NLM005618094 Hk *% THE PRINCIPLES AND PRACTICE OF SURGERY. BY JOHN ASHHURST, Jr., M.D., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SENIOR SURGEON TO THE CHILDREN'S HOSPITAL; CONSULTING SURGEON TO THE WOMAN'S HOSPITAL, TO ST. CHRISTOPHER'S HOSPITAL, AND TO THE HOSPITAL OF THE GOOD SHEPHERD, ETC. THIRD EDITION ENLARGED AND THOROUGHLY REVISED. WITH PHILADELPHIA: HENRY C. LEA'S SON & CO. 1882. Entered according to Act of Congress in the year 1882, by HENRY C. LEA'S SON & CO., In the Office of the Librarian of Congress. All rights reserved. WO D O R N A N, PRINTER. TO THE SURGEONS AND STUDENTS OF SURGERY OF AMERICA, FOR WHOSE USE IT IS DESIGNED, AND BY WHOSE FAVOR AND APPROVAL THE LABORS OF ITS PREPARATION AND REPEATED REVISIONS HAVE BEEN GREATLY L* iHTENEI , l^liis flfolume IS MOST GRATEFULLY DEDICATED BY THEIIt FRIEND AND FELLOW-STUDENT, THE AUTHOR. DEDICATION TO THE FIRST EDITION. (git Pfmavam.) TO JOSEPH CARSON, M.D., PROFESSOR OF MATERIA MEDICA AND PHARMACY IN THE UNIVERSITY OF PENNSYLVANIA, AS A MARK BOTH OF RESPECT FOR HIS DISTINGUISHED PROFESSIONAL AND SCIENTIFIC ACQUIREMENTS, AND OF GRATITUDE FOR MANY PERSONAL KINDNESSES, JfKs Wahme IS MOST CORDIALLY AND AFFECTIONATELY INSCRIBED, BY HIS FRIEND AND PUPIL, THE AUTHOR. PREFACE. The object of this work is, as its title indicates, to furnish, in as con- cise a manner as may be compatible with clearness, a condensed but comprehensive description of the Modes of Practice now generally employed in the treatment of Surgical Affections, with a plain exposition of the Principles upon which those modes of practice are based. In carrying out this object to the best of his ability, it has been, of course, necessary for the author to have regard to the views of other surgeons, in both this and other countries, and he has not hesitated, therefore, to avail himself freely of the labors both of systematic writers and of those who have illustrated particular departments of surgery by monographs and special treatises. In making use of the work of others, the author has endeavored, in every instance, to give due credit for what he has borrowed, and, should the proper acknowledgment have been in any case unfortunately neglected, hereby begs the reader to believe that the omission has been entirely unintentional. In revising his work for a third edition, the author has spared no pains to render it worthy of a continuance of the favor with which it has heretofore been received, by incorporating in it an account of the more important recent observations in Surgical Science, and of such novelties in Surgical Practice as have seemed to him to be really improvements; and by making such changes as have been suggested to him by enlarged personal experience as a Clinical Teacher and Hospital Surgeon. The general arrangement of the volume is the same as in the previous editions; every part has been carefully revised, and, though a consid- erable amount of new material has been added, yet by judicious typo- graphical changes and by a modification in the arrangement of the Index, so much space has been gained that the number of pages is but slightly increased. vi PREFACE. The series of illustrations has been further improved by the introduc- tion of a number of original cuts, chiefly from photographs of patients, and from drawings by the author's friend and former pupil, Dr. J. M. Taylor. In the case of the selected cuts, their original source has been indicated in every instance in which this could be ascertained. In concluding his work, the author ventures to express a hope that, in its present form, his volume, though necessarily compendious in its mode of dealing with many subjects, may be considered as affording upon the whole a not unsatisfactory representation of Modern Surgery. 2000 West DeLancey Place, Philadelphia, August, 1882. CONTENTS. Preface, List of Illustrations, Introductory Kemarks, xix 33 Pathology of inflammation, Clinical view of inflammation Ulceration, Granulation and cicatrization (iangrene, . Inflammatory fever, CHAPTER I. INFLAMMATION. 34 41 46 ition, .... 47 48 49 CHAPTER II. TREATMENT OF INFLAMMATION. Prophylactic treatment, .... 52 Curative treatment, .... 53 Hygienic, ..... 53 Local, ..... 55 Constitutional, .... 59 CHAPTER III. OPERATIONS IN GENERAL; ANESTHETICS. Qualifications of the surgeon, Circumstances influencing results of operations, Causes of death after operations, Preparation of patients for operation, Mode of conducting an operation, Anaesthetics, . CHAPTER IV. MINOR SURGERY, Bandaging, Revulsion and counter-irritation, Hypodermic injection, Vaccination, 62 63 66 69 71 72 80 84 85 Vlll CONTENTS. Bloodletting, Transfusion of blood, Aspiration, CHAPTER V. AMPUTATIONS. History of amputation, Conditions requiring amputation, Instruments used in amputation, Different modes of amputating, Structure of stumps, Affections of stumps, Mortality after amputation, Causes of death after amputation, CHAPTER VI. SPECIAL AMPUTATIONS. Hand, Wrist and forearm, Elbow, upper arm, and shoulder Above shoulder, Foot, Ankle, Leg, Knee, Thigh, Hip, SURGICAL INJURIES. CHAPTER VII. EFFECTS OF INJURIES IN GENERAL Constitutional effects of injuries, Shock, Traumatic delirium, Local effects of injuries, . Contusions, Strangulation of parts, "Wounds, . Incised wounds, Lacerated and contused wounds, Antiseptic treatment of wounds, Punctured wounds, Poisoned wounds, CHAPTER VIII. GUNSHOT WOUNDS. Gunshot wounds, .... Amputation and excision in gunshot injuries, WOUNDS. CONTENTS. IX CHAPTER IX. INJURIES OF BLOODVESSELS. Injuries of veins,' .... Entrance of air into veins, Injuries of arteries, Hemorrhagic diathesis, Process of nature in arresting hemorrhage, Treatment of arterial hemorrhage, Collateral circulation, Secondary hemorrhage, Gangrene from arterial occlusion, Traumatic aneurism, Arterio-venous wounds, . Lines of incision for ligation of special arteries, CHAPTER X. INJURIES OF NERVES, MUSCLES AND TENDONS, LYMPHATICS, BURS^E, BONES, AND JOINTS. Nerves, Muscles and tendons, Lymphatics, Bursa?, Bones, Joints, CHAPTER XI FRACTURES Causes of fracture, Varieties, Separation of epiphyses, . Symptoms, Diagnosis, Process of union in fractured bones, Treatment of fractures, . Simple, Complicated, Compound, Ununited fracture and false joint, CHAPTER XII. SPECIAL FRACTURES. Bones of face, Lower jaw, Ribs, Sternum, . Pelvis, X CONTENTS. Sacrum and coccyx, Clavicle, Scapula, Humerus, . Olecranon process, Bones of forearm, Radius, Bones of hand, Femur, Patella, Tibia and fibula Bones of foot, CHAPTER XIII. DISLOCATIONS. Dislocations in general Special dislocations, Lower jaw, Ribs, sternum, and Clavicle, Scapula, Shoulder, Elbow, Wrist, Hand, Hip, Patella, Knee, Ankle, Foot, pelvis, CHAPTER XIV. EFFECTS OF HEAT AND COLD. Burns and scalds, .... Operations for contracted cicatrices, Effects of cold, .... Pernio or chilblain, Frost-bite, CHAPTER XV. INJURIES OF THE HEAD, Injuries of the scalp, Concussion of the brain, Compression of the brain, Traumatic encephalitis, Contusion of the skull, Fracture of the skull, Injuries of the cranial contents, . Trephining in injuries of the head, CONTENTS. XI CHAPTER XVI. INJURIES OF THE BACK. Injuries of the spinal cord, Concussion from indirect causes; railway spine, Injuries of the vertebral column, Treatment of spinal injuries, Trephining in spinal injuries, CHAPTER XVII. INJURIES OF THE FACE AND NECK. Injuries of the face, Injuries of the neck, Injuries of the larynx and trachea, Surgical treatment of apncea, Injuries of the oesophagus, CHAPTER XVIII. INJURIES OF THE CHEST. Contusions of the chest, ..... Wounds of the chest, ..... Injuries of the diaphragm, _ . CHAPTER XIX. INJURIES OF THE ABDOMEN AND PELVIS. Contusions of the abdomen, Wounds of the abdomen, Adominal fistulae, . Injuries of pelvic organs, Injuries of male genitals, Injuries of female genitals, PAGE 329 % 335* 336 340 342 344 348 351 356 361 364 366 374 375 378 381 384 385 387 SURGICAL DISEASES. CHAPTER XX. DISEASES RESULTING FROM INFLAMMATION. Abscesses, .... Ulcers, .... Gangrene and gangrenous diseases, CHAPTER XXI ERYSIPELAS. Varieties and causes of erysipelas, Symptoms, Diagnosis, .... Prognosis and treatment, 389 395 399 408 409 410 411 Xll CONTENTS. CHAPTER XXII PYAEMIA. Nomenclature of pyaemia, Pathology, Morbid anatomy, . Causes, Symptoms, Diagnosis and prognosis Treatment, CHAPTER XXIII DIATHETIC DISEASES. Struma, ......••■ Tubercle, ......•• Scrofula, . . . . • Rickets, ......••• CHAPTER XXIV VENEREAL DISEASES. GONORRHOEA AND CHANCROID. Gonorrhoea," Complications, Balano-posthitis, or external gonorrhoea Gonorrhoea of female genitals. Ophthalmic gonorrhoea, . Gonorrhoea of nose, mouth, rectum, and Gonorrhceal rheumatism, . Chancroid,.... Complications, Treatment, . Primary bubo or bubon d'emblee, CHAPTER XXV VENEREAL DISEASES—continued. SYPHILIS. History of syphilis, Causes of syphilis, Primary syphilis, . Secondary syphilis, Tertiary syphilis, . Hereditary syphilis, Diagnosis of syphilis, Treatment of syphilis, CHAPTER XXVI TUMORS. Classification of tumors, . Cystic tumors, Simple or barren cysts, Compound or proliferous cysts, PAGE 415 416 419 420 421 422 423 425 425 426 429 431 436 1 438 438 439 umbilicus, 441 441 442 443 444 447 448 448 450 454 458 462 463 466 472 474 474 476 CONTENTS. Xlll Non-malignant solid tumors and outgrowths, Semi-malignant or recurrent tumors, Malignant tumors, Cancer, Epithelioma, Excision of tumors, 478 490 494 494 506 510 CHAPTER XXVII SURGICAL DISEASES OF THE SKIN, AREOLAR TISSUE, LYMPHATICS, MUSCLES, TENDONS, AND BURSiE. Skin and appendages, Areolar tissue, Lymphatic system, Muscles and tendons, Bursse, 511 517 517 519 522 CHAPTER XXVIII SURGICAL DISEASES OF THE NERVOUS SYSTEM. Neuritis, . Neuroma, . Neuralgia,. Tetanus, CHAPTER XXIX. SURGICAL DISEASES OF THE VASCULAR SYSTEM. 524 525 526 529 Diseases of veins, . 534 Vascular tumors or angeiomata, . 538 Diseases of arteries, 542 Aneurism, .... 545 Treatment of aneurism in general, 553 Treatment of particular aneurisms, 564 Aortic, 504 Innominate, 566 Carotid, 568 Subclavian and vertebral, . 569 Axillary, 572 Brachial, etc., 573 Abdominal and inguinal, 573 Gluteal and sciatic, 574 Iliac and common femoral, 576 Femoral and popliteal, 576 CHAPTER XXX. DISEASES OF BONE. Periostitis, ...... . 577 Osteitis, ....... . 579 Osteo-myelitis, ...... . 580 Epiphysitis, ...... . 582 Abscess in bone, ...... . 583 XIV CONTENTS. Caries, ...... Necrosis, ...... Osteomalacia, ..... Tubercle and scrofula ' . Changes in.bone due to affections of nervous system, Tumors in bone, . ... CHAPTER XXXI DISEASES OF JOINTS. Synovitis, .... Hydrarthrosis^and Pyarthrosis Arthritis, . Hip disease, Sacro-iliac disease, Rheumatoid arthritis, Periarthritis, Anchylosis, Loose cartilages in joints, Articular neuralgia, CHAPTER XXXII EXCISIONS. Excision in general, Special excisions, . Scapula, Clavicle and ribs, Shoulder-joint, Humerus, Elbow-joint, Radius and ulna, Wrist-joint, Bones of hand, Hip-joint, Knee-joint, . Bones of leg and ankle-joint, Bones of foot, CHAPTER XXXIII ORTHOPAEDIC SURGERY. Wry-neck, .... Lateral curvature of the spine, Deformities of the upper extremity, Deformities of the lower extremity, Club-foot, . CHAPTER XXXIV. DISEASES OF THE HEAD AND SPINE. Diseases of the scalp and skull, .... Encephalocele and meningocele, . ... 654 655 CONTENTS. XV and optic papilla (amaurosis Paracentesis capitis, ..... Spina bifida, ...... Antero-posterior curvature of the spine, Arthritis and necrosis of the- spine, . CHAPTER XXXV. DISEASES OF THE EYE. Diseases of the conjunctiva, Diseases of the cornea, sclerotic, and ciliary body, Diseases of the iris, Operations on the iris, Cataract, . Operations for cataract, . Diseases of the vitreous humor, choroid, retina, and amblyopia), Accommodation and refraction, Glaucoma, Affections of the entire eyeball, Strabismus, Diseases of the eyelids, . Diseases of the lachrymal apparatus, Diseases of the orbit, CHAPTER XXXVI DISEASES OF THE EAR. Diseases of the auricle, Diseases of the external meatus, Diseases of the membrana tympani, Diseases of the Eustachian tube, Diseases of the cavity of the tympanum, Various affections of the ear, CHAPTER XXXVII DISEASES OF THE FACE AND NECK. Diseases of the nose, Rhinoplasty, Diseases of the frontal sinuses, Diseases of the cheeks and lips, Diseases of the neck, CHAPTER XXXVIII DISEASES OF THE MOUTH, JAWS, AND THROAT. Diseases of the tongue, . Diseases of the jaws, Diseases of the palate, Diseases of the tonsils, Diseases of the pharynx and oesophagus, Diseases of the air-passages, PAGE 656 G-37 658 663 XVI CONTENTS. CHAPTER XXXIX. DISEASES OF THE BREAST. Hypertrophy of the breast, Supernumerary nipples or mammse, Galactocele or milk-tumor, Diseases of the nipple and areola, Mammitis and mammary abscess, Tumors of the breast, Excision of the breast, Diseases of the mammary gland in the male, CHAPTER XL. HERNIA. Causes of hernia, . Nomenclature, Structure of a hernia, Symptoms of hernia in general, . Treatment of reducible hernia, . Radical cure of hernia, Irreducible hernia, Inflamed hernia. Incarcerated and strangulated hernia, The taxis, . Herniotomy, CHAPTER XII SPECIAL HERNLE. Classification of hernise, ..... Diaphragmatic, epigastric, ventral, and umbilical hernise, Lumbar and inguinal hernia?, .... Femoral hernia, ...... Obturator hernia, ...... Perineal, pudendal, vaginal, and ischiatic hernise, CHAPTER XLII DISEASES OF INTESTINAL CANAL. Intestinal obstruction, Malformations, of the anus and rectum, Stricture and tumors of the anus and rectum, Rectal fistula?, Fistulo in ano, Fissures and ulcers of the anus, . Hemorrhoids, Prolapsus of the rectum, . Inflammation of the rectal pouches, Neuralgia of the anus, Pruritis of the anus, CONTENTS. xvii CHAPTER XLIII. DISEASES OF ABDOMINAL ORGANS, AND VARIOUS OPERATIONS ON THE ABDOMEN. Paracentesis abdominis, .... Ovarian tumors, ..... Caesarean section, etc., .... Nephrotomy for renal calculus, or nephrolithotomy, Extirpation of the kidney, or nephrectomy, Extirpation of the spleen, or splenectomy, Resection of the stomach, or gastrectomy, Pancreatectomy and pancreatotomy, Hepatectomy and hepatotomy, Treatment of abdominal abscesses, Treatment of abdominal hydatids, etc., . CHAPTER XLIV. URINARY CALCULUS. Varieties of calculus, .... Renal calculus, ..... Vesical calculus, ..... Litholysis, or solvent treatment of stone, Lithotrity, ..... Rapid lithotrity with evacuation, or litholapaxy Lithotomy, ..... Recurrent calculus, .... Urethral calculus, .... Prostatic calculus, .... Calculus in women, .... Extra-pelvic vesical calculus, CHAPTER XLV DISEASES OF THE BLADDER AND PROSTATE. Malformations and malpositions of the bladder, Cystitis, ......... Structural diseases of the bladder, ..... Hsematuria, ........ Paralysis and atony of the bladder; retention and incontinence of urine, Inflammatory diseases of the prostate, ..... Chronic hypertrophy of the prostate, ..... Retention of urine from prostatic obstruction, .... Other diseases of the prostate, ...... CHAPTER XLVI DISEASES OF THE URETHRA AND URINARY FISTULA. Exploration of the urethra, ...... Malformations of the urethra, ...... Prolapsus of the urethra and urethrocele, . 945 950 952 xviii CONTENTS. Urethritis and spasm of the urethra, Stricture of the urethra, . Urethral fever, Treatment of stricture, Tumors and fissure of the urethra, Urinary fistula in the male, Urinary fistula in the female, PAGE 953 •154 958 959 970 971 974 CHAPTER XLVII diseases of the generative organs. Male Genitals. Diseases of the penis and scrotum, Diseases of the testis, Hydrocele and hematocele, Varicocele, Sarcocele and tumors of the testis, Functional disorders of the male generative apparatus, Female Genitals. Malformations, Surgical diseases of the vulva, Surgical diseases of the vagina, Surgical diseases of the uterus, 981 989 991 997 999 1003 1005 1008 1009 1011 Index, 1017 LIST OF ILLUSTRATIONS. FIG. 1. Corpuscles and filaments in recent lymph (Bennett), 2. Fibro-plastic and fusiform cells from lymph (Bennett), 3. Pus corpuscles (Rindfleisch), . . . . 4. Section of granulating surface (Rindfleisch), 5. Sphacelus; showing line of separation (Miller), 6. Mediate irrigation ; coil prepared for use (Petitgand), 7. Mediate irrigation ; coil applied to head (Petitgand), 8. Mediate irrigation; coil applied to leg (Petitgand), 9. Irrigating apparatus (Erichsen), .... 10. Ward carriage, ...... 11. Clover's chloroform apparatus (Erichsen), . 12. Reversed spiral bandage, ..... 13. Figure-of-8 bandage, ..... 14. Spica bandage, . . 15. Four-tailed bandage, ...... 16. Bandage of Scultetus, ..... 17. Seutin's pliers, ...... 18. Corrigan's button cautery, ..... 19. Porte-moxa, ........ 20. Different forms of cautery iron, .... 21. Marshall's galvanic cautery, ..... 22. Mechanical leech, ...... 23. Aspirator, ....... 24. Petit's tourniquet, ...... 25. Spanish windlass, 26. Signoroni's tourniquet, ..... 27. Skey's tourniquet, ...... 28. Lister's aorta-compressor (Erichsen), 29. Amputating-knife, ...... 30. Double-edged catlin, ...... 31. Bistoury, ....... 32. Scalpel, ....... 33. Small amputating saw, ..... 34. Bone nippers, ...... 35. Artery-forceps, ...... 36. Tenaculum, ....... 37. Reef-knot, ....... 38. Surgical needles, ...... 39. Amputation of the arm; circular method (Druitt), 40. Amputation of the thigh; antero-posterior flap method (Bryant) 41. Amputation of the thigh; modified circular method (Skey), 42. Amputation of the leg ; Teale's method (Bryant), 43. Result of synchronous amputation of hip and leg, 44. Thigh stump, with splint for extension (Bryant), . 45. Aneurismal varix in a stump (Erichsen), ... 46. Neuromata of stump (Miller), . . . . . 47. Necrosis after amputation (Lister), . 48. Amputation of a finger (Erichsen), . . . . 49. Amputation at metacarpo-phalangeal joint (Skey), XX LIST OF ILLUSTRATIONS. FIG. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. Amputation of the thumb (Erichsen), Result of partial amputation of the hand, Amputation of the wrist (Erichsen), Amputation of forearm (Bryant), . Amputation at the shoulder-joint; Larrey's method, Result of Larrey's amputation, Amputation at shoulder-joint; Dupuytren's method (Bryant), Result of Dupuytren's amputation, Amputation of great toe with metatarsal bone (Erichsen), Amputation of metatarsus; Lisfranc's and Hey's methods (Skey) Chopart's amputation (Bryant), Pirogoff's amputation (Erichsen), . Bony union after Pirogoff's amputation (Hewson) Syme's amputation (Skey), Flap amputation of the leg (Erichsen), Amputation at the knee-joint (Erichsen), Amputation at the hip-joint (Holmes), Result of hip-joint amputation, Mounted needle, with ligature, Interrupted suture, . Continued or glover's suture, Twisted suture, India-rubber suture, Quilled suture, Serre-fine, .... Steam spray apparatus, Nelaton's probe, Bullet forceps, Screw extractor, Gunshot fracture of hip, Partial excision of radius for gunshot injury Rupture of external iliac artery, Speir's artery constrictor, . Aneurismal needle, . Grooved director, Ligation of an artery in its continuity (Bryant), Acupressure; first method; raw surface (Erichsen Acupressure ; first method; cutaneous surface (Erichsen) Acupressure; second method (Erichsen), Acupressure; third method (Erichsen), Acupressure ; fifth method (Erichsen), Arterio-venous aneurisms (Bryant), Ligation of innominate artery (Skey), Ligation of carotid and facial arteries (Bryant), . Ligation of occipital artery (Skey), Ligation of temporal artery (Skey), Ligation of subclavian and lingual arteries (Bryant), Ligation of brachial, radial, and ulnar arteries (Miller), Ligation of common iliac artery (Liston), Ligation of external iliac and femoral arteries (Bryant), Ligation of popliteal artery (Miller), Ligation of anterior tibial artery (Miller), Ligation of posterior tibial artery (Miller), Wallerian degeneration of nerve (Bertolet), Partial fracture, ..... Comminuted fracture of patella, Impacted fracture through trochanters of femur,. Deformity from injury of epiphysis, Gangrene from tight bandaging (Bell), Bavarian immovable splint (Bryant), Improved drill for ununited fracture, Gaillard's instrument for ununited fracture, Barton's bandage for fractured jaw, Attachments of outer end of clavicle; showing branches of coraco-clavic ular ligament (Gray), ...... 248 LIST OF ILLUSTRATIONS. XXI FIG. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132, 134. 135. 136. 137. 138. 139. 140. 141. 142. 143. 114. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156. 157. 158. 159. 160. 161. 102, 164. 165. 166. 167. 168. 169. 170. 171, 173. 174. 175. 176. Oblique fracture of clavicle (Gray), Sayre's dressing for fractured clavicle, Velpeau's bandage, .... Separation of upper epiphysis of humerus, Fracture of the surgical neck of the humerus (Gray), Dressing for fracture of the surgical neck of the humerus (Fergusson), Fracture at the base of the condyles of the humerus (Gray), Fracture at the base of, and between, the condyles of the humerus (Erichsen), ..... Physick's elbow splints, .... Fracture of the radius near its lower end (Liston), Bond's splint for fracture of the radius, Gordon's splint for fracture of the radius, . Fracture of neck of femur (Fergusson), . Adhesive plaster stirrup for making extension in fractures of lower extremity, ....... Weight extension with long splints for treatment of fractured thigh, N. R. Smith's anterior splint for fractured thigh, Compound fracture of thigh; treatment by bracketed long splin (Erichsen), .... Fracture of patella, .... 133. Separation of upper epiphysis of tibia, Fracture-box, with movable sides, Salter's cradle, .... Wire rack for fracture of the leg, . Clove-hitch, ..... Congenital dislocation of both hips (Holmes), Dislocation of lower jaw, Dislocation of sternal end of clavicle (Bryant), Dislocation of clavicle on acromion (Bryant), Dislocation of humerus into axilla (Pirrie), Subcoracoid luxation of humerus (Pirrie), Reduction of dislocated shoulder by heel in axilla, Reduction of dislocated shoulder by White's and Mothe's method, Forward dislocation of head of radius (Liston), . Dislocation of elbow backwards (Liston), .... Reduction of dislocated elbow, ..... Levis's instrument for reducing dislocations of thumb and finger, Anatomy of the hip-joint; the Y ligament (Bigelow), . Backward dislocation of hip, ..... Reduction of backward dislocation by manipulation (Bigelow),. Downward dislocation of hip, ..... Reduction of downward dislocation by manipulation (Bigelow), Application of rope windlass for backward dislocation of hip, . Bloxam's dislocation tourniquet applied for downward dislocation (Erichsen), ...... Pulleys applied for upward dislocation of hip, Angular extension in old dislocation of hip (Bigelow), . Contraction of arm following burn, Result of plastic operation for contraction following burn, Teale's operation for contraction of lower lip (Erichsen), 163. Severe scalp wound, ..... Fracture of skull with loss of substance, . Hey's saw, ....... Common trephine, ...... Different forms of elevator, . .... Conical trephine, ...... Bilateral dislocation of cervical vertebra (Ayres), Bony union of fractured vertebras, .... 172. Fracture of vertebral body and unilateral dislocation of a lumbar vertebra, Oblique illumination (Wells), Eversion of upper lid for detection of foreign bodies (Erichsen Application of the laryngoscope (Erichsen), Throat-mirror used in laryngoscopy, 2* xxii LIST OF ILLUSTRATIONS. tt), FIG. 177. Gross's tracheal forceps, 178. Operation of tracheotomy (Liston), 179. Tracheal tube, 180. Burge's oesophageal forceps, 181. Swivel probang, 182. Horsehair probang, or Ramoneur, . 183. Ventral hernia, following rupture of abdominal muscles 184. Lembert's suture, .... 185. Gely's suture, .... 186. Dupuytren's enterotome, 187. Enterotome applied (Erichsen), 188. Operation for ruptured perineum (Thomas), 189. Drainage-tube and forked probe, . 190. Strapping an ulcer (Liston), 191. Scissors for skin-grafting, . 192. Diagram illustrating processes of thrombosis and 193. Scrofulous ulcer of leg (Erichsen), . 194. Gonorrhoea! epididymitis (Liston), . 195, 196. Ophthalmic gonorrhoea (Dalrymple), 197. Mucous patches (Miller), . 198. Syphilitic rupia (Druitt), . 199. Syphilitic panaris, .... 200. Syphilitic permanent teeth (Hutchinson), . 201. Maury's fumigating apparatus, 202. Sebaceous tumors and horn (Bryant), 203. Structure of a fatty tumor (Bennett), 204. Fatty tumor, showing lobated' appearance (Miller 205. Fibro-cellular tumor of labium (Holmes) 206. Structure of myxoma (Holmes), 207. Structure of fibrous tumor (Erichsen), 208. Structure of fibro-muscular tumor (Benne 209. Structure of enchondroma (Erichsen), 210. Large enchondroma of scapula, 211. Multiple enchondromata of hand (Druitt) 212. Cancellous exostosis of femur (Druitt), 213. Ivory-like exostoses of skull (Miller), 214. Adenoma of mamma (Rindfleisch), 215. Lymphoma (Green), 216. Painful subcutaneous tubercle (Smith), 217. Recurrent fibroid tumor (Green), . 218. Myeloid tumor (Billroth), . 219. Several varieties of sarcoma (Bryant), 220. Alveolar sarcoma (Billroth), 221. Section of scirrhous breast (Liston), 222. Scirrhus of breast, in stage of ulceration 223. Secondary growths of scirrhus (Miller), 224. Cells from a scirrhus of the mamma (Green), 225. Microscopic appearances of scirrhus (Green), 226. Medullary cancer in stage of ulceration (Druitt), 227. Microscopic appearances of medullary cancer (Green), 228. Melanoid cancer (Bryant), 229. Haamatoid cancer of breast (Miller), 230. Microscopic appearances of colloid cancer (Rindfleisch), 231. Epithelioma of lower lip, .... 232. Concentric globes of epithelioma (Green), 233. Ecraseur, ...... 234. Elliptical incision for removal of tumors, . 235. Double S incision for removal of tumors, . 236. Warts around the anus (Ashton), 237. Malignant onychia (Druitt), 238. Toe-nail ulcer (Liston), 239. Rodent ulcer (Mackenzie), . 240. Phagedenic lupus ulcer (Druitt), 241. Elephantiasis Arabum in lower extremity (Smith) 242. Felon (Liston), ..... embolism (Callender) LIST OF ILLUSTRATIONS. xxiii nto pericardium (Erichsen), s compressor, PIG. I 243. Compound ganglion, ..... 244. Enlarged bursa over the patella; housemaid's knee (Liston), 24"). Formation of seton with trocar and canula (Erichsen), . 246. Apparatus for treatment of bunion, 247. Section of a neuroma (Smith), .... 248. Application of pins to varicose veins (Miller), 249. Aneurism by anastomosis (Fergusson), 250. Nsevus; application of quadruple ligature (Liston), 251. Subcutaneous ligature of nsevus (Holmes), 252. Diagram of ligature of flat and elongated naevus (Erichsen), 253. Diagram of tied flat and elongated nsevus (Erichsen), 254. Fatty degeneration in inner coat of aorta (Green), 255. Atheroma of aorta (Green), ..... 