in fits of great violence. In severe paroxysms the chest becomes fixed, the countenance livid, and there is dread of suffocation. Arrest of respiration is sometimes due to spasm of the glottis, but as a rule it is the result of spasm of the thor- acic muscles and diaphragm (Ross). Such fits are easily brought on by any disturbance, such as an attempt to swallow, or by any other bodily movement or mental excitement, and most remarkably by slight causes affecting the surface of the skin—such as currents of cold air. This would look like hypersesthesia, but for touch and temperature the sensibility appears to vary, being sometimes exalted, sometimes lowered. The pain complained of during a convulsive seizure is that of ordinary cramp. Re- laxation occurs during sleep, but this is generally absent. Meanwhile the intellect is undisturbed, and the pulse is at first natural, except during a severe paroxysm, which quickens it and causes perspiration and thirst, or when there is fever. The temperature is generally raised from 101° to 103° F., and may suddenly become hyperpyrexial; but even the most acute cases may be afebrile. The urine has in some cases contained sugar. Terminations.—If the case is to end fatally, the paroxysms become more frequent and violent, and the breathing more and more embarrassed by spasm; the patient may die from exhaustion or from suffocation—either be- cause the nervous system is worn out, or because respiration is suspended by the violence of the spasm long enough to asphyxiate. Asphyxia is probably less common than is usually thought, as carbonic acid relaxes the spasm be- fore death occurs. Rose (Deutsche Chirurgie) believes cardiac failure before the resistance opposed by the tonically contracted muscles to be the common cause of death. The heart sometimes stops suddenly. The most usual period of death is the third or fourth day; sometimes it is postponed till the DIAGNOSIS AND PATHOLOGY OF TETANUS. 423 eighth or tenth, but rarely later (chronic tetanus). The recorded case of a negro who injured his hand and died convulsed in a quarter of an hour is doubtful; and cases of death within twenty-hour hours are uncommon. When acute tetanus terminates favorably, the recovery may not be complete for weeks or months; the remaining tendency to spasm may yield but slowly, and it is apt to be temporarily aggravated by very slight causes, especially cold and damp. In some rare instances the disease has been removed almost instantaneously by the removal of its exciting cause. Tetanus is liable to vary greatly in intensity. In some cases there may be only locked-jaw and some stiffness of the neck-muscles. These cases have been classed as partial tetanus. Prognosis.—Acute traumatic tetanus is one of the most hopeless of dis- eases : of 363 cases in the American civil war, 336 were fatal.1 The idio- pathic and chronic cases usually do well. Death very seldom occurs after the twelfth day. As a general rule, it may be said that in traumatic tetanus the longer the interval between the injury and the occurrence of the disease the more favorable is the prognosis. Cases arising early and marked by spasms of increasing frequency and violence are nearly always fatal. Early suffocative attacks on attempting to swallow are said to be of bad significance. A high temperature, above 103°, and a frequent pulse are also signs of dan- ger. Strabismus is regarded by Wunderlich as a fatal prognostic. Diagnosis.—Tetanus may be distinguished from hydrophobia by the spasms being more continuous, by the clenched jaw, and by the patient being generally sensible and calm to the last; whereas in hydrophobia, if there are fits of general convulsions, there are perfect intermissions, and the patient is mostly delirious. In strychnine poisoning the masticatory muscles are, as a rule, the last to be affected; the disease develops much more rapidly; there is generally com- plete muscular relaxation between the attacks. Death occurs commonly in less than three hours. Tetanus is sometimes closely simulated in hysteria. The diagnosis must rest on the general evidence of this emotional disease and upon imperfect simulation. Morbid Anatomy.—Increased vascularity of the membranes and sub- stance of the spinal cord and brain are amongst the most constant changes noticed in the older books. The modern microscopical researches of Lock- hart Clarke, Dickinson, and others show that the cord may be swollen at its cervical and lumbar enlargements; its bloodvessels distended, with here and there minute extravasations. The changes affect specially the gray matter. The muscles are extremely rigid after death, and ecchymosed or ruptured in many parts. In certain cases a neuritis has been discovered ascending from the wound to the cord; in others no changes either in the wound itself or in the nerves proceeding from the wound. The blood is mostly uncoagu- lated. Pathology.—This is obscure; the changes in the cord and muscles are evidently results, not the cause. There is obviously present during the dis- ease an increased excitability of the spinal cord, and with the evidence be- fore us of the effect of strychnine poisoning, the question arises whether tetanus may not be due to the presence of a poison in the blood. Another view is, that we have to deal with an inflammatory condition of the spinal cord brought about by extension from the wound along the nerves. But either the rapid generation of a poison in the system, or its generation in the wound and subsequent absorption, or the excitation of an inflammation spreading from a wound, is most probably due to the action of some infective organism. ! Circular No. 6 : War Department, Surgeon-General's Office, dated Washington, Nov. 1, 1865. 424 INJURIES AND DISEASES OF NERVES. Nothing is known on this point, however, and evidence is wanting both as to increase of the poison and inoculability of the disease. Treatment.—The indications are: 1. To remove, so far as we are able, all conditions known or believed to have the power of exciting the tetanic state. 2. To give the patient every chance of spontaneous recovery, by husbanding his strength till the disease shall cease of itself; and 3. To use any special sedative or other treatment which the surgeon would sincerely desire to have employed on himself if he were the patient. For local treatment, all extraneous bodies should be removed from the wound. Render the wound aseptic, slitting it up freely if necessary, using sublimate lotion (1 in 500), and applying boracic fomentations. Measures have been proposed in order to remove local irritation—such as amputation ; or division of the principal nerve leading from the wound; or making a /y-incision above, so as to isolate it and cut off as much nervous communication as possible; or destruction of a ragged, contused, ill-conditioned wound by the actual cautery, which Larrey practised with great benefit; or excision of the scar if cicatrized, or nearly so. Of late stretching of the main nerve or nerves of a part has been practised, with a view of temporarily destroying its conducting power (see " Neuralgia"). Ten of fifty-one cases recovered and eleven were relieved (Omboni). Amputation