256. Atheromatous ulcer of aorta (Liston), 257. Large fusiform aneurism of aorta bursting into pericardium (Erichsen) 258. Sacculated aneurism of aorta (Erichsen), . 259. Perforation of ribs by aortic aneurism (Pirrie), 260. Aneurism of innominate artery (Erichsen), 261. Stellate rupture of aortic aneurism 262. Diagram of Anel's operation, 263. Diagram of Hunter's operation, 264. Diagram of Brasdor's operation, 265. Diagram of Wardrop's operation, 266. Carte's compressor for the groin, 267. Gibbon's modification of Charriere 268. Carotid aneurism, 269. Osteoporosis of femur (Druitt), 270. Sclerosis and eburnation of femur (Liston) 271. Abscess in tibia (Holmes), . 272. Caries (Druitt), 273. Gouge-forceps, 274. Burr-head drill, 275. Central necrosis ; new bone with cloacse (Erichsen), 276. Sequestrum forceps, ..... 277. Necrosis of femur, following gunshot fracture, 278. Senile atrophy of neck of thigh-bone (Liston), 279. Scrofulous osteitis (Erichsen), 280. Osteo-sarcoma of forearm, .... 281. Enchondroma of femur, .... 282. Gelatinous arthritis of elbow, 283. Arthritis of knee-joint in advanced stage, . 284. Barwell's splint for continuous extension, . 285. Deformity in second stage of hip disease, . 286. Deformity in third stage of hip disease, 287. Excised head and neck of femur, showing change in shape of bone in third stage of hip disease, 288. Deformity from double hip disease (Hodge), 289. Sayre's short splint for hip disease, 290. Sayre's long splint for hip disease, . 291. Agnew's splint for hip disease, 292. Head of femur in rheumatoid arthritis (Druitt), . 293. Synostosis of hip-joint (Pirrie), 294. Anchylosis of knee-joint in position of over-extension, 295. Chronic arthritis of knee-joint, with partial anchylosis in bad position 296. Barwell's splint for continuous extension in anchylosis of the knee, 297. Bigg's apparatus for contraction of knee, . 298. Adams's saw for subcutaneous osteotomy, . 299, 300. Subcutaneous osteotomy of both thigh-bones 301. Trochlea of humerus, with loose cartilages, 302. Fergusson's lion-jawed forceps, 303. Butcher's saw, 304. Chain saw, .... 305. Butcher's knife-bladed forceps, 306. Excision of shoulder-joint (Erichsen 307, 308. Excised extremities of humerus and ulna, xxiv LIST OF ILLUSTRATIONS. FIG. 309. Excision of elbow-joint (Bryant), . 310. Result of excision of elbow-joint, . 311. Diagram of Lister's method of excising wrist-joint, 312. Diagram of Heyfelder's method of excising hip-joint 313. Excised head and neck of femur, . 314. Sayre's cuirass for hip-joint excision, 315. Result of hip-joint excision, 316. Excision of both hip-joints, 317, 318. Excised extremities of femur and tibia, 319. Price's splint for excision of knee-joint, 320. Wire splint for excision of knee-joint, 321, 322. Result of excision of knee-joint, 323. Tenotome, ..... 324. Lateral curvature of spine (Erichsen), 325, 326. Dupuytren's finger contraction, 327. Apparatus for knock-knee, . 328. Talipes equinus (Pirrie), 329. Talipes varus (Fergusson), . 330. Varus shoe, with jointed sole-plate, 331. Talipes calcaneus (Bryant), 332. Talipes valgus (Pirrie), 333. Spina bifida (Druitt), 334. Antero-posterior curvature of spine (Liston), 335. Caries of the vertebrae (Liston), 336. Sayre's suspension apparatus, 337. Sayre's jury-mast, 338. Granular lids (Jones), 339. Pterygium (Stellwag von Carion 340. Pannus (Jones), 341. Paracentesis corneas (Erichsen), 342. Prolapse of the iris (Miller), . 343. Abscission of staphyloma (Stellwag von Carion) 344. Critchett's operation for staphyloma (Lawson), 345. Iritis; showing ciliary zone of sub-conjunctival injection 346. Lance-shaped iridectomy knife, 347. Curved iris forceps, . 348. Liebreich's bandage (Lawson), 349. Tyrrell's hook, 350. Iridodesis (Lawson), 351. Canula forceps, 352. Spatula hook, 353. Flap extraction of cataract (Wells), 354. Cystotome and curette, 355. Traction spoons, 356. Von Graefe's cataract knife, 357, 357 a. Diagram of Von Graefe's operation for cataract 358. Von Graefe's hook, .... 359. Bowman's stop-needle, 360. Hays's knife-needle, 361. Canula scissors, .... 362. Liebreich's portable ophthalmoscope, 363. Use of the ophthalmoscope (Erichsen), 364. Galezowski'sstrabismometer, 365. Strabismus hook, .... 366. Snellen's forceps, .... 367. Entropion forceps, .... 368, 369. Adams's operation for ectropion (Lawson), 370. Symblepharon (Mackenzie), 371. Bowman's canaliculus knife, 372. Toynbee's ear speculum, 373. Wilde's snare for aural polypus, 374, 375. Forceps for aural polypus, 376. Politzer's method of inflating the tympanum, 377. Toynbee's artificial membrana tympani, . 378. Application of the otoscope (Toynbee), (Pirrie), LIST OF ILLUSTRATIONS. 379. Catheter for Eustachian tube, 380. Siegle's pneumatic^speculum, 381. Lipoma (Liston), ..... 382. Plugging the nostril with Bellocq's sound (Fergusson) 383. Posterior nasal syringe, .... 384. Gooch's double canula, .... 385. Fibrous polypus of the nose producing frog-face, . 386. Rhinoplasty by Indian method (Fergusson), 387. Pancoast's tongue and groove suture, 388. Diagram of Syme's rhinoplastic operation, 389. Diagram of Burow's plastic operation, 390. Formation of prolabium by Serres's method, 391, 392. Serres's cheiloplastic operation, modified (Erichsen) 393, 394. Buchanan's cheiloplastic operation (Erichsen), 395. Result of Syme's cheiloplastic operation, . 396, 397. Operation for restoration of upper lip and angle of mouth, 398, 399. Restoration of upper lip (Sedillot), . 400. Diagram of single harelip (Holmes), 401. Cheek-compressor for harelip (Fergusson), 402. Malgaigne's operation for harelip, . 403. Double harelip, with projecting intermaxillary portion (Holmes 404. Macrostoma, ..... 405. Bronchocele (Greene), 406. Tumor of parotid region (Fergusson), 107. Ranula, between floor of mouth and mylo-hyoid muscles (Fergusson ■ >*8. Wood's gag for operations on the tongue, . 409. Regnoli's mode of exposing tongue (Erichsen), 410. Removal of tongue by division of lower jaw and ecraseur (Erichsen) 411. Fibrous epulis (Bryant), 412. Encephaloid of antrum (Liston), . 413. Osteoma of upper jaw, 414. Excision of upper jaw (Fergusson), 415. Disarticulation of lower jaw (Fergusson), 416. Whitehead's gag and tongue-depressor, 417. Sedillot's operation for staphylorraphy, 418. Forceps-scissors for cutting uvula, . 419. Fahnestock's tonsillotome, . 420. Stricture of the oesophagus (Druitt), 421. Epithelioma of larynx (Erichsen), . 422. Gibb's laryngeal ecraseur, . 423. Simple hypertrophy of breasts (Bryant), . 424. Strapping the breast (Druitt), 425. Brodie's sero-cystic sarcoma of breast (Druitt), 426. Mammary sarcoma with large cysts, 427. Excision of the breast (Fergusson), 428. Scrotal hernia in a child, 429, 430. Johnson's probe-knife for subcutaneous herniotomy, 431. Strangulated hernia; stricture in neck of sac (Erichsen), 432. Strangulated hernia; gangrene of intestine (Liston), 433. Herniotomy; searching for seat of stricture (Liston), 434. Hernia-knife, . . . . . • 435. Oblique and direct inguinal hernise, 43ii. Hernia into vaginal process of peritoneum (Pirrie), 437. Hernia into funicular portion of vaginal process, 438. Common inguino-scrotal hernia (Pirrie), . 439. Encysted hernia (Liston), . 440. Wutzer's apparatus for radical cure of hernia, 441. Agnew's instrument for radical cure of hernia, 442. Wood's operation for radical cure of hernia, 443. Incision for strangulated inguinal hernia (Fergusson) 444. Femoral hernia (Erichsen), .... 445. Incision for strangulated femoral hernia (Fergusson), 446. Internal strangulation by a diverticulum (Pirrie), 447. Lumbar colotomy (Bryant), 448. Imperforate anus (Ashton) .... xxvi LIST OF ILLUSTRATIONS. FIG. 449. 450. 451. 452. 453. 454. 455. 456. 457. 458. 459. 460. 461. 462. 463. 464. 465. 466. 467. 468. 469. 470. 471. 472. 473. 474. 475. 476. 477. 478. 479. 480. 481. 482. 483. 484. 485. 486. 487. 488. 489. 490. 491. 492. 493. 494. 495. 496. 497. 498. 499. 500, 503. 504. 505. 506. 507. 508. 509. 510. 511. 512. 513. 514. 515. Imperforate rectum (Ashton), Fibrous stricture of rectum (Ashton), Malignant stricture of rectum (Ashton), Rectal speculum, Protruding hemorrhoids (Ashton), Ring forceps for piles, Smith's clamp for piles, Bushe's needle and needle-carrier, . Partial prolapsus of rectum (Bryant), Section of complete prolapsus of the rectum (Druitt) Anal truss, . Tapping the abdomen (Fergusson), Sims's uterine probe, Siphon trocar, Fitch's trocar and canula, . Atlee's clamp, Sims's catheter, Uric acid deposits (Holmes), Uric acid calculus (Gross), . Oxalate of lime deposits (Holmes), Mulberry calculus (Miller), Phosphate of lime (Holmes), Triple phosphate (Holmes), Cystine calculus (Roberts), . Alternating calculus (Erichsen), Sound for examining bladder, Thompson's hollow sound, with slide and scale, . Sounding for stone behind prostate (Erichsen), . Sounding for stone above pubis (Erichsen), Sounding for encysted calculus (Erichsen), Weiss and Thompson's improved lithotrite, Fergusson's lithotrite, .... Introduction of the lithotrite (Erichsen), . Position of lithotrite in crushing the stone (Liston), Bigelow's lithotrite, ..... Clover's evacuating apparatus, Bigelow's evacuating apparatus for litholapaxy, . Urethral forceps, Lithotomy staff, ..... Lithotomy forceps, ..... Lithotomy scoop, ..... Tube for plugging wound in lithotomy, Position of patient and incision in lateral lithotomy (Erich Deep incision in lithotomy (Fergusson), . Position of finger and scoop in extracting stone (Erichsen) Physick's cutting gorget, Frere Come's lithotome cache, Dupuytren's lithotome cache, Bilateral lithotomy, . Urethral dilator, Female staff, . , 501, 502. Plastic operation for extroversion of bladder Keyes's apparatus for washing out the bladder, Polypoid tumors of the bladder (Civiale),. Enlarged median lobe of prostate (Erichsen), Hypertrophied bladder and prostate (Thompson), Mercier's elbowed catheter, Prostatic catheters, .... Squire's vertebrated prostatic catheter, Catheterization in enlarged prostate (Erichsen), . Puncture of bladder through rectum, and above pubis (Phillips French flexible bougie and catheter, Bougie a boule, Introduction of the catheter (Voillemier) Desormeaux's endoscope, LIST OF ILLUSTRATIONS. XXvii FIG. 516. 517. 518. 519. 520. 521. 522. 523. 524. 525. 526. 527. 528. 529. 530. 531. 532. 533. 534. 535. 536. 537. 538. 539. 540. 541. 542. 543. 544. 545. 546. 547. 548. 549. 550. 551. 552. 553. 554. 555. Epispadias; Duplay's operation, Hypospadias; Duplay's operation, Stricture of urethra at sub-pubic curvature (Thompson), Stricture of urethra near orifice (Thompson), False passages (Druitt), Thompson's stricture expander, Holt's instrument for splitting stricture, . Civiale's urethrotome, Syme's staff for external division of stricture, Tapping the urethra in the perineum (Bryant), Papillary tumor of female urethra (Boivin), Urinary fistulas in the male (Liston), Dieffenbach's lace suture, . Urethroplasty by Dieffenbach's method (Erichsen), Urethroplasty by Le Gros Clark's method (Erichsen), Duck-billed speculum for the vagina, Emmet's vaginal speculum, Knife for vesico-vaginal fistula, Operation for vesico-vaginal fistula; sutures in position (Simon), Coghill's wire twister, .... Bozeman's button suture, .... Operation for vesico-uterine fistula (Thomas), Transverse obliteration of the vagina (Simon), Circumcision (Erichsen), .... Reduction of paraphimosis (Phillips), Hypertrophy or elephantiasis of scrotum (Titley), Epithelioma of the penis, .... Epithelioma of the scrotum (Curling), Strapping the testicle (Velpeau), . Hernia of the testicle (Curling), Tapping for hydrocele (Erichsen), . Wood's instrument for varicocele, . Cystic sarcocele (Bryant), .... Division of spermatic cord in castration (Erichsen), Cylindrical speculum for the vagina, Cusco's vaginal speculum, .... Thomas's clamp for elytrorrhaphy, Fibro-cellular uterine polypus protruding from vulva (Boivin and Dug Interstitial uterine fibroid (Barnes), .... Amputation of the cervix uteri with the ecraseur (Chassaignac), ADDENDA. While these sheets have been passing through the press, and since page 152 was printed, Prof. Lister has, through his assistant, Mr. W. W. Cheyne (Anti- septic Surgery, its Principles, Practice, History, and Results. By W. Watson Cheyne, M.B., F.R.C.S., etc. London, 1882), at last responded to the repeated challenges of other British surgeons, by publishing, in more or less detail, statis- tics of his practice for the last ten years, together with a very large number of figures, chiefly derived from German sources, showing the results of the Antisep- tic Method in the hands of other operators. I have examined Mr. Cheyne's tables with a great deal of interest, but do not find that the results there recorded are better than those which are habitually obtained, in this country at least, by care- ful surgeons who do not adopt the Antiseptic System. The statistics from Ger- man surgeons do not embrace sufficient details to make them of much value for comparison with those of other operators, but they certainly show an improvement over the rather frightful mortality from operations which seems to have formerly prevailed in German hospitals. Whether, however, this improvement is solely due to the adoption of Listerism, cannot, it seems to me, be decided from the facts which have thus far been published. A twenty-second case of ligation of the innominate artery is to be added to those tabulated on page 571, the operator being Mr. W. Thomson, of the Richmond Hospital, Dublin. The ligature employed was that made from the aorta of the ox, as advised by Mr. Barwell: the patient died from hemorrhage on the forty- second day. Additional cases of oesophagostomy have been reported by Mr. Reeves and Mr. Holmes, and one of ozsophagotomy (for foreign body) by Mr. Spanton. Additional gastrostomies have been recorded by several surgeons, in- cluding Kni, Fowler (of Brooklyn), Langton, Vincent Jackson, and MacCormac. Tait, Cullingworth, and Eldert have recorded nephrectomies, and Fowler (of Bath) a nephrotomy for pyo-nephrosis. Rydygier is credited (by a writer in the Gazette Medicale de Paris) with a second (fatal) case of extirpation of the pylorus, and another pyloric gastrectomy (successful) is attributed to Van Kleef, of Bel- gium. This case, with Tait's and Elder's nephrectomies, and MacCormac's gastrostomy, is to be added to the list of successful operations in abdominal sur- gery. Holmes's, Spanton's, Langton's, and both the Fowlers' cases are known to have terminated fatally. THE PRINCIPLES AND PRACTICE OF STJKGERY. The word Surgery, or Chiruryery, as it was formerly written, is derived from the two (ireek words xe'lP (the hand) and "epyov (a work). In its earliest and narrowest signification, it was therefore limited to certain manual opera- tions, which we accordingly find that the surgeon was formerly in the habit of executing under the direction and guidance of the physician, who Avas considered as occupying a higher grade in the profession, and who took entire charge of, and was responsible for, the management of the constitutional condition of the patient. In the modern application of the term, however, surgery embraces a far wider field; and hence the division adopted in France, into internal and external pathology, is in some respects preferable to that into medicine and surgery, which is habitually used in England and in this country. The consideration of surgical affections naturally divides itself into the discussion of (1 ) Surgical Injuries, and (2) Surgical Diseases. These will therefore form the topics of the principal divisions of this work. As, how- ever, the condition known as Inflammation, or the Inflammatory Process, with the corresponding constitutional state designated by the term Inflam- matory Fever, are common attendants upon both classes of affections, it will be convenient to consider these before entering upon the two great divisions of the subject; more especially as without definite ideas as to the course and treatment of inflammation, the student can scarcely hope to pursue his further investigations into surgical science with either pleasure or profit. It will likewise be convenient, in this introductory portion of the work, to consider the subjects of operations in general and the use of anaesthetics, together with the lesser manipulations usually classed as belonging to minor surgery, and the various amputations, which are applicable to so many dif- ferent lesions and morbid conditions, as to entitle them to be looked upon rather as a part of general than of special surgery. CHAPTER I. INFLAMMATION. Inflammation, or the Inflammatory Process, may be considered from two points of view: the Pathological and the Clinical. In discussing it clinically, its causes, symptoms, course, terminations, and treatment will be 3 34 INFLAMMATION. successively dwelt upon; but it will be better, in the first place, to examine briefly into what is known of its nature and pathological phenomena. Pathology of Inflammation. Inflammation was formerly considered as a disease, an entity, a something superadded to the natural condition of the part. This view is now almost universally abandoned, and authors, though differing as to the proper expla- nation to be given of many of the phenomena of inflammation, are, I think, generally agreed that those phenomena are mere modifications of the phe- nomena of natural, textural life. These changes, which are always due to the action of an irritant, no matter whence derived, may be observed as affecting the phenomena respectively of function, nutrition, and formation, and in each the changes are primarily$& the direction of excess. Changes of Function.—Thus, as regards function, the first effect of an irritant upon muscular fibre is to produce contraction (an increased func- tional activity), followed by nutritive changes, and, possibly, the formation of new material, pus, etc. Irritation involving a nerve of special sense will similarly be attended in the first place by functional disturbances, flashes of light and photophobia in the case of the optic, and tinnitus aurium and increased sensitiveness to sound in the case of the auditory nerve. The application of an irritant to a secreting gland will, in the same way, cause excessive functional activity, manifested by increased secretion. The in- creased functional activity may in any case be succeeded by perverted or diminished action. Changes of Nutrition.—The consideration of the modified phenomena of nutrition which are due to inflammation, brings up the question of the share taken by the blood and its containing vessels in the process under discus- sion. That the quantity of blood in an inflamed part is increased, and that the size of its bloodvessels is greater than in corresponding uninflamed struc- tures, was so patent as to have been the subject of early observation; and hence it is not surprising that, in the absence of more accurate investiga- tions, all the phenomena of inflammation should have been attributed (as was the case for many years) to what was called an " altered activity of the bloodvessels." Modern pathology has, however, shown that nutrition and formation are due to cell-action, and that the office of the bloodvessels is purely that of a servant, to bring new material, and to remove that which is effete and useless. Hyperemia.—While, as has been said, the quantity of blood is increased in a part which is inflamed, or in which the inflammatory process is in pro- gress, this increase, or ITypercemia, is not necessarily a part of, nor in any way connected with, inflammation. A simple reference to any of the erec- tilevtissues of the body will suffice to illustrate this point. Again, there may be a true hypercemia, dependent on purely mechanical causes, such as the application of a tight bandage, the pressure of a tumor preventing the return of venous blood from a part, or a diminution of the natural elasticity of the walls of the bloodvessels themselves, not an unfrequent coincidence of the general loss of tone which usually attends advancing age. These forms of hyperemia, which are always passive and due to mechanical causes, are properly designated by the term Congestion, which might well be reserved for these conditions; the form of hypersemia which many writers have called Active Congestion being more conveniently distinguished by the name Flux- ion (a term used by Billroth), or Determination. CHANGES OF NUTRITION. 35 Ditirmhiatlon is essentially an active condition. It is, as we shall here- after see, clinically speaking, the first stage of Inflammation. A familiar example is the active hyperemia of the mammary gland which is apt to occur a few days after parturition, and which is sometimes with difficulty prevented from running into absolute inflammation of the part. While de- termination has been spoken of as an active condition, it is not to be looked upon as a cause of the nutritive and other changes which accompany it in the inflammatory process, but rather as caused by them. As Mr. Simon has well put it, "A part does not inflame because it receives more blood. It receives more blood because it is inflamed." The vessels of an inflamed part are then enlarged. Whether this enlarge- ment is primary or not, has been doubted. As we have seen that the first effect of an irritant is to increase functional activity, and as contraction is the manifestation of functional activity proper to the vessels in a state of health, it would be natural to infer that the primary effect would be contrac- tion. As a matter of observation, it is found that the condition varies accord- ing to the nature of the irritant employed, and, as F. Darwin suggests, may depend upon whether the inhibitory or constrictor fibres of the vaso-motor nerves are most affected. When the inflammatory process is established in a part, there can be no question that its vessels are dilated. This fact, as regards the arteries and veins, has been a matter of common observation from the days of Hunter to our own, and as regards the capillaries it has been repeatedly established by the now classical microscopic observations of the web of the frog's foot or bat's wing. Not only are the arteries dilated in inflammation, thus admitting more blood, but they become elongated and tortuous; they have also been observed to become pouched at points, pre- senting at different parts of their walls aneurismal or fusiform dilatations. The red corpuscles of the blood likewise find their way into vessels which in the uninflamed state were too narrow to admit of their entrance. More blood is brought to an inflamed part than the same part would re- ceive in health, and more blood is likewise carried through it when inflamed than when healthy. This was shown by an experiment of Lawrence, draw- ing blood from both arms of a patient who had a whitlow on one hand and not on the other. With regard to the immediate cause of the hypersemia of inflammation, it would appear to be due to an increased attraction exerted by the tissues of the inflamed part upon the blood circulating within its minute vessels. This theory, the germ of which may be found in the writ- ings of Haller, seems more consonant with what is known of the textural changes which occur in inflammation than either the now exploded view of an increased activity of the vessels themselves, or the notion of a vis a tergo which would make the hypersemia due to increase of the heart's action, an increase which, as we shall see hereafter, is rather an effect than a cause of the inflammatory process. Blood changes.—Beside the changes which are observed in the blood- vessels, in the course of inflammation, the blood itself undergoes certain alterations. The red corpuscles adhere together by their flat surfaces, forming aggre- gations or clusters, and tend to produce the stagnation which is observed in the capillary circulation under the microscope. In the. later stages of in- flammation, the number of red corpuscles falls considerably below the nor- mal standard. The white corpuscles appear to be increased in number in the blood of an inflamed part. It is, however, doubtful whether this increase be absolute or only relative, the number of red corpuscles, as lias been seen, rapidly dimin- ishing as the inflammation continues. The white corpuscles adhere to the 36 INFLAMMATION. sides of the vessels, and thus further increase the tendency to stagnation of the circulating fluid. The proportion of fibrin in the blood is notably increased in inflammation. It is estimated by Andral and Gavarretthat its proportion may rise from 2i in 1000 parts to 10 per 1000. The albumen and salts of the blood are some- what reduced in amount, and the proportion of water somewhat increased by the inflammatory process. Owing to the changes in the constitution of the blood in inflammation, its mode of coagulation differs from that of blood in the normal state. The cras- samentum or clot forms more slowly than in health, and is smaller and firmer in consistence. The slowness of coagulation and the increased cohe- siveness of the red corpuscles allow the separation of the fibrin and white corpuscles to take place before the process of clotting is completed, and this gives rise to the peculiar appearance which is known as the buffy coat. This buffy or fibrinous coat is somewhat contracted and elevated at the sides, and depressed in the centre, whence the clot of inflammatory blood is said to be cupped. Other nutritive changes.—The modifications of the phenomena of nutrition due to inflammation are not confined to the blood and bloodvessels. Impor- tant changes take place in the parenchymatous tissues, and it is indeed in these that, according to Virchow, the first manifestations of the inflammatory process are to be traced. The parenchymatous tissues become swollen, the swelling being, according to Virchow, due to the fact that the cells of the part become enlarged, through the absorption of new material; this power of taking up an increased quan- tity of material is, according to the doctrines of the cellular pathology, inhe- rent in the cells themselves, and not dependent upon any previously estab- lished modification in the vascular or nervous state of the part. According to Billroth, however, the first step is a distention and increased pressure in the capillaries, a larger quantity of blood plasma than in the normal state thus passing into the surrounding tissues, the swelling of which is therefore only a secondary phenomenon. The nervous tissues, likewise, doubtless undergo modification in the inflam- matory process, and by a form of reflex action, which it would be foreign to the scope of this work to consider, react in time upon both bloodvessels and parenchyma. The swelling of the parenchymatous tissue, which is, according to Virchow, at first scarcely distinguishable from a true hypertrophy and which may be conveniently designated as temporary hypertrophy, together with the accom- panying vascular and nervous changes, correspond to what will be hereafter spoken of as the first stage of inflammation. Formative Changes; Lymph and Pus.—The third series of changes to be noticed as due to inflammation, are the formative, consisting in the formation of the substances known to surgeons as lymph and pus. A micro- scopic examination of inflamed tissue, made at a period varying from a few to twenty-four hours after the commencement of the inflammation, shows the part to be filled with a large number of cells, about 2x00" °f an inch in diameter, spherical or nearly so, pellucid, and colorless or grayish-white. The origin of these cells, which are commonly called lymph cells or cor- puscles, and which form the corpuscular element of what is known as in- flammatory lymph, cannot be said to be positively determined. The doctrine which was generally received a few years ago, and which taught that the lymph corpuscles resulted from molecular aggregation, in a substance ex- uded from the bloodvessels in a fluid condition and subsequently coagulated FORMATIVE CHANGES. 37 is now almost universally abandoned; and the three theories which at pres- ent chiefly divide the suffrages of pathologists are, (1) Virchow's, which looks upon the newr cellular elements as the result of proliferation1 of pre- existing cells; (2) Cohnheim's, which regards the cells of inflammatory lymph as identical with the white blood corpuscles and cells found in the lymphatic vessels: as identical, in fact, with the wandering cells2 which Recklinghausen has described as existing in connection with the ordinary connective-tissue corpuscles; and (3) Strieker's, which ascribes the new cells to a retrograde metamorphosis of tissue, in which the part returns to the embryonic con- Fig. 1. dition; the basis substance itself, as well as the previously existing cells, thus taking a share in the new production.3 Inflammatory lymph, as ordinarily observed by the surgeon, is a yellowish or grayish-white, semi-solid sub- stance, which is somewhat elastic and semi- transparent, resembling a good deal the buffy coat of an inflammatory clot. Chemically, it consists of fibrin with an admixture of oily and saline matters,* while when examined 'mleroscoplcidly, it is found to contain fibrils5 and corpuscles (which have already been re- Corpuscles and filaments in recent ferred to), in varying proportion. The fibrd- lymph. (Bennett.) Ions, or as Paget calls it, fibrinous element of lymph, is, according to that author, probably exuded from the capillary bloodvessels in a fluid state, and subsequently coagulated; that there is in inflammation an exudation from the capillaries into the surrounding tissue, is, as we have already seen, in accordance with the doctrines of Billroth and 1 It would appear from the observations of Virchow and others, that new may origi- nate from previously existing cells, by one of two processes, viz., (1) division, and (2) endogenous growth, or the formation of new cells within the cavity of the old. The first process, or that of simple division, is much the more common, and is that to which the term proliferation is habitually applied. The first thing observed in this process is the enlargement of the nucleolus, which subsequently becomes constricted in the middle, and finally divides into two. Afterwards the nucleus, and finally the cell it- self, undergo similar changes, and thus from one, two or more new cells are developed. The second process, that of endogenous cell-formation, is extremely seldom met with, and indeed the possibility of its occurrence has been doubted by some writers. It is said sometimes to occur normally in cartilage, the supra-renal capsules, the pituitary body (Kolliker), and the thymus gland (Virchow); and has, according to Paget, been met with in certain encephaloid and epitheliomatous tumors. 2 These cells, in common with many others, possess a power of spontaneous move- ment which, from its resembling that of the amoeba, has been called amoeboid or a.ma>baform; they probably originate in the lymphatic system, from which they pass into the bloodvessels, wandering thence into the surrounding tissue, where they may become fixed, or whence they may wander back again and re-enter the circulation. 3 According to Strieker, the theory of the migration of cells is based on an illusion ; the supposed "wandering" is simply the rapid conversion of basis substance into cells, and the reconversion of cells into basis substance; in other words, it is the image seen under the microscope that wanders, and not the cell itself. (Article on Pathology of Inflammation. International Env.yc.tonmlm of Surgery, vol. i., p. 35.) 4 According to Hoppe-Seyler, the lymph corpuscle contains glycogen while its power of movement continues, but upon becoming rigid (transformation into pus cell) loses its glycogen and contains sugar. 5 Paget speaks of fibrinous and corpuscular lymph, this division corresponding pretty closely to that of Williams and others into plastic and aplastic, and to that of Eoki- tansky into fibrinous and croupous lymph. Inflammatory lymph is, however, essen- tially the same under all circumstances, though the relative proportion of its constituents may vary in different cases. oo INFLAMMATION. other modern German pathologists; and it is to this exudation that the characteristic succulence of inflamed parts is due. It cannot, however, I think, be considered as established that this exudation takes any direct part in the formation of lymph. According to Billroth, during the active cell- wandering which has been described as taking place in an inflamed part, the filamentary intercellular substance of the connective tissue itself grad- ually changes to a homogeneous, gelatinous substance.1 Hence it would appear not improbable that both elements of inflammatory lymph may originate in pre-existing structures, the corpuscular from an increase in the number of wandering cells, from proliferation of the ordinary connective tissue cells, or from both sources, as well as from a return of the basis sub- stance to an embryonic condition, and the fibrillous element also from a transformation of the intercellular substance. Lymph is said to be absorbed, to be developed into new tissue, or to undergo various forms of degeneration. In some cases where absorption of lymph is supposed to have taken place, it is probable that the true pathological con- dition has been rather the temporary hypertrophy before referred to, due to the nutritive changes introduced by inflammation, without any lymph having been really produced. There can be no doubt, however, that lymph can actually disappear by a process which may be properly called absorption, as is not unfrequently seen in cases of iritis. When lymph is absorbed, the lymph corpuscles may be gradually utilized in the normal nutrition of the part, being converted into ordinary con- IG' ' nective-tissue corpuscles, or may possibly / ,/, t resume their migratory habits and re-enter .-'' // // /: ,• .' / the circulation. In the development of ?-o0 '".\/" ** lymph into new tissue, it passes through \ ' < - • / *'. the fibro-cellular condition, beyond which, '' ~*-'*°. • ; ' /? indeed, it frequently does not advance. It -.;.' ^f*-., --'; .,;.•£/ /?' is this material which constitutes the ad- - , ^ „./' hesions, bands, etc., which are so frequently ''*~&^\----?€*<--.......rf^^ met w^n after the inflammatory process "' "." ".r.'.^of.yTr"'" has subsided. Lymph that undergoes de- • —r->- velopment becomes vascular; new vessels Fibro-plastic and fusiform cells from re- jn ft apparentlv originating from cent lymph on the pericardium. Similarcells ,/ • .1 t " • in are found in granulations. (Bennett.) th°Se ™ the Grounding tlSSUeS, and form a capillary net-work through which the circulation is carried on. It is somewhat doubtful as yet whether any pro- duction of nerve-fibres takes place in lymph that has become developed into new tissue. The lymph corpuscles during the process of development pass through the forms which have been variously designated as plastic cells, fibro-cells, fibro-plastic or caudate cells, etc. (see Fig. 2). Lymph may undergo various forms of degeneration, as the calcareous, fatty, or granular (the degenerated lymph cells forming the so-called granule or granular cells, inflammatory globules, etc.); it may become the seat of pigmentary deposits, or, when exposed to the air, may'form shrivelled and horny masses of effete material. Finally (a frequent change), lymph may be transformed directly into pus; the second stage of inflammation, that of lymph formation (lymphization, lympho- genous), then passing into the third stage, or that of pus formation (pyogenes] s). Pus is a creamy, whitish-yellow fluid, sometimes having a greenish tino-e' 1 Virchow also refers to this liquefaction (as he calls it) of the intercellular substance of connective tissue, as accompanying proliferation. Strieker, as already remarked maintains that, in inflammation, the entire tissue returns to an embryonic condition' FORMATIVE CHANGES. 39 thick, opaque, smooth, and slightly glutinous to the touch, with a faint odor and slightly sweetish taste. It is of variable specific gravity, ranging from 1.021 to 1.042, and is neutral or slightly alkaline in its reaction. This description is to be understood as applying to what is called healthy or laud- able pus, derived from an ordinary suppurating wound in a person of good constitution. Beside this form, surgeons speak of sanlous pus (mixed or tinged with blood), ichorous pus (when it is thin and acrid), and curdy pus (when it contains cheesy-looking flakes). Muco-pus and sero-pus are of course pus mixed respectively with mucus and serum. Chemically, pus contains water, albumen, pyine (which appears to be almost identical with fibrin), fatty matters, Fig. 3- and salts. When formed in connection with diseased bone, pus has been found to contain 2 J per cent, of the granular phos- phate of lime, and Mr. Coote, in Holmes's System of Surgery, quotes from a paper by by Dr. (libb, of Canada, ten cases in which pus presented a blue1 color from contain- ing the cyanuret of iron. Orange-colored ^T •^fz&C', pus has been observed by Delore, Broca, Vemeuil, and Other SUl'geOnS.2 Pus corpuscles, a. From a healthily granu- Under the microscope, pus is found to lat,nf wound- b- F;°m an abscess !n th? „ i n • • i areolar tissue, c. The same treated with consist of corpuscles floating m a homo- dilute acetic acid d From a sinus in bone geiieOUS liquid (HqUOr purls). These COr- (necrosis). e. Migratory pus-corpuscles. puscles, which are variably termed pus (Rindfleisch.) corpuscles, pus globules, or pus cells, have a diameter ranging from -g-oVg-th to -guVoth °f an incn- Tney usually con- tain several nuclei, which become apparent upon the addition of acetic acid. With these pus corpuscles there are commonly found granular mat- ter, shreds of fibrin, and disintegrated lymph corpuscles. The above de- scription applies to what must be called dead pus cells,3 the living cells pos- sessing the power of active amoeboid movement, and corresponding in every respect with the wandering cells already referred to. It is even more difficult to speak positively of the origin of the pus cell than of that of the lymph corpuscle. In many cases (as in abscesses) the former seems to originate directly from the latter by a simple liquefaction of the gelatinous intercellular substance of lymph (p. 38) ; but in other instances the pus cell appears to have a different source. Virchow and other observers believe that pus corpuscles originate from rapid proliferation (luxurlatlon) of connective-tissue and other nucleated 1 Billroth and others speak of blue suppuration, resulting from the development of small vegetable organisms in the pus of a wound, but the coloring matter (which, according to Sedillot, pertains not to the pus cells but to the liquor puris, and may .also be found in the serum of the blood) has been isolated in a crystalline form by Fados, who calls it pyocyanine; it is believed by Boucher and Jacquin to be of vege- table origin. Longuet recognizes three varieties of blue suppuration, viz., (1) that due to a change in the fluids of the part (true blue suppuration); (2) that due to the development of vegetable organisms; and (3) a third variety, which he calls cyano- chrosis, which he believes to be due to the presence of an unknown substance, and which occurs epidemically, and particularly when the atmosphere is charged with ozone. 2 The color of orange pus is, according to Kobin, due to the presence of hematine or crystals of hematoidine; it is often, though not exclusively, met with in pyiemic cases, and is believed by Verneuil to indicate the existence of some grave constitu- tional condition, such as alcoholism, diabetes, phosphaturia, etc. 3 The absence of glycogen may, according to Hoppe-Seyler, serve to distinguish the pus cell from the lymph corpuscle. (See note to p. 37.) 40 INFLAMMATION. cells, while Cohnheim,1 on the other hand, maintains that the sole origin of the pus corpuscle is the migration by amoeboid movement! of the white blood corpuscles through the vascular walls.2 Prof. H-tricker, again, denying the migration of cells, maintains that pus is formed by the return of tissue— basis substance as well as cells—to an embryonic condition, setting free masses of protoplasm, which divide into amoeboid cells, these being mingled with granules, shreds from the cell net-work, and portions of tissue debris which lose their connection with surrounding parts before the suppurative process is completed, while Schiff declares that pus cells arise by prolifera- tion of the endothelial cells of the vessels of the inflamed part, a catarrhal condition of the lining coats of the vessels thus causing a true suppuration in the blood, before its occurrence in the parenchymatous tissues. Destructive Changes due to Inflammation.—We have now traced in- flammation through its nutritive and formative changes, considering in succession the temporary hypertrophy from cellular enlargement, and the development of lymph and of pus, both forms of new material derived from pre-existing elements in the part inflamed. We have next to consider the inflammatory process as affecting already formed tissue in another way, namely, by degeneration or liquefaction. The application of an irritant, such as a blister, excites the inflammatory process, causing the formative changes which have been described, to occur beneath the cuticle. But the cuticle itself undergoes a change, and is thrown off as effete material, leav- ing a raw surface or abrasion. If the irritant act with greater intensity (as in the case of a burn), the destructive effect will be greater, the superficial tissues being thrown off in larger or smaller masses, and an ulcer being left. When the process is accomplished by the death of visible particles, it is called sloughing or gangrene, and the separated parts are called sloughs; when the particles thrown off by the destructive action are indistinguish- able to the eye, the process is called ulceration. Ulceration and gangrene cannot be looked upon as essential parts of the inflammatory process ; they are indeed often regarded as terminations or effects of inflammation rather than as themselves parts of the process in question. Pathological Summary.—Let us now, before entering upon the clinical study of inflammation, briefly recapitulate what has been said as to its pathological phenomena. The inflammatory process, according to the de- gree of irritation present, modifies the phenomena of natural textural life as regards function, nutrition, and formation : in each case the modification is primarily in the direction of excess. As regards function, there is first increased activity, followed by perversion, and eventually, perhaps, bv dimi- nution or even total abolition. The nutritive changes are shown in' an al- tered state of the vascular system of the part (hypersemia, determination); in an altered state of the blood itself; in an altered condition of the paren- 1 Mr. William Addison, more than a third of a century ago, maintained " that pus corpuscles of all kinds are altered colorless blood corpuscles; and that no new elementary particles are formed by any inflammatory or diseased action'.'"' (See his "Experimental Researches," etc., in Trans. Prov. Med. and Surg. Assoc. vol. xi., pp. 247-253.) Dr. Augustus Waller, also, in 1846, described the passage of white blood corpuscles through the walls of tbe capillaries. 2 A recent writer, however, Dr. Eichard Caton, concludes from observations on the frog, fish, and tadpole, that (1) the migration of white corpuscles is due not to amoebaform movements, but to congestion, as in the case of escape of red corpuscles and that (2) suppuration may exist without migration (" ausvmnde?'ung") and on the other hand, migration may exist without suppuration (Journ. of Anat. \nd Physiol., Nov., 1870). Strieker, as already remarked, believes that the whole theory of migration is based upon an optical illusion. ^ CAUSES. 41 chvma (temporary hypertrophy); and in a change as regards the neurotic condition, which doubtless reacts upon both vessels and parenchyma. The formative changes consist in the production of lymph and of pus. There may be also a d est met Ion of existing tissue, resulting in its being thrown off as effete material by the processes of Ulceration or gangrene. Clinical View of Inflammation. In the clinical study of inflammation, there are to be considered succes- sively its causes, its symptoms, its course, its terminations, and its treatment in its various stages and conditions. Causes.—The causes of inflammation may be divided into the predis- posing, and the exciting or determining causes. The predisposing causes may be said, in general terms, to be any circumstances which impair the general health of an individual, or which render his tissues less capable of resisting the injurious influences to which they may be subjected. Thus the various conditions of a person's life, the nature and amount of food which he consumes, the thermometric and other meteoric conditions to which he is subjected, the nature of his occupation, his having been affected with various diseases at previous periods of life, even his age, temperament, etc., may all be considered at times as causes predisposing to the development of the in- flammatory process. The exciting or determining causes are usually said to be either heal or constitutional, arising either from ivithout or from within. I think, however, that it is more correct to look upon the determining causes of inflammation as always local or external, those which are commonly con- sidered as acting constitutionally, being really either predisposing causes, or else properly to be termed local, though acting from within the body, and therefore, in that sense of the word, internal. The determining causes of inflammation are either mechanical or chemical. Among the mechanical causes are to be enumerated the results of external violence, blows, cuts, wounds of all kinds, fractures and dislocations (in these cases acting from within the body), the presence of foreign bodies, whether introduced from without or originating internally (as a renal calculus), dis- tention of parts, as in the cutaneous inflammation which often accompanies dropsy of the lower extremities, and compression, whether from without or from within. Among the chemical causes may be classed heat and cold, the application of acids or alkalies, poisoning of the blood by septic matters, various forms of contagion, as of gonorrhoea or chancre, etc. Certain forms of nerve lesion may probably be considered determining causes of inflamma- tion. It has long been known that injuries or diseases of nerves may act as predisposing causes, by diminishing the natural power of the tissues to resist the external influences to which they are constantly and unavoidably sub- jected ; thus after spinal injuries, sloughing of the paralyzed parts may be produced by circumstances which Avould have no perceptible influence in a state of health, and carbuncle, a disease in the progress of which inflamma- tion plays a prominent part, appears to be often associated with diabetes, which there are strong reasons for believing to be, in some cases, an affection of the nervous system. Some experiments, made by Dr. Meissner, would appear to show further that certain nerve fibres exercise a peculiar "trophic" function, and that a lesion of such fibres may be the immediate and deter- mining cause of an inflammatory condition of the parts supplied.1 1 See upon this point, Holmes's Syst. of Surgery, 2d edit., vol. i., pp. 40-41, and Paget's Surgical Pathology, 3d edit., p. 36. A clinical observation of* Dr. Geo. C. Harlan's, is confirmatory of the same view (Phila. Med. Times, Dec. 13, 1873). 42 INFLAMMATION. It is sometimes said that certain abnormal properties of the circulating blood are to be considered as determining causes of inflammation ; but from what has gone before, I think it will appear that this is incorrect. Either a plethoric or an ansemic condition of the blood may indeed act as a predis- posing cause, by impairing the general health ; or the blood may carry in its course through the system septic or other morbid elements derived either from within or from without, but in this case its function is ministerial merely, and those morbid elements themselves are to be looked upon as the determining causes of the inflammatory process, not the blood, which is simply their vehicle of transmission. Symptoms.—We have next to consider the symptoms1 of inflammation. These may be distinguished into the local, and the constlhdional or general symptoms. The latter will be treated of on a subsequent page, under the heading of symptomatic or inflammatory fever. The local symptoms of inflam- mation maybe classified under six heads, viz.: (1) alteration of color, (2) alteration of size, (3) alteration of temperature, (4) modification of sensation, (5) modification of function, and (6) modification of nutrition. One or more of these symptoms may exist in a part without that part being inflamed, and it is only when they are present in combination, that the diagnosis of the inflammatory process can properly be made. The phenomena of the erectile tissues furnish a familiar example. Again, certain nervous lesions give rise to a combination of these symptoms so striking as to have been considered by many excellent observers to indicate a true inflammatory condition (the so-called neuro-paralytical inflammation), and, indeed, this state is one that can be converted into true inflammation by the action of very slight external causes. The degree in which any one of these symptoms is manifested, de- pends, in a great measure, upon the nature of the tissue in which the in- flammatory process is going on. Thus in the case of the skin or of mucous membranes, a change of color is the most prominent symptom. Inflamma- tion of the connective or areolar tissue is particularly distinguished by the swelling by which it is attended. In the fibrous tissues, pain is the best marked symptom. Conjunctivitis or a superficial burn, inflammation of the subcutaneous fascia, and periostitis, may be taken as illustrations of these propositions. Again, modification of function is more prominent in an in- flammation involving the eye, than in one affecting a much larger area of the skin or of the alimentary canal, while in some tissues, cartilage for instance, almost the only change that can be recognized after a long duration of the inflammatory process, is an alteration in the nutrition of the part involved. Bedness, the first of the symptoms made classical by the description of Celsus,2 is perhaps the most noteworthy of all the signs of inflammation. It varies from a bright scarlet, as in the skin, to a deep crimson, or even a dusky, almost purple hue, as in some mucous membranes. In some tissues, other forms of discoloration take the place of redness; thus the inflamed iris becomes gray or brown. The redness of an inflamed part is undoubtedly due to its being in a hypersemic condition, the capillaries being dilated so as to contain more blood than in the natural state, and the red corpuscles of the 1 Inflammation limited to its first stage (temporary hypertrophy), as is seen in the repair of trivial injuries by immediate union, may be attended with such slight dis- turbance as to present no recognizable symptoms. Hence immediate union of wounds is said by Paget to be accomplished without inflammation. Clinically speaking this may be accepted as correct, but if the pathological views given above be true the inflammatory process must exist, though unattended by definite symptoms. 2 " Notae vero inflammationis sunt quatuor, rubor, & tumor, cum calore & dolore (Celsus, de re medicd, Lib. III., c. 10. Opera, ed. L. Targse, Lugd.-Bat., 1785 p. 109)! S Y M P T 0 M S. 43 blood entering into vessels which, in their normal condition, were too narrow to admit them. In some depressed states of the system, there is an absolute oozing of the coloring matter of the blood through the walls of the capillaries, thus adding a new source of discoloration, while when the inflammatory proc- ess has gone on to the formative stage, the new tissue developed from the inflammatory lymph, being very vascular, causes a more or less permanent redness, which, as is well known, may persist in a scar or in a part that has been inflamed for a considerable period. The next symptom that demands our attention is swelling. This is of course due in some measure to the hyperemia of the part, the increased amount of blood in the vessels naturally adding to the common bulk. It is, however, probable that the principal cause of inflammatory swelling, in the first stage, is the increased absorption of nutritive material, this stage of in- flammation being indeed, as remarked by Virchow, almost indistinguishable from a true hypertrophy. The swelling may be further increased, if the in- flammation continue, by the presence of what are ordinarily called the prod- ucts of inflammation, viz., by the formation of lymph or pus, or by the ex- udation of the watery constituents of the blood, or even, in certain cases, of the blood itself. The amount of swelling varies greatly, according to the looseness or closeness of texture of the part affected. Thus the eyelid, when inflamed, swells so rapidly as often to completely close the eye, while inflam- mation involving the cancellous structure of bone may give rise to the most excruciating suffering, and even run on to suppuration, with almost no swelling in the whole course of the affection. The increase of size of an inflamed part may be evanescent, or may remain as a kind of hypertrophy, as is often seen after the healing of old ulcers of the leg, or still more mark- edly in the (-ase of bone after long duration of osteitis. On the other hand, from certain nutritive changes to which we shall have occasion to refer again, a part which has been inflamed may become permanently smaller than it was in the natural condition. The third symptom to be considered is alteration of temperature, increased heat. The illustrious John Hunter entertained the view that the increased temperature of an inflamed part was directly and solely due to the fact of its receiving an additional quantity of blood, and hence it is frequently said that the temperature of an inflamed part cannot possibly exceed that of the left ventricle of the heart. The experiments upon this point of Mr. Simon and of Dr. Edmund Montgomery seem to me to establish incontrovertibly the incorrectness of Hunter's view. Their observations, which were made with the aid of a very delicate thermo-electric apparatus, are detailed in Mr. Simon's able article on inflammation in Holmes's System of Surgery (2d edit., vol. i., p. 1ressors, which are designed so as not to control the smaller vessels; however useful these may be for cases of aneurism or accidental hemorrhage, they are not, I think, as good as Petit's instrument for employment in ordi- nary amputations. In certain special operations, hoAvever, these are very valuable; thus hip-joint amputation is shorn of half its terrors by the use of Skev's tourniquet or Lister's aorta-compressor (Fig. 28). Amputating Knives.—Formerly surgeons used for the circular operation a knife with but one edge and a very heavy back, shaped someAvhat like a sickle ; the modern amputating knives, how'ever, Avhich are adapted for either the circular or the flap operation, have a sharp point, and are usually doubled-edged for an inch or tA\o at the extremity. The length of the knife should be about one and a half times the diameter of the limb to be removed, and its breadth from three-eighths to three-quarters of an inch. Thus, a knife Avith a cutting edge eight or nine inches longAvill answer for most amputations of the thigh, Avhile one Avith an edge of six or seven Spanish windlass. 96 AMPUTATION. inches will do for smaller limbs. Double-edged ccdllns (Fig. 30) are used principally for the leg and forearm, and are convenient in freeing the inter- osseous space for the application of the saw; their Avidth should not exceed three-eighths of an inch. Beside the ordinary amputating knives, the sur- geon should have at hand one or two strong scalpels or bistouries (Figs. 31 and 32), about three inches long, while for smaller amputations, as of the fingers, a very slender knife with a heavy back Avill be found convenient. Fig. 27. Fig. 28. Skey's tourniquet. my OAvn part, I much prefer a small knife to a large one, and am, in- deed, in the habit of using a three-inch blade for the largest limbs, having found it quite ample even for amputation at the hip-joint. The Fig. 29. Amputating knife. handles of amputating knives should be of rough ebony, Avhich is less likely to slip Avhen bloody than either bone or ivory. Catlin or double-edged knife. Saws.—The amputating saAV should be about ten inches long by two and a half wide ; it should be strong, Avith a heavy back, so as to give additional firmness, and the teeth not too Avidely set, but just enough to prevent bind- INSTRUMENTS. 97 ing. For operations about the hand or foot, a small saw with a movable back (Fig. 33) will often be found useful. Fig. 31. Bistoury. Bone-nippers or Cutting Pliers may be used in amputating the phalanges, or for smoothing off any rough edges left by the saw in larger operations. Fig. 32. Scalpel. Ten to twelve inches is a good length, of which the blades should not occupy more than two inches; the blades, which are sharp, should be set at an ob- Fig. 33. Small amputating saw. tuse angle Avith the handles, which must be very strong, and roughened to prevent the hand from slipping. Fig. 34. Bone-nippers. Artery Forceps and Tenacula are used in taking up the vessels; the best form of forceps is essentially that invented by Liston, and known as the "bull-dog forceps;" the blades should be expanded a short Fig. 35- distance above the points, that the ligature may easily slip over Avithout including the in- strument itself in the knot; they may be made to fasten with a catch, or, which I think is better, be provided with a spring which keeps them closed except Avhen opened by pressure of the surgeon's fingers. The tenaculum, or sharp hook, must be of sufficient size and but slightly curved; it is not as good an instrument as the forceps for most cases, but is sometimes useful, especially Avhere the parts are matted together by inflammation, and the artery cannot be separated by the forceps ; sometimes it is necessary to take up a little mass of muscle or areolar tissue Avith two tenacula, and throw a ligature around the Avhole. Though I have never seen any harm result from this ligature en masse, it should not be practised Avhen it can be avoided, 7 Artery forceps closing by their own spring. 98 AMPUTATION. Fig. 36. Tenaculum, or sharp hook, with which the arterial orifice is picked out. Fig. 37. and, as far as possible, each vessel should be drawn from its sheath and tied separately. Dr. Hodgen, of St. Louis, has devised an ingenious artery for- cei... which draAVS the ar- tery from its sheath by its own weight, and is pro- vided with a cutting slide to divide the ligature, thus enabling the surgeon to dispense with the aid of an assistant. Ligatures may be made of a variety of materials, such as catgut, horsehair, iron or silver wire, or more commonly, and I think better, of fine whip-cord or strong sewing-silk. The silk should be cut into lengths of about eighteen inches, and must be well waxed to fit it for use. The ordinary skein of silk contains about six yards, and is thus sufficient for twelve ligatures. In ordinary amputations the number of vessels requiring ligature ia about six or seven, but if there has been in- flammation, causing enlargement of the small arteries, as many as twenty or twenty-five lig- atures may be necessary. The artery having been drawn out of its sheath by the forceps or tenaculum, the ligature is thrown around it and secured by what is called the reef-knot, the The reef-knot. peculiarities of which can be better understood from the annexed cut than from any descrip- tion. It is usual after tightening the knot to cut off one end of the ligature, allowing the other to hang out at the wound. It is convenient to retain both ends of the ligature which surrounds the main artery, knotting them together for purposes of distinction. Short-cut ligatures were very highly commended by Hennen and others at the beginning of this century, but are now, I be- lieve, generally abandoned, except in the form of the carbolized ligature of Prof. Lister; catgut is the material usually employed, but Maunder prefers carbolized silk. I have myself suc- Fm- 38> cessfully tied the common carotid with a short-cut, carbolized, catgut ligature, and have no doubt that, when a good article is employed, it is quite safe, at least for arteries ligated in their continuity. For securing wounded arteries, how- ever, or those divided in amputa- _^^^_________________ tion, I still prefer the ordinary silk 1 ' ' ligature. When catgut is em- Surgical needles. ployed, three knots instead of two should be tied, to prevent slipping. Some surgeons apply a single knot only to small vessels. I see no advantage m this plan, which is certainly not as safe as the use of the common reef- knot. Acupressure may be used to secure arteries after amputation, as may various ingenious modifications of acupressure, in which a Avire is 'used in- stead of a needle; these will be considered in the chapter on wounds of arteries. The Retractor consists of a piece of muslin, six to eight inches wide one end of which is split into two tails for the thigh or arm, and into three for the leg or forearm. It is applied around the bone or bones to keep the soft OPERATIVE PROCEDURES. 99 tissues from being injured by the saw, and to prevent bone dust from being caught among the muscles, an occurrence which Avould greatly interfere with the rapidity of the healing process. The Sutures may be applied with the ordinary " surgeon's needle," which for use in stumps should be large, strong, and but slightly curved; or, if the flaps be very thick, a needle, mounted in a handle and with the eye near the point, such as is used in the operation of strangulating a nsevus, will be found convenient. The best material for the suture is, I think, silver, lead, or malleable iron wire, though this is a matter Avhich may be safely left to the fancy of the operator. Scissors are used to cut the ligatures and sutures, or to retrench any pro- jecting nerves, tendons, or masses of fascia. Operative Procedures.—The various modes of amputating may be con- sidered as mere modifications of the two original forms of the operation, the circular and the flap; thus the oval operation, or that of Scoutetten, is based upon the circular, Avhile the different methods of Vermale, Sedillot, Teale, Lee, etc., are but varieties of the flap operation. Circular Method.—An amputation by the circular method is thus per- formed : Anaesthesia having been induced, and the seat of operation washed Fig. 39. Amputation by circular method. (Druitt.) and shaved, the patient is brought to the side or the foot of the operating- table, so that the limb to be removed projects well over the edge. The cir- culation should be controlled by means of a tourniquet, or by manual press- ure exercised by an assistant, Avhile another assistant holds the affected limb in such a position as is convenient for the operator. The latter should stand so that his left hand Avill be towards the patient's trunk; thus, in amputating the right leg the surgeon stands on the patient's right side, while in removing the left leg he stands between the patient's limbs. The surgeon then, steady- ing and draAving upwards the skin with his left hand, slightly stoops, and carries his right hand, Avhich holds a knife of sufficient length, around the patient's limb, so that the back of the knife is towards his OAvn face. Press- ing the heel of the knife Avell into the flesh, he makes a circular SAveep around the limb, rising as he does so, and thus being enabled to complete the whole or at least the greater part of the cutaneous incision with one motion; a few light touches of the knife Avill now allow considerable retraction of the skin, and, if the limb be slender, this degree of retraction may be sufficient. The 100 AMPUTATION. first incision must completely divide all the structures doAvn to the muscles. If the skin have not retracted sufficiently, the surgeon now, either with the same knife or with an ordinary scalpel, rapidly dissects up a cuff of skin and fascia, about half as long as the limb is thick. In doing this, care must be taken to cut always towards the muscles; neglect of this rule Avill cause di- vision of the cutaneous vessels and consequent sloughing of the part. Having done this, the operator grasps the cuff of skin with his left hand, and, with the large knife, makes another circular cut at the point of the cuff's reflec- tion, through all the muscles and down to the bone. A wide gap is usually immediately produced by the retraction of the cut muscles; if it be not suf- ficient, however, the surgeon quickly separates the muscular structures from their periosteal attachments with the finger or the handle of a scalpel, press- ing them back and thus cleaning the bone for the space of about tAvo inches. If the limb contain two bones, the interosseous tissues must be divided with a double-edged knife or with the ordinary scalpel. The retractor being ap- plied and firmly drawn upwards, the bone is now to be sawn at the highest point exposed. It is well first to divide the periosteum Avith a knife, and to use the saw lightly at first, so as to avoid splintering. The saw should be held vertically, and if two bones are to be divided, they should be sawn to- gether. The assistant who holds the limb must exercise care to keep it in such a position as neither to interfere with the action of the saw nor to alloAV the bone to break before the section is completed. As soon as the limb is re- moved the surgeon secures the vessels, momentarily loosening the tourniquet, if necessary, that the gush of blood may indicate the position of the smaller arteries, and, when all bleeding is checked, proceeds to dress the stump. If any projecting spiculse have been left by the saw, they must be removed with strong cutting pliers, and any tendons or nerves that hang out from the stump should be cut short with sharp scissors. The skin cuff is then brought to- gether Avith sutures, so as to convert the circular into a linear incision, its direction being horizontal, vertical, or oblique, according to the fancy of the operator. It is well to apply a bandage with circular turns from above downwards, to the stump, so as to prevent spasm or subsequent muscular retraction. Sometimes great difficulty is experienced in turning up the skin cuff, from the conical shape of the limb. In such cases the surgeon may slit the cuff at one or both sides, thus converting the procedure into a modified flap operation. Flap Method.—Amputation by the flap method is susceptible of an almost infinite number of variations. Thus there may be only one flap, more com- monly two, or even a larger number. The flaps may be cut antero-posteriorly, laterally, or obliquely; they may be made by transfixing the limb and cutting outAvards, or may be shaped from without inwards, or one may be made by transfixion and the other from Avithout. They may include the Avhole thick- ness of tissue doAvn to the bone, or merely the skin and superficial fascia, or they may embrace the superficial muscles, while the deeper layer is divided circularly (Sedillot). Finally, they may have a curved outline, or they may be rectangular. In practising the ordinary double-flap amputation, the surgeon stands as for the circular amputation, and grasping and slightly lifting the tissue which is to form the flap, enters the point of the long knife at the side nearest himself; then pushing it across and around the bone with a decided but cautious motion, and slightly raising the handle when the bone is passed, he brings the point out diametrically opposite its place of entrance. Hold- ing the blade in the axis of the limb, he then shapes his flap by cutting at first downwards, with a rapid sawing motion, and then obliquely forwards. Turning up the flap, he re-enters the knife at the same point as before car- OPERATIVE PROCEDURES. 101 ries it on the other side of the bone, brings it out Avith the same precautions as at first, and cuts his second flap. He then applies the retractor, makes a circular sweep to divide any remaining fibres, and saws the bone as in the circular operation. In many situations, as in the front of the Fig. 40. leg where the bone is superficial, it is impossible to make a flap by transfixion, and in any part, if the limb be large, the flap thus made is unwieldy, the skin retracting more than the mus- cles, which project and interfere with the closure of the wound. Hence it is often better to make at least one flap by cutting from without inwards, dividing the skin and superficial fascia by the first incision, and the mus- cles by a second, at a higher point. In view of the wasting and Amputation by antero-posterior flap operation. (Bryant.) gradual disappearance of mus- cular tissue, which always takes place in a stump, some surgeons think to save time and trouble by making flaps of skin only; but, apart from the danger of sloughing, which always attends these long skin flaps, unsupported by muscle, the resulting stump is not so serviceable, for though the true muscular structure does indeed disappear, the fibrous sheath of the muscle remains, becoming condensed into a thick pad Avhich forms a very necessary covering for the bone. In making antero-posterior flaps by transfixion, the anterior one should be cut first; if the flaps are shaped from without inwards, the lower should be formed first, as otherwise the blood from the first incision would obscure the line of the second. In making lateral flaps, the outer should be the first cut, and, generally, it may be stated that that flap should be first formed which does not contain the principal artery. I have advised that for the flap as well as for the circular operation the surgeon should stand with his left hand towards the patient's trunk. Many authors, hoAvever, including Mr. Liston and Mr. Erichsen, direct that exactly the opposite posture should be assumed, with the left hand on the part to be removed. I have no doubt that every one Avill find that position most con- venient to Avhich he is most accustomed ; but consider that which I have recommended to be the best, as enabling the operator to have more control over hemorrhage, in case of sudden slipping of the tourniquet or relaxation of his assistant's grasp. Oval and Elliptical Methods.—The oval amputation in its simplest form may be considered as a circular operation, in which the cuff of skin has been slit at one side, and the angles rounded off. In this form it is used for disarticulation at the metacarpo-phalangeal joints, and, Avith a slight modifi- cation, constitutes Larrey's Avell-known method of amputating at the shoulder- joint. Another form of the oval operation, Avhich in this case should rather be called elliptical, is particularly adapted to the knee and elboAV-joints, though it is applied by the French to other parts as well. The incision in this form of amputation constitutes a perfect ellipse, coming below the joint on the front or outside of the limb; the resulting flap is folded upon itself, making a curved cicatrix and furnishing an excellent covering for the stump. 102 AMPUTATION. Modified Circular Operation.—This plan seems to have been suggested by Mr. Liston, and was afterwards improved and largely employed by Mr. Syme. It may be regarded as the ordinary circular operation, with the skin cuff slit on both sides and the angles trimmed off. It is done by cutting with a suitable knife two short curved skin-flaps, and dividing the muscles with a circular sweep of the instrument: it is particularly adapted to amputations through very muscular limbs. Fig. 41. Modified circular amputation. (Skey.) leak's Method by Rectangidar Flaps.—This operation, which Avas intro- duced and systematized by Mr. Teale, of Leeds, about twenty-five years ago, undoubtedly furnishes a most elegant and serviceable stump. There are two flaps of unequal length, the shorter always containing the main vessel or ves- sels of the limb. The flaps are of equal Avidth, but while one has a length of half the circumference of the limb at the point Avhere the saAV is to be ap- plied, the other is but one-quarter as long (i. e., one-eighth of the circumfer- ence). ^ The lines of the flaps should be marked Avith ink or crayon before beginning the operation, as otherwise, especially in dealing with a conical limb, it is almost impossible to cut the long flap of the requisite rectangular shape. Both flaps are to embrace all the tissues down to the bone, and the long flap, which is in shape a perfect square, is, after sawing the bone, folded on itself, and attached by points of suture to the short flap. The advantages of this mode of amputating are that it secures a good cushion of soft parts over the end of the stump, and that the resulting cicatrix is entirely with- draAvn from the line of pressure, in adapting an artificial limb: its disadvan- tage is that, if used upon a muscular limb, it requires the bone to be divided at a much higher point than would otherwise be necessary, and thus, in the case of the thigh at least, adds much to the gravity of the operation. Hence it has been suggested by Prof. Lister to alter the relative dimensions of the flaps, making the longer of just sufficient size to bring the cicatrix out of the line of pressure, while its diminished length is compensated for by in- creasing that of the short flap. I have myself employed this modified form of Teale's operation (keeping, however, the rectangular shape of the flaps), and have found it to answer quite as well as the original. Relative Merits of the different Methods.—I do not purpose to enter into a discussion of the supposed advantages of one method of amputating over another, believing that excellent results may be obtained by any of these DRESSING OF THE STUMP. 103 Fig. 42. plans, and that the difference in the results of amputation in the hands of various operators is not so much due to the particular procedure em- ployed, as to the judgment displayed in selecting cases for operation, and the care manifested in conducting the after-treatment. When I began to operate, I practised one or other form of the flap amputation almost exclusively, having a prejudice against the circular method, which is certainly less easy of execution and less brilliant than the other. During late years, however, my views upon this point have under- gone some modification, and I now prefer the circular operation in cer- tain localities. The surgeon should not, I think, confine himself to any one method exclusively, but should vary his mode of operating according to the exigencies of the particular case. If any general rule were to be given, I should say that the circular incision or Teale's method gives the best stumps in the forearm, the modified circular in the upper-arm and the upper part of the thigh, the single or double flap operation immediately above or below the knee, the circular or lateral-flap in the lower part of the leg, and the oval operation at the joints. The points to be considered in choosing an operation for any particular part of the body will be referred to in discussing the special amputations. Teale's amputation. (Bryant.) Simultaneous, Synchronous, or Consecutive Amputation.—It occasion- ally becomes necessary, in eases of severe injury, to remove tAvo or more limbs by primary amputation at the same time. Sometimes this has been done by tAvo surgeons operating simultaneously, but it is better for one to do both amputations consecutively, beginning Avith the limb that is most severely hurt. Though the prognosis of these double amputations is always unfavorable, yet recoveries have followed with sufficient frequency to justify the surgeon in having recourse to the knife, when the condition of the patient will at all permit it. If the hemorrhage can be effectually controlled by tour- niquets, it is better to remove both limbs before stopping to take up any ves- sels ; though if the first amputation have produced much depression, it may be necessary to pause and administer restoratives before proceeding to the second. One of the most remarkable cases of synchronous amputation1 on record is that done by Dr. Koehler, of Schuylkill Haven, Pennsylvania, who thus removed both legs and one arm from a boy of thirteen, the lad making an excellent recovery in spite of this severe mutilation. I have myself successfully resorted to synchronous amputation of the right hip-joint and left leg (Fig. 43), for a raihvay injury occurring in a lad of fifteen. Dressing of the Stump.—After an amputation, the stump should not be dressed until all hemorrhage has ceased. Sometimes after all the recog- nizable vessels have been secured, a troublesome oozing continues from the 1 Quadruple amputations, or amputations of both upper and both lower extremities, have been successfully performed by Dr. Alfred 3Iuller, Acting Assistant Surgeon, U. S. A., Dr. Begg, M. Champenois, and other surgeons, but it does not appear that the operations in any of the eight cases to which I have references, were synchronous. 104 AMPUTATION. face of the stump ; this is usually venous bleeding, and will commonly cease of itself Avhen the tourniquet is removed. If it do not, it may probably be checked by elevating the stump, and pouring over it a stream of cold water, or of diluted alcohol.1 Bleeding from the medullary cavity of the saAvn bone may be stopped by inserting a piece of dry lint, a plug of Avood, or better, a pellet of previously softened white wax; the latter has the advantage of being perfectly unirritating, so that, if Fig. 43. necessary, it may be allowed to remain when the flaps arebrought together. A plug of catgut is preferred by Riedinger. If the surgeon have any reason to fear consecutive hemorrhage, the stump should not be finally closed for some hours, or until complete reaction has occurred, a piece of lint, dipped in olive oil, being meaiiAvhile laid be- tAveen the flaps (as suggested by Mr. Butcher), to prevent their adhering, and the sutures left loose until the surgeon is ready for the final dressing. The liga- tures are to be brought out at one or both angles of the wound, as may be most convenient; it has been suggested to bring each one through the face of the flap by a separate puncture, but such Primary synchronous amputation of left leg and right hip- a plan Seems to me more adapted joint. (From a patient in the University Hospital.) to ,}elay union by producing in- Creased irritation, than to pro- mote quick healing. The edges of the amputation Avound are to be brought together, not too tightly, by the use of sutures, and the flaps, if heavy, may be additionally supported by the use of adhesive strips. It is a great mistake to hermetically seal a stump; there is always a considerable flow of serum for some hours after an amputation, and if this fluid be not alloAved to escape from the stump, it inevitably decomposes and produces irritation. Various modes of dressing a stump have been employed; Mr. Teale directed Avhat has been called dry-dressing, Avhich was, in fact, no dressing at all, the stump being simply laid on a pilloAV (which was covered Avith gutta-percha cloth), and protected by throAving over it a piece of thin gauze. Sir J. Y. Simpson highly commended the exposure of both amputation and other Avounds to the air, calling the scab produced by this exposure a " natural Avound lute." Dr. J. R. Wood, of New York, goes still further, treating stumps by what he calls the " open method," without either sutures, plasters, or dressings. MM. Guerin and Maisonneuve have, on the other hand, devised Avays of treating stumps in exhausted receivers, giving their respective plans the 1 Under the name of parenchymatous hemorrhage, Dr. Lidell has described (follow- ing Stromeyer) a general capillary oozing, due to dilatation of the capillary vessels either by the inflammatory process, or as the result of obstruction of the principal veins from thrombosis. The treatment recommended in the former case consists in the application of the persulphate or perchloride of iron, hot water, or the actual cautery ; in the latter, ligation of the main artery or amputation at a higher point (U. S. San. Commission Surgical Memoirs, vol. i., pp. 237-250). STRUCTURE OP A STUMP. 105 euphonious titles of "pneumatic occlusion" and "pneumatic aspiration." A. Guerin has recently recommended the employment of cotton, as a means of excluding deleterious germs, Avhich are supposed to exist in the atmos- phere. The " antiseptic method" of Prof. Lister has been quite extensively used in the treatment of stumps, and, I doubt not, answers a very good pur- pose. The dressing Avhich I myself prefer, consists of a piece of sheet lint soaked in pure laudanum, covered Avith oiled silk or Avaxed paper, and secured in place Avith a light recurrent bandage; the local use of the narcotic is soothing to the patient, Avhile the styptic and antiseptic properties of the alcoholic menstruum are often useful. In military practice cold Avater is the most convenient application to a recent stump, and, if not too long con- tinued, answers very Avell. AVhatever dressing is used, the stump should not be disturbed for forty-eight or seventy-two hours, by Avhich time suppu- ration Avill usually have begun ; the wound may then be dressed Avith diluted alcohol, Avith lime-water, or Avith any other substance that the condition of the part may indicate. If organic sutures have been used, they should be removed about the third or fourth day; metallic sutures may remain longer, and need not usually be taken aAvay until firm union has occurred, and until they are therefore of no further use. The ligatures may be expected to drop from the smaller vessels after the fifth or sixth day ; from the larger arteries after the tenth or twelfth. The ligatures should always be allowed to drop of themselves ; but Avhen the time usually requisite for their separation has elapsed, the surgeon may at each dressing gently feel them, to ascertain if they are loose. If acupressure has been employed, the pins or needles from the smaller vessels may be re- moved on the second day; that on the main artery on the third or fourth, according to the extent of the clot formed, Avhich may be estimated by the point at Avhich pulsation in the flap ceases. Structure of a Stump.—A stump continues to undergo changes in its structure for a long Avhile after cicatrization is completed ; the muscular sub- stance A\astes, and the museles and tendons become converted into a dense fibro-cellular mass, Avhich surrounds the bone; the bone itself is rounded off, and its medullary cavity filled up; the vessels are obliterated up to the points at which the first branches are given off, firm fibrous cords marking their place beloAV; the nerves' become thickened and bulbous at their extremities, these bulbs being composed of fibro-cellular tissue, Avith numerous nerve fibrils interspersed. Upon the firmness and painlessness of a stump, depend greatly the facility and comfort Avith A\hich an artificial limb can be Avorn. In the case of the upper extremity, there is comparatively little difficulty, and very ingenious and serviceable arms and hands are noA\' supplied by the manufacturers. In the loAver extremity, it is found that very feAV stumps will bear the entire pressure produced by the Aveight of the body in Avalking upon an artificial limb, and hence a portion at least of the pressure should be taken off by giving the apparatus additional bearings upon the neighboring bony prominences ; thus for an amputation of the leg, the artificial limb should bear upon the knee, Avhile in the case of a thigh stump, the tuber ischii and hip should receive the principal pressure. 1 Localized atrophy of that half of the spinal cord which corresponds to the side on which amputation has been performed has been observed by Dickinson, Clarke, and Vulpian, and is, according to the latter author, directly due to the section of the nerves of the amputated limb. Similar changes have been observed by S. G-. Webber, Genzmcr, Dickson, Leyden, and Dreschfeld, while Chuquet and Luys have observed cerebral atrophy on the opposite side. Berard, many years ago, noted atrophy of the anterioi roots of the spinal nerves corresponding to the amputated part. 106 AMPUTATION. Affections of Stumps.—Any one of the constituents of a stump may give trouble after an amputation, and the treatment of the morbid conditions of a stump is a very important matter for the surgeon's consideration. 1. Spasm of the muscles often occurs and causes much suffering a feAV hours after an amputation ; it is best treated by the use of a moderately firm bandage around the part, and by the exhibition of anodynes. Dr. Mitchell and Dr. H. C. Wood have recorded cases in which persistent and intract- able choreic spasms occurred at a later period. 2. Undue retraction of the muscles may occur and continue for days or even weeks after an amputation, interfering with cicatrization, and giving rise to a very intractable form of ulceration, Fig. 44. or even going so far as to produce what is called a conical or sugar-loaf stump. The mechanical ulcer, as it is called, of stumps, requires the limb to be firmly bandaged with circular and reversed turns from above doAviiAvards; the action of the muscles is thus restrained, and the soft parts coaxed down- Avards, as it Avere, and enabled to heal Avhile the tension is remo\Ted; or extension may be Thigh stump, with splint for extension. applied by means of a Aveight and broad (Bryant.) strips of adhesive plaster, or a light splint, as in Fig. 44. There is, however, another cause for the production of conical stumps, in cases of young persons, apart from muscular retraction or Avasting by suppuration ; this is a positive elongation of the bone by growth subsequent to amputation. This is chiefly seen in the leg and upper arm, and the occurrence in these situations, rather than in the thigh or forearm, is easily accounted for by remembering the physiological fact, that the upper extremity grows principally from the upper epiphysis of the humerus and the lower epiphyses of the radius and ulna, Avhile the lower extremity grows chiefly from the lower epiphysis of the femur and the upper part of the tibia. Hence, in amputations of the thigh or forearm, the principal source of groAvth for that particular member is taken away ; while Fig. 45. Aneurismal varix in a stump. (Erichsen.) in the upper arm or leg, it remains, and is liable to cause subsequent protru sion of the bone through the soft parts. To whatever cause the existence of a conical stump be traceable, if the stum]) will not heal over the bone, or if though a cicatrix form, it be thin, tender, and constantly liable to re-ulcerate there is but one remedy, which is to resect the projecting end of the bone • this is fortunately a proceeding which is attended with but little risk, and its results are usually satisfactory. 3. Erysipelas or diffuse cellular inflammation may attack the tissues of a stump; and either constitutes, under these circumstances, a very serious affection. All sutures should be at once removed, soothing and emollient AFFECTIONS OF STUMPS. 107 Fig. 46. dressings applied, and the general treatment adopted which will be described when speaking of those diseases. 4. Secondary hemorrhage may occur from the vessels of a stump, at any time before complete cicatrization has taken place. If it be not profuse, elevating the part, and the application of cold, or pressure, Avill often be suffi- cient to check the bleeding ; if it continue, or recur, more decided measures must be adopted, Avhich Avill be discussed in the chapter on wounds of arteries. 5. Aneurismal enlargement of the arteries of a stump occasionally occurs ; the annexed wood-cut (Fig. 45), from Mr. Erichsen's Surgery, illustrates a case of aneurismal varix occurring after amputation through the ankle- joint. b\ Neuroma, or painful enlargement of the nerves of a stump, occasionally occurs. This distressing affection is, according to Mitchell, not due to the bulbous enlargement of the nerve (which is, indeed, met with in all stumps), but to the existence of neuritis,1 or of a sclerotic condition resulting from inflammatory changes. Should the pain evidently arise from any distinct tumor connected Avith a nerve, it would be proper to cut doAvn and remove it; under other circumstances the nerve may be stretched, or a portion ex- cised at a higher point, or re-amputation performed, though unfortunately these are by no means infallible remedies; Dr. Kott gives a case in Avhich a man sub- mitted to three re-amputations and three nerve excisions for neuralgia of a stump, deriving at last only questionable benefit from this large experience in operative surgery. As a palliative remedy, the application to the stump of the strong tincture of the root of aconite is occa- sionally useful, or hypodermic injections of morphia may be used, as in other cases of neuralgia. Girard records a case in which relief Avas obtained by the repeated employment of electro- puncture. Leeches, ice, and counter-irritants may also prove serviceable in some instances. 7. The tendons in the neighborhood of a stump may become contracted and cause troublesome deformity; thus, after Chopart's amputation on the foot, the natural arch of that organ being destroyed, the tendo Achillis may be dnnvn up by the poAverful muscles of the calf, and a painful form of club- foot result, the cicatrix being thrown against the ground in Avalking. The occurrence of this condition should, if possible, be prevented by the use of appropriate splints and bandages, and it may be sometimes even necessary to resort to tenotomy Avhen milder measures Avill not suffice. 8. Periostitis, Osteitis, and Osteo-myelltls, one or all, may occur in a stump, and may defeat the surgeon's anticipations of a successful issue. If acute and extensive, these affections endanger life, and, especially in the femur, are apt to terminate fatally. The diffuse suppurative form of osteo-myelitis is especially apt to occur Avhen the division of the bone has exposed the 1 Ascending neuritis in a stump may, according to Nepveu, lead to paralysis and contraction of other parts, by causing myelitis, which may be either unilateral or transverse. Neuromata of stump, after amputation of the arm. A large neuromatous mass at a; opposite b, the tumors, are more defined. (Miller.) 108 AMPUTATION. Fig. 47. medullary cavity, and is almost sure to end in pyaemia and death; the best mode of treatment is re-amputation at the nearest joint, Avhich is of course an almost desperate remedy, though Konig effected a cure in one case by scooping out the diseased medulla and stuffing the cavity with cotton satu- rated Avith a strong solution of chloride of zinc. Less violent forms of bone inflammation result in the occurrence of— 9. Necrosis, A\hich may likewise be produced by injury from the saAv, at the time of operation. The treatment of this condition consists pretty much in waiting for the natural separation of the necrosed part, which will then be exfoliated as a ring of dead bone, or as a long conical sequestrum (Fig. 47). I do not believe that anything is to be gained, under these circumstances, by inter- ference with the slow but safe processes of nature; in the case, hoAvever, of the occurrence of acute necrosis, as it is sometimes called, or more properly diffuse subperiosteal sup- puration, it may be necessary to amputate to save life, just as it would be under the same circumstances occurring else- were than in a stump. 10. Caries may occur in the bone of a stump. I have seen benefit result in such cases from the injection of the prepara- tion introduced by M. Notta, under the name of Liqueur de Villate. (R. Zinci sulphatis, Cupri sulphatis, aa gr. xv.; Liq. plumbi subacetatis f'3ss; Acid. acet. dilut. vel Aceti alb. fSiijss. M.) 11. Finally, an adventitious bursa may be formed over the bone of a stump, as in any other part subjected to much press- ure. If this bursa become painful, the artificial limb should be altered so as to relieve it from pressure; if this be not sufficient, an effort may be made to obliterate the bursa by the introduction of the tincture of iodine or by establishing a small seton, or the bursa itself may be excised. Necrosis of the bone after ampu- tation. (Liston.) Mortality after Amputation.—The results of amputation depend on a variety of conditions. Some of these are common to this as to other serious operations, and have mostly been sufficiently referred to in the chapter on operations in general; the most important circumstances coming into this category are the age and the constitutional state of the patient, and the hy- gienic conditions to Avhich he is subjected before, at the time of, and after the amputation. The relation between the barometric condition of the atmos- phere and the mortality after amputation has been particularly investigated by Dr. Addinell HeAvson. He finds that, at the Pennsylvania Hospital, the mortality varied from 11 per cent, with an ascending, to 20 per cent. Avith a stationary, and 28 per cent, with a falling barometer. While the column of mercury was rising, the average duration of life, in fatal cases, was only seven days, but was thirteen Avhile the column was falling; and of all the cases that died within three days, over 75 per cent, proved fatal while the barometer was rising. " Surely," he adds, " these figures need no commentary as to how well they sustain the idea that the results of operations are materially influenced by the weather, and that the risks from shock are increased by opposite conditions" (Penna. Hosp. Reports, vol. ii., p. ?A). Recent statistics as to the influence of the age of patients upon the results of amputation have been collected by several surgeons, including Dr T G Morton, Mr. Golding-Bird, Dr. Gorman, and Mr. Holmes, the latter of Avhoni finds that " the risk of amputation is constantly rising throughout life and MORTALITY AFTER AMPUTATION. 109 at any given period after thirty years of age the risk is more than tAvice as great as it was at the same period after birth." Besides the circumstances which have been referred to, there are others which affect the result of amputation, and Avhich are peculiar to this as dis- tinguished from other operations; these are hoav to be considered. 1. Locality.—The part of the body at Avhich an amputation is performed exercises an important influence on the result; amputations of the lower extremity are more apt to prove fatal than those of the upper, and in the same limb the rate of mortality varies directly with the proximity to the trunk of the point of amputation. These facts Avill appear from the folloAving table, Avhich I have prepared from the published statistics of British1 and American2 hospitals, and from those of our late Avar,3 together with those of the Avar in the Crimea.4 Table showing Mortality of Amputations in Different Parts of the Body, for Traumatic Causes, in Civil and in Military Practice. Civil Hospitals. American and Crimean Wars. Aggregates. Locality. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality, per cent Cases. Deaths. Mortality, per cent. Thigh, . Leg, . . Arm,. . Forearm, 367 633 332 298 197 264 86 41 53.68 41 71 25.90 13.76 3516 3278 6415 2181 2715 1089 1805 444 77.22 33.22 28.14 20.35 3883 3911 6747 2479 2912 1353 1891 485 74.99 34.59 28.03 19.56 Totals, . 1630 588 36 07 15,390 6053 48.85 17,020 6641 39.02 In amputations of the thigh, the mortality varies according as the operation is done in the upper, lower, or middle third. The following are the per- centages given respectively by Legouest and Macleod, both referring to the British army in the Crimea, though for different periods of the war. Legouest. Macleod. Upper third,.......87.2 86.8 Middle third,.......58.5 55.3 Lower third,.......55.0 50.0 2. The part of the bone Avhich is divided in an amputation influences the result, the mortality being greater Avhen the medullary cavity is opened than Avhen only the cancellous structure at the end of the bone is involved. This appears to be OAving to the greater probability of pyaemia supervening under the former circumstances. Of 291 cases of amputation Avhich Avere followed by pyaemia during our late Avar, 155, or 52.5 per cent., Avere through the shaft of the femur ( Circular No. 6, 8. G. O., 1865, p. 43). 3. The nature of the affection for Avhich an amputation is done, exercises a most important influence upon the result: thus amputations for injury are 1 St. George's Hosp. Reports, vol. viii.; Med.-Chir. Trans., vol. xlvii.; and Guy's Hnsp. Reports, 3d s., vol. xxi. 2 Am. Journ. Med. Sciences, April, 1875; Boston City Hosp. Reports, 2ds., 1877; and Boston Med. and Surtr. Journ., 1871. 3 Circular No. 6, S. G. O., Wasliingfon, 1865, and Surgical History of the War. * Legouest, Chirurgie d'Armee, pp. 722-735. 110 AMPUTATION. much more fatal than those for disease; the removal of a limb for cancer is more likely to be followed by death than the same operation if practised for caries or a chronic joint affection ; Ayhile amputations of complaisance or expediency (as for deformity) are less successful than those for other patho- logical conditions. The relative mortality of amputations for injury and disease, as exhibited by the published reports of hospital practice in various countries, is shown in the following table: Amputations for Injury. For Disease or De-formity. Totals. Place of observation. V o P Mortality, per cent. V U a Mortality, per cent. 3 u •5 a Mortality, per cent. French Hospitals,1 English Hospitals,2 American Hospitals,3 652 610 1252 378 250 400 57.98 40.98 31.95 947 1107 629 406 251 117 42.87 22.67 18.60 1599 1717 1881 784 501 517 49.03 29.18 27.49 Aggregates, . . . 2514 1028 40.89 2683 774 28.85 5197 1802 34.67 The mortality which attends amputations of expediency has been particu- larly investigated by Mr. Golding-Bird, of Guy's Hospital, who finds it to be (in that institution) 26.8 per cent., as compared with a death-rate of 21.1 per cent, for other pathological causes; or, if the lower extremity alone be considered, the former class of cases gives a mortality of 42.8 per cent., and the latter of 29.1 per cent. 4. In amputations of the same category, the time at which the operation is done exercises an important influence over the result; thus, amputations for acute affections of the bones or joints are much more fatal than those of chronic diseases of the same parts. Amputations for traumatic causes are usually divided by surgical writers into primary or immediate, and secondary or consecutive. Primary amputations are such as are done before the devel- opment of inflammation, a period rarely exceeding twenty-four hours, though, if there have been much shock, it may reach to forty-eight hours, or possibly still longer, from the time at which the injury was received. A better classi- fication is that of military writers who make a third class, the intermediate, Avhich embraces all operations done during the existence of active inflamma- tion, reserving the term secondary for such as are done after the subsidence of inflammatory symptoms, and Avhen the condition of the part somewhat assimilates the case to one of amputation for chronic disease. Verneuil applies to these three divisions the terms antepyretic, intrapyretic, and meta- pyretic, respectively. It is now, I believe, universally acknowledged among military surgeons that primary amputations (except of the hip-joint and the upper part of the thigh) do better than others ; of those which are not primary, the secondary do better than the intermediate. It is, however, commonly said that in civil practice secondary amputations are more successful than primary, and this 7o-nMalgaigne ^ATch' G<§n-' Avril et Mai'1842)' and Tr<51at (Les°uest> °p- citat-> p- 2 St. George's Hosp. Reports, vol. viii.; Med.-Chir. Trans., vol. xlvii.; Guy's Hosp. Reports, 3d s., vol. xxi. 3 Am. Journ Med Sciences, April, 1875; Boston City Hosp. Reports, 2d s., 1877, and Boston Med. and Surg. Journ., 1871. MORTALITY AFTER AMPUTATION. Ill difference has been accounted for by the different hygienic circumstances by which soldiers and civilians are respectively surrounded. I believe that the usual statement upon this point is erroneous, and that a careful collation of statistics will shoAV that in both civil and military practice, primary amputa- tions are folloAved by better results than others. To illustrate this point, I have drawn up the table Avhich folloAvs, and in which the results of primary amputations, or those performed in the pre-inflammatory stage, are compared Avith those of all others for traumatic causes. Primary. Secondary and Intermediate. Observations from Civil Hospitals. i •5 V 0 O V go. U ■5 V Q 2 <■> O V go. Reporter. Reference. 49 64 18 74 169 180 50 48 40 71 93 144 37 29 656 241 164 240 75 55 34 15 7 39 62 60 9 18 8 23 15 60 12 14 164 84 68 104 31 16 69.4 23.4 38.9 52.7 36.7 33.3 18.0 37.5 20.0 32.4 16.1 41.6 32.4 48.3 25.0 34 9 41.5 43.3 41.3 29.0 33.7 20 28 5 43 53 87 6 43 9 10 37 42 24 13 118 87 50 94 5 17 791 13 10 2 26 37 61 1 19 6 3 13 17 7 7 45 32 21 53 4 8 385 65.0 35.7 40.0 60.5 69.8 70.1 16.7 44.2 66.7 300 35.1 40.4 29.1 53.8 38 1 36.8 42.0 56.4 80.0 47.0 48.6 Malgaigne. James. South. Laurie. Steele. McGhie. Hussey. Erichsen. Parker. Fen wick. Callender. Spence. Buel. Lente. Morton. Chadwick. Gorman. Golding-Bird. Varick. Ashhurst. Arch, de Med., 1842. [vol. xvii. Trans. Prov. Med. & Surg. Assoc, Notes to Chelius, vol. iii. James, loc. cit. Ibid. [367. Macleod, Surg, of Crimean War, p. Ibid. [p. 81. Science and Art of Surgery, vol. i., Cooper's Surg. Diet., vol. i., p. 121. Ibid. Med.-Chir. Trans., vol. xlvii. Lectures on Surgery, vol. ii., etc. Am. Journ. Med. Sci., 1848. Trans. Am. Med. Assoc, vol. iv. Surg, in the Penna. Hosp., 1880. Bost. Med. and Surg. Journ., 1871. Bost. City Hosp. Rep., 1877. Guy's Hosp. Rep., 3d s., vol. xxi. Am. Journ. Med. Sci., 1881. Internat. Encycl. of Surg., vol. i. 2497 843 Aggregates. It will be perceived from this table that, except in the reports of Malgaigne, Hussey, Femvick, Spence, and Buel, the primary amputations have been in- variably less fatal than the others; while in the aggregate, the mortality of the primary has been about 1 in 3, compared with a death-rate of 1 in 2 for the intermediate and secondary operations. I do not know of any extended statistics to shoAV the relative mortality of the two latter classes of amputa- tions in civil practice ; but as far as they have been distinguished by writers on the subject, the general impression has been confirmed that intermediate operations are very fatal, and that those done when the inflammatory symp- toms have subsided are comparatively successful. These numerical considerations, however, though interesting, scarcely give a fair vieAV of the whole merits of the case; for primary operations are natu- rally done in cases Avhere there is no possibility of saving the limb, while consecutive amputations are, on the other hand, performed in cases which are to a certain extent selected. Moreover, the least hopeful cases among any large number are eliminated by death before the secondary period is reached, so that even if the numerical chances of consecutive operations 112 AMPUTATION. were the best, it would by no means be proved that more lives Avould not have been saved had more limbs been primarily amputated. The practical rule to be derived from what has been said, is that, in any case of injury in Avhich it is evident that an amputation will be needed, the operation should be done as soon as possible after reaction has occurred, and before the injured part has become inflamed; but if by any chance this golden opportunity has been lost, and the intermediate or inflammatory stage has come on, operative interference must, if possible, be postponed until the inflammation has measurably subsided, and till the patient's condition has become assimilated to that of a case of chronic disease rather than of trau- matic lesion. To complete this part of the subject, I quote from Dr. Macleod (Notes on the Surgery of the Crimean War, p. 367), the folloAving summary of the re- sults of primary and secondary amputations in military practice. Primary operations, 1047 cases, 374 deaths ; mortality, 35.7 per cent. Secondary " 594 << 314 " " 52.8 " A percentage Avhich, it will be observed, corresponds very closely with that derived from observations in civil hospitals. The statistics of amputation in the late war of the rebellion have not yet been all published; but, as far as they go, they serve to confirm what has been already said: thus 4806 primary amputations of the upper extremity recorded in Dr. Otis's Surgical History of the War, gave 821 deaths, or 17.08 per cent., while 1516 intermediate amputations gave 481 deaths, or 31.73 per cent., and 666 secondary amputations gave 163 deaths, or 24.47 per cent. Causes of Death after Amputation.—The causes of death after amputa- tion have been made the subject of special study by several Avriters, among whom may be particularly mentioned Malgaigne, James, Bryant, Holmes, and Birkett. The three last-named gentlemen are among the most recent authorities on the matter, and I will terminate this chapter by quoting some of the conclusions appended to their excellent papers. Mr. Holmes finds from examining the records of 300 cases— "1. That a considerable proportion of cases must occur in hospital prac- tice, in which death is really inevitable, although it is not known to be so at the time of amputation. . . . " 2. That of the fatal cases which remain, in about one-half death is due mainly to previous disease or injury. " 3. That secondary hemorrhage is hardly ever a cause of death, except in persons Avith diseased arteries. "4. That death from exhaustion hardly ever occurs Avithout previous dis- ease, obviously proved both by symptoms and post-mortem appearances. "5. That the other hospital affections (erysipelas, diffuse inflammation, and phagedena or hospital gangrene) are rare in subjects previously healthy, and that, as a rule, they only prove fatal when they are the precursors of pysemia. " 6. That therefore any attempt to estimate the dangers of amputation in hospital practice, or to diminish its mortality, must be based upon a knoAvl- edge of the conditions under which pygemia occurs in cases treated separately, and in patients congregated in hospital Avards." (St. George's Hospital Re- ports, vol. L, pp. 321-322).1 1 Mr. Holmes's second paper, based on 500 cases (St. George's Hospital Reports, vol. viii.) confirms the above conclusions. AMPUTATIONS OF THE HAND. 113 Mr. Bryant's tables likewise include 300 cases, and from his "General Conclusions " I select the following: "That pyaemia is the cause of death in 42 per cent, of the fatal cases,and in 10 per cent, of the Avhole number amputated. " That exhaustion is the cause of death in 33 per cent, of the fatal cases, and in 8 per cent, of the Avhole number amputated. " That the following causes of death are fatal in the annexed propor- tions : Of fatal cases. Of whole number. Secondary hemorrhage Thoracic complications Cerebral " Abdominal " Renal " Hectic " Traumatic " 7.0 per cent. 5.6 " 3.0 " 1.4 " 3.0 « 3.0 " 7.0 " or 1.66 per cent. 1.33 .66 .33 .66 .66 1.66 Pyaemia is the chief cause of death after pathological amputations, after those of expediency, and after primary amputations for injury. Exhaustion is the chief cause of death after secondary amputations for injury, and ranks next to pysemia as a cause of death after the primary, and those classed as pathological (see Med. Chir. Trans., vol. xlii., pp. 85-90). Mr. Birkett, from a study of 171 cases, in which the operation Avas per- formed either by himself or under his direction, concludes that a "large proportion of the patients submitted to amputation, when inmates of a metropolitan hospital, are the subjects of more or less advanced chronic dis- ease of the thoracic or abdominal viscera," and that "the chances of death after operations appear to depend almost entirely upon the previous state of each patient's constitution" (Guy's Hosp. Reports, 3d s., vol. xv., p. 599).1 CHAPTER VI. SPECIAL AMPUTATIONS. Upper Extremity. Amputations of the Hand.—Amputations of different parts of the hand are frequently rendered necessary by injuries, or by diseases of the bone, as in neglected cases of whitloAv. As no mechanical contrivance can possibly equal the natural hand in utility, it should in all cases be the surgeon's ob- ject to save as much as possible; there is but one exception to this rule, and that is Avhen in the case of the middle fingers it becomes necessary to go as high as the first interphalangeal joint; as there is no special flexor tendon for the proximal phalanx, it will, in such cases, be usually better to go at once to the metacarpo-phalangeal joint; but in the forefinger, even a single phalanx Avill be of use, as affording a point of opposition to the thumb, while the proximal phalanx of the little finger may be properly preserved, in order to give greater symmetry to the hand. 1 In my article on Amputations in the International Encyclopaedia of Surgery, vol. i., I have given many elaborate tables bearing upon the mortality and causes of death after amputation, for which I have not space here. 114 SPECIAL AMPUTATIONS. Fingers.—The fingers may be amputated at any of their joints, or through the phalanges: if the latter operation be decided upon, it may be done by cutting suitable flaps with a straight bistoury, and dividing the bone with cutting pliers or a small saw. Amputation of the terminal or middle pha- langes may be done by opening the joint from the back of the finger, dividing cautiously the lateral ligaments, disarticulating, and cutting a palmar flap of sufficient'length to cover the stump. In this operation it must always be re- membered that the prominence of the knuckle is due to the upper bone, and that hence the incision must be made below the knuckle, or it will not expose the joint. The palmar flap may be made first, either by transfixion or other- wise, and the joint opened subsequently; I think, however, the plan first mentioned is the best. Another method is to attack the joint from the side, cutting one lateral ligament, disarticulating, Fig- 48. an(j ^hen making a long lateral flap from the other side of the finger: this has been particularly recommended in the case of the fore and little fingers, but I do not see that it possesses any advantage over the common palmar flap operation. There is usually but little hemorrhage after the removal of a phalanx, and if any vessels bleed, they can generally be controlled by means of torsion; in some cases, however, the digital arteries are much enlarged, and require ligature. Amputation at the Metacarpophalangeal Joint is best done by the oval method, though it may also be conveniently executed Amputation of part of a fin^ cutting *>7 making two lateral flaps. _ In the oval from above. (Erichsen.) operation, the point of the knife is entered just beloAv the knuckle, on the back of the hand, and the blade is drawn obliquely downwards through the interdigital web, across the palmar surface of the finger, and obliquely upwards to the point of commencement; a few light touches of the knife free this oval flap, and disarticulation is then effected by cutting the extensor tendon (if it be not already divided) and the lateral ligaments. In the case of the forefinger the knife should be entered on the radial side, and in the case of the little finger on the ulnar side, instead of at the back of the joint. Some difference of opinion exists as to the propriety of removing the head of the metacarpal bone in these amputations. The hand may indeed be rendered more sym- metrical by its removal, but this gain of symmetry is more than counter- balanced by the loss of firmness and strength entailed; besides, the removal of the head of the metacarpal bone exposes the patient to the risk of inflam- mation and suppuration in the deep tissues of the palm, and thus renders the operation more serious than it would be othenvise. Hence, if the metacarpal bone itself be uninsured, its head should be, as a rule, allowed to remain : if, however, it be decided to remove it, this can be easily effected by cutting it with strong pliers (Fig. 49), the section, in the case of the fore and little fingers, being oblique, so as to give a tapering form to the part Avhen it is healed. The entire thumb, with its metacarpal bone, may be amputated by making an oval flap from the palmar surface : in the case of the left thumb (Fig. 501, the joint may be first opened by an oblique incision on the back of the hand, beginning above and a little in front of the ioint, and coming doAvn as far as the web which separates the thumb from the forefinger; the palmar flap is then made by thrusting the knife upwards to its point of entrance, and cut- AMPUTATIONS OF THE HAND. 115 ting downwards and outwards; in amputating the right thumb, it is more convenient to make the palmar flap first, by transfixion, the remaining steps of the operation being done subsequently. The thumb alone is almost as Fig. 49. Fig. 50. Amputation of an entire finger. (Skey.) Amputation of the left thumb. (Erichsen.) useful as the other four fingers together; hence, in operations on this im- portant member, no part should be sacrificed that can by any possibility be preserved. Amputation through one or more metacarpal bones may be required, and may be done by cutting from without inwards thick flaps of sufficient dimen- sions to cover the parts Avithout undue stretching. In making these flaps, the palm should be respected as much as possible, the necessary incisions Fig. 51. Partial amputation of the hand. (From a patient in the Episcopal Hospital.) being preferably made through the dorsum of the hand. It is better to leave the carpal ends of the metacarpal bones, so as to avoid opening the wrist- joint. Any part of the hand that can be kept, should be scrupulously pre- served, as even a single finger with the thumb is far more useful than the best artificial substitute. Fig. 51, from a case formerly under my care at the Episcopal Hospital, shows the result of an operation of this kind. If a metacarpal bone be injured Avithout injury of its corresponding finger, the 116 SPECIAL AMPUTATIONS. former may be excised while the latter is retained, or the finger may, per- haps, be adapted to another metacarpal bone Avhich has lost its own finger, as has been ingeniously done by Prof. Joseph Pancoast, of this city. The risks of amputation below the carpus are slight, 7902 cases referred to in Dr. Otis's Surgical History of the War, having furnished but 223 deaths, of which 19 were after re-amputation at a higher point. The mortality of amputations through the hand is thus less than 3 per cent. Amputations of the Arm. 1. Amputations at the Wrist.—The hand has occasionally been removed at the carpo-metacarpal articulation, or between the rows of carpal bones; the stumps thus formed are, however, irregular, and the carpal bones are apt to become subsequently diseased and to require removal. Hence, when it is necessary to invade the carpus at all, it is better to go at once to the radio- carpal joint, and amputate at the wrist. Amputation at the wrist-joint may be conveniently effected by the circular operation, by means of the elliptical incision, by making oval flaps cut from without inwards, or by cutting a single flap from the palm of the hand. The resulting stump is a very good one, though it is said to be less suited for the adaptation of an artificial limb than one that is shorter. Its principal advantage is in its preserving the power of pronation and supination, though even this may be lost from inflammatory adhesions binding to- gether the radius and ulna. Sixty- eight cases of this amputation re- corded in Dr. Otis's Surgical History, gave only seven deaths, a mortality of but 10.6 per cent. 2. Amputation of the Forearm.— The best operation in this locality is, Amputation at the wrist. (Erichsen.) I think, the circular; though excel- lent stumps may be produced by other plans, especially by the rectangular flap method of Mr. Teale. At one time I was in the habit of amputating the forearm by making antero- posterior flaps cut from without inwards, but having, on several occasions, Fig. 53. Amputation of forearm by modified circular method. (Bryant. ) met with dangerous secondary hemorrhage from the interosseous artery, which, in this operation, is apt to be cut obliquely, I have been led to prefer either the circular or Teale's, in neither of Avhich is this risk so apt to be encountered. In any of the flap operations, particularly in the lower third of the forearm, trouble may be caused by the tendons projecting from their sheaths. Under snch circumstances, the surgeon should draAv them down, AMPUTATIONS AT THE SHOULDER-JOINT. 117 and cut them off at as high a point as possible, that they may retract, and not interfere Avith the healing process. Perhaps the most brilliant operation on the forearm is that in which a dorsal flap is cut from without, and a palmar flap made by transfixion. The length of the flaps should be pro- portioned to the size of the limb, but two inches may be given as the aver- age. Five or six vessels usually require ligature in amputations of the fore- arm, and of these the interosseous is that Avhich is most likely to give trouble, from its tendency to retract between the bones, in which position its orifice may elude detection. 3. Amputation at the Elbow may be effected by either the circular or ellip- tical incision; it may also be done, though less conveniently, by making an anterior or an external flap by transfixion. It is sometimes recommended to leave the olecranon in place, dividing the ulna below it with a saAv; no particular advantage, however, attends this plan, and the olecranon, if left, is apt to become necrosed, and interfere with the healing of the stump. Amputation at the elboAV Avas done in forty cases during the late Avar, and only three of these terminated unsuccessfully. 4. Amputation through the Arm.—The arm may be removed at any part and by any of the methods which have been described; those wdiich seem to me the best are the oval and the modified circular. The bone, hoAvever, is situated so nearly in the middle of the limb, that an elegant and useful stump may be formed by any operation, and indeed the arm is frequently indicated as the typical locality for making double flaps by transfixion. If this opera- tion be resorted to, lateral flaps are the best, and the outer should be cut first; the principal precaution to be taken is to divide the musculo-spiral nerve Avith a clean sweep of the knife around the back of the bone, before apply- ing the saw. In amputating the arm, the possibility of a high division of the main artery must be remembered; occasionally the brachial will be the only vessel that requires ligature, though usually there will be bleeding from six or seven, or, if the parts have been long inflamed, tAvelve or fifteen. If the arm be amputated very high up, particularly if the limb be muscular, there may not be room for the application of the tourniquet in the usual place ; it may then be safely applied to the axillary artery, the arm being kept extended, so as to make the head of the humerus project into the axilla, where it forms a firm point of resistance against which to exercise pressure ; or the surgeon may, if he prefer, have the subclavian artery com- pressed as it passes over the first rib, by means of a wrapped key in the hands of an assistant. Amputation at the Shoulder-joint.—This is in appearance a most for- midable operation, and yet it is one of Avhich the results are tolerably favor- able. Thus, 841 cases, recorded in Dr. Otis's Surgical History, gave 595 re- coveries and 246 deaths, a mortality of only 29.2 per cent. When performed for other than traumatic causes, it is still more successful. Amputation at the shoulder-joint may be practised in several Avays, the most important being those commonly knoAvn by the names of Larrey, Dupuytren, and Lisfranc. 1. Larrey's Method.—The surgeon enters the point of a short knife below and a little in front of the acromion process, and makes a deep incision about three inches long, in the direction of the axis of the arm. From the middle of this incision, two others are made obliquely dowmvards (and slighty con- vex, if the limb be muscular), so as respectively to terminate at the points where the anterior and posterior folds of the axilla end in the tissues of the arm ; it is usually directed that the anterior incision should be made first, as the posterior circumflex artery is larger than the anterior, but if the sub- 118 SPECIAL AMPUTATIONS. clavian be well commanded over the first rib, there need be no fear of hem- orrhage, and it will then be most convenient to make the posterior incision first, that its position may not be obscured by bleeding from the other. The Fig. 54. Fig. 55. surgeon next disarticulates, rotating the arm first outwards so as to make tense the subscapular muscle, which he divides with a perpendicular stroke of the knife, then cutting the capsule and the tendon of the long head of Fig. 56. Amputation at shoulder-joint; Dupuytren's method. (Bryant.) the biceps, and finally rotating the arm inwards so as to reach the supra- and infra-spinatus muscles, and the teres minor. The lateral incisions are lastly connected by a transverse cut through the tissues of the arm either from without or from within. Before this final incision (Avhich divides the brachial artery) is made, an assistant should slip his thumb into the wTound * AMPUTATIONS AT THE SHOULDER-JOINT. 119 Fig. 57. and control the vessel, Avhich may ahvays be found in the first muscular interspace from the anterior edge of the axilla; the limb being removed, the vessels are to be secured, and the edges of the wound brought together so as to make a linear cicatrix. The appearance of the stump resulting from this operation is w7ell shoAvn in the accompanying illustration (Fig. 55), from the photograph of a patient on whom I performed this amputa- tion at the Episcopal Hospital. 2. Dupuytren's Method.—This method consists in making, either by trans- fixion or from Avithout inwards, a large flap, embracing almost the Avhole of the deltoid muscle, then disarticulating, and finally cutting a short flap (in Avhich is the vessel) from the inside of the arm. This operation is more quickly performed than Larrey's, but makes a larger wound, and is not, I think, so generally applicable. In either method the principal difficulty is in disarticulating, to accomplish which (in the case of fracture preventing the use of the arm as a lever in effecting rotation) it may be necessary to intro- duce the forefinger of the left hand into the capsule, and forcibly drag down the head of the bone so as to expose the ligamentous attachments. In making the deltoid flap by transfixion, the knife should be entered about an inch in front of the acromion process, and, being pushed directly across the joint and capsule, should be brought out at the posterior fold of the axilla. As in Lar- rey's operation, an assistant should slip his thumb into the wound, and secure the artery before the final incision is made. 3. Lisfranc's Operation consists in making antero-posterior flaps, which come together very much as the inci- sions in Larrey's method, over Avhich it presents no particular advantage. The shoulder-joint can also be reached by a circular incision, as practised by Vel- peau and others, and in fact all con- ceivable varieties of amputation at this point have been employed, and claimed as the best by different surgeons, though those Avhich I have described have been most generally adopted. Amputation above the Shoulder, or amputation of the arm with a part or the Avhole of the scapula, and perhaps a portion of the clavicle, is occasionally required in cases of accident or of dis- ease. No special rules can be given for the performance of this operation, to Avhich, wheneA'er possible, excision of the parts concerned is to be preferred. In cases of injury, the surgeon must make his flaps as best he may, in vieAv of the extent and direction of the laceration, and in cases of amputation for tumors, etc., must be guided by the size and shape of the morbid growth. The results of this operation have been more favorable than might haA*e been antici- pated : fourteen cases are on record, Avhich, though the arm and a part or the whole of the scapula Avere torn off by accidental violence, terminated favor- ably, while fiftv-one cases in which the arm and part or all of the scapula, Result of amputation by Dupuytren's method. (From a patient in the Episcopal Hospital.) 120 SPECIAL AMPUTATIONS. with or without a portion of the clavicle, were removed by the surgeon at the same operation, gave thirty-eight recoveries and only thirteen deaths. Lower Extremity. Amputations of the Foot.—The phalanges of the toes seldom require amputation, but, if necessary, this little operation may be conveniently done, as in the case of the fingers, by opening the joint from the dorsum, and covering the stump with a plantar flap. Amputation at the Metatarso-phalangeal Joint is best done by the oval in- cision. It must be remembered that the web reaches about half-way between the joint and the end of the toe; hence the incision must be placed high, or the joint will be missed. Disarticulation is facilitated by forcibly flexing the toe, and dividing the extensor tendon by a transverse incision. It is some- times recommended that in amputating the great toe, the head of the meta- tarsal bone should be also removed; I do not think this desirable, as by so doing a very important point of support to the -arch of the foot is taken away, an evil which would not be compensated for by the greater symmetry of the resulting stump. Amputation of the Great Toe, with a part or the whole of its Metatarsal Bone, may be required. If the anterior portion or head only is to be removed, an oval incision may be employed, which is prolonged backwards for a sufficient distance on the side or back of the foot. The bone may be divided by cut- ting pliers or by a chain saw. If the whole bone is to be removed, it is better to shape an antero-lateral flap, by entering the knife on the back of the foot, between the first and second metatarsal bones, and on a level with the tarso-metatarsal joint, cutting forwards to the ball of the toe, then across to a point corresponding to the position of the web, and then backwards again along the inner edge of the sole; this flap is dissected up, taking care to keep it as fleshy as possible. The knife is then re-entered between the metatarsal bones, and made to cut directly forwards through the web. Then pressing the toe away from the next one, the surgeon, with the point of his knife, cautiously effects disarticulation, and separates the part to be removed, taking care not to wound the dorsal artery of the foot. Hemorrhage having been checked, the flap is brought dovra and attached by points of suture in the usual way. Amputation of the Fifth Meta- tarsal Bone may be effected by the oval incision, made so as to avoid wounding the sole. The point of the oval is usually made on the dorsum of the foot, and may be extended in a curve doAvnwards and outwards to the edge of the sole, thus forming a curved tri- Removal of metatarsal bone of great toe; flap formed; angular flap, which is dissected joint being opened. (Erichsen.) down to gjye mQre gpace- ^ gome. what similar modification of the oval incision is practised by A. Guerin, in amputating the metatarsal bone of the great toe. AMPUTATIONS OF THE FOOT. 121 Amputation of two or more of the Metatarsal Bones may be conveniently done by the oval operation, the point of the oval beginning on the dorsum above the joint at which disarticulation is to be effected, and its branches spreading to embrace the requisite number of toes. Amjjutation through the Continuity of all the Metatarsal Bones is best done by cutting a short dorsal and a long plantar flap, the latter of which may be made, if preferred, by transfixion, saA\ing the bones on the same level, and bringing up the long flap, so as to free the cicatrix from pressure in Avalking. The resulting stump is Avell formed and useful. Amputation of the Entire Metatarsus (which is said to have been practised by the North American Indians as a means of preventing the escape of prisoners) may be effected by making a long plantar and a short dorsal flap. The general line of the articulation is irregularly oblique, the base of the first metatarsal being much loAver than that of the fifth. The second metatarsal dips in between the first and third, while this again articulates at a loAver level than the fourth or fifth. The plantar flap may be cut first from with- out imyards, as directed by Mr. Hey, or disarticulation may be effected first, and the long flap made last, as practised by Lisfranc. The guides to the articulation are the prominent tuberosity of the fifth, and the Fig. 59. tubercle of the first metatarsal bone (Lisfranr), or the tube- rosity of the fifth metatarsal, and the prominence of the scaphoid (Hey). The French operation is a pure disarticu- lation, but Hey sawed across the projecting internal cunei- form bone. This amputation is somewhat difficult of execu- tion, and is now seldom per- formed. Choparfs Amputation re- moves all of the tarsus except the astragalus and the calca- neum. As in the case of the last described Operation, the Amputation at the tarso-metatarsal joint. (Skey.) plantar flap may be made first, or not until after disarticulation has been effected; the former plan is, in some respects, the best, as allowing the flap to be more regularly shaped. The incision should start on the outside of the foot from a point midway between the external malleolus and the tuberosity of the fifth metatarsal bone, and on the inside from a point about half an inch behind the prom- inence of the scaphoid. Disarticulation may be much facilitated by forcibly bending the foot doAvn, so as to make tense the anterior ligaments of the joint. The scaphoid bone has often been left, unintentionally, in performing this operation, the resulting stump being nevertheless quite satisfactory. Care must be taken, in the after-treatment, to pre\rent retraction of the heel, A\hich is apt to occur, and Avhich may require division of the tendo Achillis. Mr. Hancock has collected 152 cases of Choparfs amputation, of Avhich 120 resulted in recovery Avith serviceable stumps, 2 in re-amputation, and 11 in death, Avhile in 15 the result as regards utility of the limb Ay as uncertain, and in 4, though life Avas preserved, the stumps Avere not satisfactory. The mortality is thus only 7.2 per cent. Sub-astragaloid Amputation.—In this operation all the bones of the foot 122 SPECIAL AMPUTATIONS. are removed except the astragalus. Lisfranc did this amputation by cutting a dorsal flap, Lignerolles Avith two lateral flaps, and Malgaigne by taking a single flap from the inner part of the plantar surface. The best plan, however, and that which I have myself followed, is to make a flap from the heel, as in Syme's opera- tion (to be presently described), which flap is then brought over the astragalus and attached to a short dorsal flap in front. Mr. Hancock has collected tAventy-two cases of this operation, the results of which appear to have been usually satisfactory. Pirogoff's Amputation. — In this operation the Avhole of the foot is taken away except the posterior part of the os calcis, Avhich is brought up and placed in contact with the sawn extremities of the tibia and fibula, from which the malleoli have been removed.1 The operation is thus done: a someAvhat oblique incision, convex forwards, is carried across the sole of the foot from Fig. 61. Fig. 62. Pirogoff's amputation. Application of saw to os calcis. Bony union between calcaneum (Erichsen.) and tibia, after Pirogoff's amputa- tion. (Hewson.) one malleolus to the other, and the flap thus marked out dissected backwards for about a quarter of an inch; a second incision, slightly convex forwards, is then made across the front of the ankle, so as to open the joint; the astragalus is next disarticulated, when the surgeon, applying a narroAv-bladed saAV or a " Butcher's saw " to the upper and posterior part of the calcaneum, behind the astragalus, divides it obliquely downwards, in the line of the plantar incision. The malleoli and articulating surface of the tibia are then likewise saAvn off, and the two cut surfaces of bone approximated. If Butcher's saw be used, 1 Sir W. Fergusson, Prof. Agnew, and Dr. Quimby have modified this operation by leaving the malleoli and pressing up the sawn os calcis between them. I. S. Wight, of Brooklyn, saws through the calcaneum, and then removes the foot and malleoli together, without disarticulating. Chopart's amputation. (Bryant.) AMPUTATIONS OF THE FOOT. 123 the position of the blade may be reversed for the latter part of the operation, so as to saw off the malleoli from behind forwards. This amputation makes an admirable stump, the remaining portion of the calcaneum becoming firmly attached to the bones of the leg, and the natural length of the limb being retained. It is particularly adapted to cases of injury, though it may also be employed in those of disease, provided that the calcis itself be not involved. Hancock has collected 70 cases of Pirogoff's amputation, done by British sur- geons, death occurring in only six, while a useful stump is known to have re- sulted in 57. Five required re-amputation. Seventy-seven operations col- lected from all sources by Gross (of Nancy) and Pasquier, gave only eight deaths, Avhile useful limbs were knoAvn to have been obtained in 44 cases. Stephen Smith and Hewson have particularly investigated the merits of Piro- goff's amputation, and the latter believes it to be, in one point, superior to any1 operation done higher up, in that it enables the patient to run upon his stump as well as to walk. The accompanying cut (Fig. 62), from Hewson's paper, shoAvs very well the bony union between the calcaneum and the tibia in a successful case of this operation. The same precautions as to retraction of the heel are necessary in the after-treatment of this, as in that of Chopart's operation; the purpose was well accomplished in HeAvson's cases by apply- ing a weight of four or five pounds to the back of the leg, by means of a broad strip of adhesive plaster. Amputation at the Ankle-joint (Syme's Operation).—The folloAving is Mr. Syme's own description of this operation : " The foot being held at a right angle to the leg, the point of a common straight bistoury should be introduced immediately beloAV the fibula, at the centre of its malleolar projection, and then carried across the integuments of the sole in a straight line to the same level on the opposite side. The operator having next placed the fin- gers of his left hand upon the heel, and inserted the point of his thumb into the incision, pushes in the knife with its blade parallel to the bone, and cuts close to the osseous surface, at the same time pressing the flap backwards until the tuberosity is fairly turned, when, joining the two extremities of the first incision by a transverse one across the instep, he opens the joint, and carrying his knife downwards on each side of the astragalus, divides the lateral liga- ments, so as to complete the disar- ticulation. Lastly, the knife is drawn round the extremities of the tibia and fibula, so as to expose them suffi- ciently for being grasped by the hand and removed by the saAv. After the vessels have been tied, and before the edges of the Avound are stitched together, an opening should be made through the posterior part of the flap, Avhere it is thinnest, to afford a dependent drain for the matter, as there must ahvays be too much blood retained in the cavity to permit of union by the first intention." Syme's amputation. (Skey.) 1 Mr. Syme also claims this advantage for his operation at the ankle-joint. 124 SPECIAL AMPUTATIONS. This operation has been varied by other surgeons, some making the heel flap longer,1 and others shorter, than directed by Syme himself. Again, some only dissect back the flap to the point of the heel, dividing the tendo Achillis and completing the separation of the calcaneum after disarticulation. How- ever it be done, an excellent stump results, provided that care be taken to keep close to the bone in making the heel flap, so as not to destroy its vascular connections. The death-rate of Syme's operation is but small, 219 cases col- lected by Hancock having given but 17 fatal terminations, a mortality of less than 8 per cent. The stump is, according to Stephen Smith, better than that of Pirogoff's operation, for use Avith an artificial limb. Macleod and J. Bell modify Syme's operation by preserving the periosteum of the os calcis. Other Amputations on the Foot.—Mr. Hancock has ingeniously combined Pirogoff's with the subastragaloid amputation, preserving the ankle-joint, and bringing the saAvn surface of the os calcis into contact with a transverse section of the astragalus; in this operation the head of the latter bone is also removed. In the course of lectures (before the Royal College of Surgeons), published in the Lancet for 1866, in Avhich this operation, Avhich may be called Hancock's, is described, the same surgeon ably advocates the propriety of looking upon the foot as a AArhole, for operative purposes, and of dividing the tarsal bones Avith a saAV, Avithout regard to the position of the joints, taking care merely to remove all parts that are diseased or irretrievably injured. This is a revival of the old teaching of Mayor, of Lausanne, and, though con- trary to the generally received views of modern surgery, is, I think, founded in reason; acting upon this principle, I myself in one case removed the front portion of the foot, saAving through the scaphoid bone, the posterior part of which Avas healthy, and removing the anterior diseased surface of the calca- neum ; the case did perfectly Avell. By this proceeding amputations of the tarsus are greatly simplified, it being merely requisite to make antero-poste- rior flaps of sufficient size, and to saw off the diseased or injured parts of the foot. Tripier, of Lyons, has modified the subastragaloid operation by leaving the upper part of the calcaneum, which he saws through on a level with the sustentaculum tali, and at right angles to the axis of the leg; the external incisions are made as in Chopart's amputation. The statistics of amputations of the foot and ankle are quite favorable; thus, in our late war, 790 amputations of the toes gave but six deaths, 119 partial amputations of the foot gave eleven, and 67 of the ankle-joint gave nine {Circular No. 6, S. G. O., 1865, p. 45).2 Amputations of the Leg.—The leg may be amputated at any part, the rule being to give the patient, in every case, as long a stump as possible. It Avas formerly customary, in the case of laboring men who could not afford to procure costly artificial limbs, to amputate just below the tubercle of the tibia, that a peg might be adapted which Avould press on the front of the knee; but by using a short peg with a socket, the limb can be fixed in the extended position, so that the benefits of a long stump can now be equally well given to patients in all conditions of life. Amputation at the Lower Th ird of the Leg may be conveniently performed by the ordinary circular method, or by making two lateral flaps principally 1 Dr. J. A. "Wyeth, of New York, has shown, by numerous dissections, that the chief blood supply to the heel flap is from the calcaneal branches of the external plantar artery, and that hence a long flap is more likely to preserve its vitality than a short one. 2 Larger's tables, however, derived principally from French sources, give a less favorable picture—149 complete amputations of the foot havino- furnished but 90 recoveries, and 80 partial amputations but 57 recoveries. AMPUTATIONS OF THE LEG. 125 composed of skin, and dividing the muscles by a circular incision a short distance above. Amputation at the Middle or Upper Part of the Leg, provided that the limb be not too muscular, may be done by the common double-flap method, a short anterior skin flap being cut from Avithout inwards, and a long posterior flap by transfixion. When the calf of the leg is very large, this plan gives an unwieldy posterior flap, which must be trimmed before adjustment, and is even then clumsy and troublesome; hence in such cases the flap should be cut from without inwards, or, better still, Sedillot's or Lee's method may be adopted. Sedillot's plan consists in cutting by transfixion a single flap from the outside of the limb, while the tissues on the inside are divided by a trans- verse incision slightly convex fonvards; after saAving the bones, the large flap is brought around and attached by stitches, forming a beautiful stump. Lee's method, like that of Teale, consists in making rectangular flaps, of which, however, the longer is formed from the tissues of the calf; it embraces only the superficial layer of muscles, the deep layer being transversely divided on a level with the line of the short flap. In whatever way the flaps are formed, the bones must be cleared for the saw by a circular sweep of the knife, and in cutting between the bones special care must be taken not to turn the edge of the knife upAvards, lest the tibial arteries should be cut at too high a point—an accident which by the subsequent retraction of the vessels might cause trouble in arresting the Fig. 64. Flap amputation of the leg. (Erichsen.) hemorrhage. In sawing the bones, the fibula may properly be divided half an inch higher than the tibia; it is often recommended to saw the edge of the latter obliquely, under the impression that it is thus less likely to per- forate the anterior flap; I believe, hoAvever, that, except from undue tension, this accident is not likely to occur, and that the risk of necrosis is increased by the oblique division of the tibial spine. If it be done at all, it is best done by rounding off the bone with a Butcher's saAv, as recently advised by Mr. Porter, of Dublin. A preferable plan is, I think, to preserve a short flap of periosteum, which is allowed to fall over the saAvn surface of the tibia, as recommended by Oilier, of Lyons. Four or five arteries usually must be tied in amputations of the leg, and in cases where the vessels are enlarged by the inflammatory process a much larger number may need ligature ; Avhile, on the other hand, if the section be made above the origin of the tibials, the popliteal alone may require atten- tion. A great deal of trouble is occasionally experienced in endeavoring to secure the anterior tibial, OA\ing to its retraction above the section of the in- terosseous membrane. A very good plan in such a case is to turn the patient on his face, when the Aveight of the stump Avill tend to extend the limb, thus bringing the artery into the direction of a straight line, and making it much 126 SPECIAL AMPUTATIONS. Fig. 65. easier of access. For all amputations of the leg or parts below, the tourni- quet may be conveniently applied to the popliteal artery, a large compress being placed over the vessel, and the plate of the instrument fixed at a point diametrically opposite, above the knee. Amputation at the Knee-joint is comparatively a modern operation. Its introduction into general surgical practice is principally due to the efforts of Velpeau, though it has probably been more frequently resorted to in Great Britain and in this country than on the continent of Europe. It may be done by either the circular or the elliptical incision, or by means of flaps. Elliptical Method.—In this operation, which bears the name of Baudens, the surgeon enters his knife three fingers' breadth below the tuberosity of the tibia, cutting at first transversely, then obliquely upwards and around the limb to a point in the popliteal space one finger's length above the joint; the < incision then passes transversely across the back of the limb, and is continued obliquely downwards to its point of commencement. This oval flap is dis- sected up to the line of the joint, and disarticulation easily effected by sever- ing the ligamentum patellae, and the lateral, crucial, and posterior articular ligaments. The semilunar cartilages are usually removed, though A. Guerin advises that they be allowed to remain. The articular cartilage may properly be left, though, if preferred, it may be removed by saAving around the condyles of the femur with Butcher's saw, or the condyles them- selves may be removed in the same way; the statis- tics of the operation show, however, according to Dr. Brinton, that it is rather better to allow the condyles to remain. Some difference of opinion prevails as to whether or no the patella should be removed. I think, with Mr. Erichsen and Mr. Pollock, that it is better to retain it, and its retrac- tion may be prevented, as suggested by the first- named surgeon, by turning up the flap and divid- ing the insertion of the quadriceps femoris muscle. Anterior Flap Method.—This, which is the best of the flap methods, consists in making a long, rather square, cutaneous flap from the front of the leg, disarticulating, and cutting a short posterior flap by transfixion. The posterior flap method, in which a large fleshy flap is formed from the calf, is easier of execution, but less satisfactory in its results. The lateral flap method, of Rossi, was a good deal employed during our late Avar, and has the advantage of affording room for drainage at the lowest part of the wound. In any form of knee-joint amputation, the popliteal artery, with perhaps some of its branches, and the articular arteries, will require ligation. The statistics of knee-joint amputation have been investigated by Dr. John H. Brinton, of this city, in an elaborate paper in the Amer. Journ. of Med. Sciences for April, 1868. He finds that 164 cases from American and foreign sources gave 111 recoveries and 53 deaths, a mortality of 32.31 per cent. Of 211 cases recorded in the office of the Surgeon-General, U. S. A., 106 died, or 50.2 per cent. The annexed table shows the respective mortality of Long anterior flap at knee. (Erichsen.) AMPUTATIONS OF THE THIGH. 127 amputations of the leg and of the thigh, compared with those of the knee- joint, in cases of gunshot injury. Cases. Deaths. Mortality, per cent. Amputation of the leg1 . . . 3278 1089 33.22 " at the knee-joint2 . . 296 181 61.15 " of the thigh1 . . . 3516 2715 77.22 In amputation at the knee-joint for chronic disease, the mortality is given by Dr. Brinton at 22.58 per cent., a death-rate which does not differ materi- ally from that of amputation under similar circumstances either just above or just below the joint; the death-rate of this amputation for traumatic causes generally, he gives at 40.62 per cent. Amputation through the Condyles of the Femur, or at the knee as distin- guished from the knee-joint, is best done by Carden's method, the superiority of which over that proposed by himself has been candidly acknowledged by Prof. Syme. In this operation a single broad flap is taken from the front of the knee, the condyles being sawn through on a level with a simple trans- verse incision made beloAv. The patella is removed, and the condyles may be advantageously divided in a curved line by using Butcher's saw. This operation gives an excellent stump, and is particularly applicable to cases of disease of the knee-joint, for which, indeed, it is claimed by Mr. Syme to be in every way superior to the operation of excision. Its results are very favorable, 30 cases of all kinds having giAren in Mr. Carden's hands a mor- tality of but 5, and 32 cases in Volkmann's hands a mortality of but 7. The resulting stump is longer and more serviceable than that from amputation of the thigh, and the medullary cavity not being involved, there is less risk of diffuse suppurative osteo-myelitis and consequent pyaemia. Amputations of the Thigh.—Amputation of the thigh is frequently re- quired in cases of both disease and injury. The operation may be done at any part of the limb, and the mortality is directly proportional to the prox- imity to the trunk of the line of section. Supra-condyloid Amputation of the thigh is the name proposed by Stokes, of Dublin, for a modification of Carden's method of amputating at the knee; in this modification an oval flap is taken from the front of the leg, there being also a posterior flap fully one-third of the length of the anterior; the femoral section is made at least half an inch above the antero-superior edge of the condyloid cartilage, and the cartilaginous surface of the patella is removed by means of a small saw. A similar operation is that known as Gritti's, from the name of an Italian surgeon by whom it was first suggested. Dr. Weir, of New York, has collected 76 cases of one or other of these opera- tions occurring in civil practice, the number of deaths having been 22, or nearly 29 per cent. Amputation at the Lower Third of the thigh may be conveniently done by the ordinary double-flap operation. Mr. Erichsen recommends the operation by lateral flaps, for this situation, and I doubt not that an excellent stump may be obtained by this method. But I have myself always practised, in amputating at the lower third of the thigh, the antero-posterior flap method, and I have found it perfectly satisfactory. The anterior flap is cut first, from Avithout imvards, and should be about four inches in length, extending to the upper edge of the patella; it should be rather square in shape, with the corners rounded off, and should embrace all the tissues down to the bone. The posterior flap, Avhich contains the main artery, is made by transfixion, 1 See Table on page 108. 2 See Dr. Brinton's paper, and Legouest, op. cit, p. 735. 128 SPECIAL AMPUTATIONS. and should be about the same length as the other, thus allowing for the inev- itable retraction of the muscles at the back of the thigh. Both flaps are then turned back, when a circular sweep of the knife clears the bone for the application of the saw. When the flaps are adjusted, it will be found that the bone is well covered by the front flap, and the resulting cicatrix is drawn entirely behind the line of pressure. Seven or eight vessels usually require ligature, though, if the case be one of chronic joint disease, the number may be larger. Amputation at the Middle or Upper Third of the thigh, if the limb be not too muscular, may be done in the same way, by antero-posterior flaps, one or both made by transfixion, according to circumstances. But if the limb be a large one, a better stump can be made by resorting to the modified circular operation, as practised by Syme and Liston, making short skin flaps, and dividing the muscles at a higher point by a circular incision (see Fig. 41). The posterior muscles of the thigh always retract more than the anterior, and should, therefore, be cut rather longer. In amputating at the upper portion of the thigh, there is scarcely room for the application of the tourniquet, and the surgeon, therefore, commonly has to rely upon manual compression of the femoral artery, as it passes over the brim of the pelvis, though in some cases the aortic tourniquet might perhaps be advantageously employed. If manual pressure be resorted to, the assistant who has charge of this department should grasp the great trochanter with the fingers of the hand corresponding to the limb to be removed, and press firmly on the artery as it emerges from be- neath Poupart's ligament with the thumb of the same hand; the opposite thumb is superimposed to assist and regulate the pressure, and to prevent any risk of slipping. In cases of injury, the form and extent of the laceration will often compel the surgeon to make irregular flaps, and to cover his stump as best he may under the circumstances. Oblique flaps may be employed in such a case, or a single long flap from any part of the thigh; it is more important to make the amputation at as low a point as possible, than to follow any one or other particular mode of operating. Amputation through the Trochanters may be occasionally required in cases of injury, or of malignant tumor involving the lower part of the femur. It is a procedure of less risk than exarticulation of the whole limb, and, in cases of malignant disease, appears to be no more likely to be followed by a return of the affection, than the graver operation. It is, moreover, very easy to convert this amputation into a disarticulation, by dissecting out the head and neck of the femur, if these parts be found to be diseased. leak's Amputation by Long and Short Rectangular Flaps makes a beau- tiful and most serviceable stump Avhen applied to the thigh, but is objec- tionable on account of requiring the bone to be sawn at a much higher level than would be necessary with the ordinary operations: thus, if the laceration of the soft tissues extended to the upper border of the patella, and the thigh Avas only sixteen inches in circumference (by no means a large measure- ment), the long flap would need to be eight inches square, and the bone would be divided at just about its middle, fully four inches higher than would be required by the common double-flap operation. Amputation at the Hip-joint.—This, which may fairly be considered the gravest operation in the whole range of surgical practice, is a procedure of comparatively recent introduction. The first case which is usually classed as anamputation at the hip-joint is that in Avhich Lacroix (1748) removed the right thigh at the joint, on account of gangrene, which affected both limbs, and had been produced by the use of ergot. The amputation had AMPUTATION AT THE HIP-JOINT. 129 been nearly completed by nature, and he merely divided with scissors the round ligament and the sciatic nerve. Four days afterwards he amputated, through the line of separation, the left thigh at the trochanters; the patient, Avho was a boy of fourteen, survived the last operation for eleven days. Perault, in 1774, performed a somewhat similar operation, in a case of gan- grene from external violence, the patient recovering. The first genuine case of hip-joint amputation through living parts was done by Kerr, of Northampton, about the same time, on a girl of eleven years, suffering from hip disease complicated with pelvic abscess and pulmonary phthisis; she died on the eighteenth day. The first case of this amputation for gunshot injury Avas Larrey's, in 1793; while the first, undisputed, successful case in military practice Avas that of Mr. BroAvnrigg, in 1812. A great many different plans have been suggested for effecting disarticu- lation at the hip-joint—Farabeuf has collected more than forty-five—but I shall content myself with describing five principal methods, viz., the oval, the modified circular, that by a single flap, that by antero-posterior, and that by lateral flaps. Oval Method.—This has not been employed very often. It is done by entering the point of a strong but short knife on the outside of the limb, either over the trochanter or below the anterior superior spinous process of the ilium, and making two oblique incisions, one forwards and doAvmvards, and the other backwards and doAvnwards, to meet in a transverse line on the inside of the thigh. The muscles are divided in the same lines or a little higher, and disarticulation being effected from the outside of the joint, any Fig. 66. Amputation at the hip by the long anterior and short posterior flap. A. The femoral and profunda ves- sels, with branches of the anterior crural nerve. B. The great sciatic nerve and its companion artery. A large branch of the sciatic artery is seen in front, c. The muscular mass from the tuber ischii and the obturator externus muscle. Large branches are seen on either side from the profunda and gluteal, d. The psoas and other muscles immediately in front of the joint. (Holmes.) remaining tissue is severed, as in Larrey's shoulder-joint amputation, by a single stroke of the knife. Malgaigne recommends a preliminary longitudi- nal incision, by Avhich the operation is still more assimilated to that of Larrey on the shoulder. On a slender limb this form of amputation would give an admirable stump, but it is obvious that under opposite circumstances the 9 130 SPECIAL AMPUTATIONS. Fig adductor muscles of the thigh Avould form a cumbrous mass, Avhich would require retrenchment before the Avound could be properly closed. Modified Circular Operation.—This is done by cutting, from Avithout in- wards, short antero-posterior cutaneous flaps, and then dividing the muscles on a level with the joint by a circular incision. This method has been successfully employed by several American surgeons, including the late Dr. J. Mason Warren, of'Boston, and is particularly adapted to cases of tumor encroaching on the upper part of the thigh. Single Flap Method.—In this operation, a single, large, anterior flap is cut, either by transfixion (Manec), or from without inwards (Plantade, Ashmead). The soft parts on the back of the limb are divided by a circular incision, either before or after disarticulation. In other forms of this operation the flap has been taken from the inside, or even from the back of the limb. The single flap method might be desirable in a case in which the laceration of the soft parts Avas such as to forbid any other, but, Avhen the surgeon has a choice of operations, it is better to employ either the oval or modified circu- lar, or the double flap method of Guthrie, Avhich Avill be presently described. Antero-posterior Flap Method.—There are three A^arieties of this operation, which bear the names, respectively, of Beclard, Liston, and Guthrie. Beclard's operation consists in making both flaps by trans- fixion. It is thus performed: The point of a long straight knife is entered a little above the position of the great tro- chanter, thrust across the limb, dipping slightly backwards so as to graze the back of the cervix femoris, and brought out at the innermost part of the gluteal fold; a posterior flap is thus cut from the gluteal mus- cles, and the surgeon then re- entering his knife at the same point, pushes it in front of the joint, and, bringing it out as before, cuts an anterior flap from the front of the thigh. The plan which is more com- monly adopted in England and in this country, and Avhich is essentially that of Liston, differs from Beclard's in that the an- terior flap is cut first, and that the knife, instead of being entered just above the tro- chanter, is thrust in about tAvo fingers' breadth below the anterior superior spine of the ilium, and having grazed the front of the joint, is brought out just above the tuber ischii; the flaps thus formed are more oblique than in the French operation. Guthrie's plan, which seems to me to be better, differs merely in that the flaps are cut from without inwards; the operation is done with a small knife, and the posterior flap should be cut first. It is not quite so rapidlv executed as the operation by transfixion, but is more certain of affording well-shaped flaps, and, I think, gives a better stump; this operation has been several times Result of hip-joint amputation by Guthrie's method. (From a patient in the Episcopal Hospital.) AMPUTATION AT THE HIP-JOINT. 131 employed in this country, and is that to which I have myself resorted in four cases in Avhich I have had occasion to perform this operation. Lateral Flop Method.—This method, as its name implies, consists in making tAvo flaps, from the outside and the inside of the limb. Larrey and Lisfranc made both flaps by transfixion, the former cutting the inner flap first, while the latter began with the outer. Dupuytren modified this operation by shaping the internal flap from Avithout inwards. Neither of these plans appears to present any advantages over those Avhich have been previously described. Whatever method be employed in amputating at the hip-joint, the surgeon must take special precautions against the occurrence of hemorrhage, for a very feAv jets from the femoral artery, in this situation, Avill almost insure the death of the patient. Larrey directed that the main vessel should ahvays be secured in the groin, as a preliminary measure, and this plan has been since frequently folloAved. It seems to me, however, that the extensive separation of the artery from the surrounding tissues, which is unavoidable in this preliminary ligation, must expose the patient to greater risk of secondary bleeding, than when the vessel is simply picked up by forceps or tenaculum, after division, as in other amputations. Hence, I think it better to rely upon mechanical means to control the circulation, or, in the absence of these, to trust to the manual pressure of intelligent assistants. The circulation can be conveniently controlled by compressing the aorta, either with Lister's instrument (Fig. 28), a modification of Dupuytren's compressor, or Avith the apparatus Avhich has been repeatedly used in this city under the name of the abdominal tourniquet, and Avhich is merely an enlarged form of that devised by Mr. Skey (Fig. 27). Spence prefers to make pressure by putting a thick pin-cushion over the aorta, and keeping it in place by surrounding the body Avith an elastic band. In addition to the aortic compressor, it is desirable to have in readiness a large flat sponge, as suggested by Mr. Butcher, for application to the whole posterior flap, Avhile the surgeon's attention is given to securing the main artery Avhich is in the anterior. In order to prevent the loss from the general circulation of the blood which is in. the limb, an ingenious suggestion of Dr. Erskine Mason should be adopted ; this consists in rendering the part bloodless by the application of Esmarch's bandage and tube, the latter being fixed just below the line of incision, and kept in place during the operation. Although the benefits derived from the use of the aortic compressor in this t operation are unquestionable, yet the pressure necessarily exercised upon the important nervous structures contained in the abdominal cavity must be at least undesirable, if not positively injurious; hence the vessels should be secured promptly, that this pressure may not be continued longer than is absolutely necessary. The point at Avhich the pad of the compressor should be applied is on a level with the umbilicus, and, usually, a little to its left side, though this must be determined by feeling for the pulsation of the aorta; it is Avell, before screA\ ing down the pad, to roll the patient gently OA^er to the right side, that the bowels (Avhich should have been previously emptied by a dose of castor oil and an enema) may, as far as their mesenteric attachments will alloAv, fall out of the line of pressure. Should it be determined to rely on manual compression, this may be applied to the abdominal aorta (if the patient be very thin), to the external iliac artery just Avithin the brim of the pelvis, or to the femoral as it emerges from beneath Poupart's ligament; the hands of an assistant should moreover folloAV the knife of the operator, and catch the artery in the anterior flap as soon as it is cut, or, if the flap be made by transfixion, before the section is completed. Dr. Woodbury, of this 132 SPECIAL AMPUTATIONS. city, and Dr. Van Buren, of New York, have suggested that the iliac artery should be compressed by an assistant's hand introduced into the rectum, and an instrument for making pressure from the same direction has been devised by Mr. R. Davy, of London, who reports ten cases thus treated, Avith a combined loss of less than seventeen ounces of blood. After the operation the stump may be closed in the usual Avay, the deep parts of the wound being approximated by the use of suitable compresses. The statistics of hip-joint amputation are more favorable than might be expected from the severity of the operation: of 633 cases of all kinds col- lected for me by Dr. F. C. Sheppard, of this city, 220 are known to have ended in recovery, and 393 in death, while the result in 20 is undetermined; of these, there were 43 cases of re-amputation of stumps, of which 28 were successful. My own tale of cases is four operations with two recoveries and two deaths. The following tables exhibit—first, the comparative mortality of hip-joint and thigh amputations, for the causes met with in civil life, and in military surgery ; second, the comparative mortality of these operations, according as they were performed, in civil life, for injury or disease; and third, the statistics of hip-joint amputation for gunshot injuries, with refer- ence to the periods at which the operations Avere performed. Table showing Results of Hip-joint, as compared with Thigh Amputation, for Causes incident to Civil Life, and in Military Surgery. Civil Practice. Gunshot Wounds. Aggregates. Amputation. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality, per cent. Hip-joint,1 Thigh,' 395 2090 186 862 47.1 41.2 238 3516 207 2715 87.3 77.2 633 5606 393 3577 64.1 63.8 Table showing Mortality of Hip-joint, and of Thigh Amputation, for Injury, and for Disease, in Civil Life. Amputation for Injury. For Disease. Locality. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality, per cent. At hip-joint,3 ..... In continuity of thigh,4 . 71 964 47 576 66.1 59.7 276 1465 105 477 . 40.25 32.5 Table showing Results of Hip-joint Amputation in Military Practice, according to the Period at which the Operation was performed? Period of operation. Cases. Died. Recovered. Doubtful. Death-rate. Primary, . Intermediate, Secondary, Re-amputations, Not stated, 96 63 27 7 45 89 59 17 3 39 7 4 10 4 5 i 92.7 93.6 62.9 42.8 88.6 Aggregates, . 238 207 30 l 87.35 1 International Encyclopaedia of Surgery, vol. i., p. 676. 2 Ibid., p. 630. 3 Ibid., p. 676. * Erichsen's Surgery, vol. i., 5 Doubtful cases omitted in computing percentages. 6 International Encyclopaedia of Surgery, vol. i., p. 676. 80. SHOCK OR COLLAPSE. 133 CHAPTER VII. EFFECTS OF INJURIES IN GENERAL; WOUNDS. External violence or injury, of whatever kind, affects the state of the part to Avhich it is immediately applied, and the general condition of the patient at the same time. Hence the effects of injuries are said to be both local and general or (institutional. The local effects of external violence vary according to the nature of the violence and the circumstances under which it is inflicted ; the constitutional effects, though very different in de- gree, are the same in kind for all forms of injury. Constitutional Effects of Injuries. These may be either immediate or remote. The immediate constitutional effect of an injury is called shock, which, if present in an aggravated degree, constitutes collapse. Shock or Collapse is a condition, of the essential nature of which, it must be confessed, we are as yet in ignorance. It is often spoken of as purely an affection of the nervous system, and an analogy is drawn between this and hemorrhage as an affection of the vascular system; yet this view is contra- dicted by the fact that very serious lesions of the nervous system are not necessarily, nor indeed commonly, accompanied by shock. Experimental physiology has shown that large portions of the brain can be cut away from birds, without the development of this condition, except in so far as would be accounted for by the mechanical injury, and a similar experience is re- vealed by the study of morbid anatomy. No one Avould pretend to say that the formation of an abscess in the brain, or the degeneration of large tracts of the spinal cord, is accompanied by shock, and yet this ought to be the case if shock Avere purely an affection of the nervous system. In fact, here, as Ave saAV in studying the process of inflammation, it is impossible reasonably to mark out and divide the nervous from the vascular system, or either from the parenchymatous structures around them, and say this is, and that is not, the scat of the affection. Shock is the general or constitutional effect of injury, and as the synergy of health unites all the tissues of the human body in normal life and action, so under the effect of injury they are still united by sympathy, and one tissue cannot suffer without the others. Still, this sympathy is brought out through the agency of the nervous sys- tem, by a process of reflex action in fact, and, accordingly, it is not surprising to find that the symptoms of shock can be artificially induced by irritation applied directly to certain nerve structures. Drs. Mitchell, Morehouse, and Keen, of this city, Avho have devoted special attention to this subject, give the following explanation as to the probable mode in Avhich the symptoms of shock are brought about: " These very interesting states of system," they say, " may be due, it seems to us, either to an arrest or enfeeblement of the heart's action through the mediation of the medulla oblongata and the pneu- mogastric nerves, or to a general functional paralysis of the nerve centres, 134 EFFECTS OF INJURIES IN GENERAL. both spinal and cerebral, or finally to a combination of both causes;"1 and from an experimental investigation of the subject, Dr. C. C. Seabrook con- cludes that the phenomena of shock are due to paralysis of the vaso-motor centres. Hence, while it is incorrect to speak of shock as exclusively an affection of the nervous system, it is through the agency of that system that its phe- nomena are brought about, and it is to a clearer understanding of the laws of nervous action that Ave must look for more definite and precise ideas as to the essential nature of this curious physical condition. A good deal of confusion exists as to the meaning of the word shock, from this condition not being distinguished from others which often coexist with it, especially cerebral and spinal concussion and mental perturbation. Thus, a violent blow on the head may doubtless be accompanied by shock, but it will also probably be accompanied by cerebral concussion, an entirely distinct affection, and yet one which is not unfrequently spoken of by surgical Avriters as a typical instance of shock. Again, mere mental emotion, trepidation, or fright, may cause fainting or even death, and yet this is not shock in the true sense of the term. That true shock is a purely physical condition is seen from its occurrence in the lower animals, even in those which are cold- blooded, and from its being met Avith after operations done Avhile the patient is under the full influence of an anaesthetic, and Avhile mental emotion is therefore out of the question. Still, so intimately connected are mind and body, that it is often in practice difficult, if not impossible, to separate the mental condition from the purely physical state of shock. Causes of Shock.—While in general terms it is correct to say that every injury produces a certain amount of shock, yet there can be no doubt that certain classes of injury are more liable to be followed by this condition than others, that shock is particularly apt to follow injuries of certain parts, and that the susceptibility to shock of any individual may vary Avith the particu- lar circumstances to which he is subjected at the time of receiving the injury. Gunshot wounds have ahvays been looked upon as especially apt to be fol- lowed by shock. "When a bone is shattered," says Mr. Longmore, "a cav- ity penetrated, an important viscus wounded, a limb carried away by a round-shot, pain is not so prominent a symptom as the general perturbation and alarm which supervene on the injury. . . . This emotion is in great measure instinctive; it is witnessed in the horse mortally wounded in action no less than in his rider; it is sympathy of the whole frame Avith a part sub- jected to serious injury, expressed through the nervous system." Severe lacerated and contused wounds, such as are produced by railroad and machinery accidents, are very frequently folloAved by shock in a marked degree. One of the most decided instances of shock that I have ever witnessed was in the case of a lad whose thigh was caught in a machine called a " lapper," in a rope factory. The whole limb, from the toes to above the middle of the thigh, was marked by punctures from the teeth of the machine, which were of steel and over three inches long; the thigh Avas broken, one of the punctures ren- dering the fracture compound, while another penetrated the knee-joint. There Avas comparatively little hemorrhage, and absolutely no exhibition of mental emotion; yet there was profound shock, from which even partial reac- tion did not occur until nearly thirty hours after the accident. Burns and scalds, involving a considerable extent of surface, are apt to be attended with severe shock, which not unfrequently proves fatal without the occurrence of reaction. Other things being equal, the degree of shock is usually proportionate to the severity of the injury received, but the modifying circumstances are so 1 Circular No. 6, S. G. O., 1864, p. 2 SHOCK OR COLLAPSE. 135 many and so effective, that the exceptions to this rule are almost as numerous as its instances. The degree of shock varies with the part of the body injured; in the case of the extremities, the shock appears to be greater as the lesion is nearer the trunk, Avhile Avounds of the abdominal cavity are attended Avith more shock than those of the chest. Drs. Mitchell, Morehouse, and Keen infer from the cases which they have examined, that gunshot wrounds of the upper third of the body are more likely to be attended with shock than those of other regions. The shock attending injuries of the head or spine is very apt to be complicated by concussion or paralysis. Wounds of the testicle are fre- quently accompanied by a state of shock, much more marked than can be accounted for by the severity of the injury. The various circumstances by Avhich a patient is surrounded at the moment of receiving an injury, greatly influence the degree of shock experienced. Anything that tends to a\ eaken a patient increases the liability to shock, and thus hemorrhage, previous ill-health, certain forms of visceral disease, etc., are all found to have an unfavorable influence upon the results of operations by increasing the risk of shock. The most remarkable examples of the influ- ence of surrounding circumstances are, hoAvever, seen on the field of battle: one man, moved by a sense of duty and heavy responsibility, Avill continue in the front, though he has received a severe and, perhaps, painful injury; Avhile another, not necessarily a coAvard, may be completely unmanned by a comparatively slight scratch, and, forgetting everything else, cry like a child, or scream like a maniac. Symjjloms of Shock.—In a slight case of shock there may be merely a momentary, almost imperceptible, change of color, Avith a feeling of sinking in the precordial region, and perhaps slight qualmishness. In more marked cases there are evidences of great prostration; the patient lies helpless, and almost unable to move, the muscular relaxation affecting sometimes even the sphincters; the whole surface is very pale, even the lips appearing utterly bloodless; the skin seems shrunken, and the flesh softened; the sur- face is bathed in a cold sAveat; the features are shrunken, the eyelids droop- ing, and the Avhole appearance is that of impending dissolution. The heart's action is ahvays feeble, sometimes preternaturally sIoav and intermitting, but more usually fluttering and rapid; the pulse is commonly small and com- pressible, and in bad cases almost or altogether imperceptible. The respi- ration is feeble and gasping—sighing, as it is termed—or it may be so weak as scarcely to be noticed. There is often vertigo, dimness of vision, and slight deafness; though, on the other hand, there may be perfect mental clearness, and unnatural sensibility to light and sound. There may be various nervous manifestations, such as hiccough or subsultus, and in slighter cases, or during recovery from those Avhich are more severe, there is frequently vomiting. The temperature in cases of shock has been particularly investigated by Wagstaffe, who finds that a marked difference exists in the depression in temperature observed during collapse in fatal and in non-fatal cases. Thus, assuming the normal temperature to be 98.4° Fahr., a fall of 2° or more affords ground for a very gloomy prognosis. In exceptional cases, however, a very low temperature (91.2°) has been found compatible Avith recovery, and one still loAver (81.75°) Avith existence.1 According to Redard, who has also paid attention to this subject, if the temperature be below 35.5° Cent. (about 96° Fahr.), the injury Avill almost certainly prove fatal, and no oper- ation should be performed; while in any case in Avhich reaction as regards 1 Nicolaysen reports a case in which, from exposure to cold, the temperature fell to 76.4° Fahr., and yet the patient recovered. 136 EFFECTS OF INJURIES IN GENERAL. temperature is not observed Avithin four hours from the moment of injury, the prognosis must be considered unfavorable. When death occurs directly from shock, it is from the heart ceasing to act; post-mortem examination shoAvs the heart (especially the cavities of the right side) and the great venous trunks distended with blood, Avhich is sometimes fluid, and always coagulates Avith difficulty. In recovery from shock, the patient passes through the stage of reaction; the pulse gradually becomes stronger and more regular, the respiration grows deeper, and, after a feAV pro- found sighs, is perhaps fully re-established, vomiting often occurs, the tem- perature rises, the color improves, and the patient, from lying on his back, turns to one or the other side. The stage of reaction often passes too far, a feverish condition being developed, with great mental excitement, constituting Traumatic Delirium (see page 137), or the reaction may be incomplete, and that state come on to Avhich Travers gave the name of "prostration with ex- citement." There seems to be no definite relation betAveen the different stages of shock, as to their duration and severity. The first stage, or that of de- pression, may be so slight, and last so short a time, as to escape observation, the stage of excitement, accompanied sometimes by the wildest delirium, being the first that attracts the surgeon's attention. Curious cases illustrat- ing this statement may be found in Avorks on military surgery, and it is sug- gested by Longmore, Legouest, and others, that the state of great excitement in Avhich a soldier in action naturally must be, may probably determine the occurrence of these phenomena. When shock proves directly fatal, it is, as has been said, through the heart that death occurs. Shock may, however, be complicated Avith other condi- tions, the result of the local effects of injury, the symptoms of which may gradually supersede those proper to shock, and life may thus be extinguished in other ways. Thus there may be concussion of the brain or spine coexist- ing with shock; or an important viscus, such as the liver, may have under- gone laceration, when death may occur before reaction, and yet not from shock, but from internal hemorrhage or incipient peritonitis. Treatment of Shock.—The object of the surgeon in managing a patient suffering from shock is, of course, to bring about reaction. As death from shock depends on the heart ceasing to act, the treatment must be directed to increasing the force and the regularity of the cardiac pulsations, and, in some few cases, this may perhaps best be done, as pointed out by Mr. Savory, by resorting to venesection. It is known that after death from shock the heart is filled with blood, and is, in fact, paralyzed from distention; it is knoAvn, from experiments on the lower animals, that in such a condition, even after all pulsation has ceased, the heart's action can be restored by mechanically relieving the organ by a puncture in the right auricle, or in the jugular vein; hence the inference is reasonable, and is confirmed by experience, that Avhen —as in shock—death is imminent from engorgement of the right side of the heart and venous trunks, relief may be afforded by bloodletting. To make this as effective as possible, the blood should be draAvn from the jugular vein. It is, of course, only in extreme cases, and in such as have not already suf- fered from hemorrhage, that this mode of treatment can be required, and it should be looked upon as an extreme remedy. In all cases of shock, stimulation, both internal and external, should be employed. Dry heat is to be applied to the surface by means of hot bottles, hot bricks, etc.; sinapisms may be placed on the abdomen and chest, and cordial draughts administered if the patient be able to swallow, and if not, stimulating enemata resorted to instead. The general treatment of this con- dition has been already referred to in Chapter III., in discussing shock as a cause of death after operation, and I will merely repeat here that the arterial TRAUMATIC DELIRIUM. 137 stimulants administered should be preferably such as are evanescent in their effects, as the preparations of ammonia; though in any severe case the use of brandy A\ill be found essential, and, indeed, is often retained by the stomach better than anything else. Subcutaneous injections of ether may be em- ployed Avith the greatest advantage. As during the stage of depression, ab- sorption is greatly impeded, if not altogether checked, it is idle to give food until at least partial reaction has occurred, and even then it should be given with caution, and in small quantities at a time. For the same reason, opium, A\hich is an invaluable remedy in these cases, is more effective Avhen given hypodermically than by either the mouth or rectum. In any case, as long as the heart's action continues, there is hope; and if natural breathing fail, artificial respiration should be resorted to, and con- tinued systematically and perseveringly. Electricity is often used to excite the heart to reneAved activity, but, at least in my own experience, without much benefit. Easley, of Little Rock, Ark., and McGuire, of Richmond, Va., recommend large doses of quinia, before operations, as a prophylactic against shock, Avhile the same remedy, in combination Avith the camphorated tincture of opium, is employed in the form of enema by Lund, of Manchester. Traumatic Delirium.—When reaction occurs, it is often excessive. In the treatment of Traumatic Delirium (p. 136), the surgeon must keep in mind that he is dealing with increased action, not Avith increased power. In fact, this condition always approaches more or less to Travers's "prostration with excitement," though the degree of debility of course varies in different cases. The symptoms of Traumatic Delirium are very much those of the ordinary Delirium Tremens, and indeed, in the case of hospital patients, many of whom are habitually hard drinkers, it is often quite impossible to draAV an exact line, and say which condition is actually present. There are the same brightness of eye, heat of head, slight acceleration of pulse, constant and irrepressible muscular action, and sleeplessness with Avandering delirium and rapid succession of spectral delusions, usually of a frightful and painful character. I do not believe that depletion is ever necessary in cases of pure traumatic delirium ; if complicated with cerebral inflammation, the case may be different, but this is a question Avhich A\*ill be referred to in its proper place. The head should be slightly elevated and kept cool by means of ice- bags, or Petitgand's apparatus (Fig. 7), and the patient kept as quiet as pos- sible, in a rather dark room; as there is usually constipation Avith a furred tongue, a mercurial cathartic may be given, though profuse purging should be avoided. An anodyne and diaphoretic mixture will almost always be proper, to Avhich, if there be great cerebral excitement, small doses of tar- tarized antimony may perhaps be cautiously added. The most important remedy in the treatment of traumatic delirium is opium, Avhich should be given freely, and Avith brandy or Avhiskey in quantities proportioned to the debility of the patient. Food is quite as important as medicine, and should be regularly administered in a concentrated form, in small quantities at fre- quent intervals. Amputation during Shock.—Before leaving the subject of shock, there is one question Avhich demands consideration, Avhich is, whether or no an am- putation should be performed during the continuance of this condition. As a general rule there can be no doubt that it is right to Avait for reaction to occur, before subjecting the patient to the additional source of depression Avhich must come from the operation, and in any case it would be proper to Avait a short time and endeavor to procure reaction in the way that has been directed. In some instances, hoAvever, especially in the cases of compound fracture produced by railroad or machinery, the mangled limb seems by its 138 EFFECTS OF INJURIES IN GENERAL. presence to act as a continual source of depression, and in such cases prompt amputation, even during the existence of a certain amount of shock, will give the patient a better chance than delay. Particularly is this the case when the injured part is very painful, and when bleeding is going on from small vessels that cannot be controlled. Under these circumstances it is a good plan to try the effect of anaesthesia; if the inhalation of ether produces an amendment in the patient's condition, making the pulse fuller and stronger, it is probable that the depression is purely one of shock from the external injury, and the surgeon will be justified in resorting to immediate operation. If, on the other hand, in spite of the anodyne and stimulating effect of the anaesthetic, the patient continue to sink, there is grave reason to apprehend that some severe visceral lesion is superadded to the obvious external injury, and under such circumstances operative interference will not be advisable. The surgeon may be aided in coming to a decision under these circumstances by observing the temperature of the patient; if this be beloAv 96° Fahr., no operation as a rule is admissible (see p. 135). Remote Constitutional Effects of Injuries.—These are even more ob- scure than those effects which are immediately produced. The state of system to which the older writers gave the name of secondary or insidious shock has already been referred to (p. 67). It is probably due, at least in the majority of cases, to the formation of coagula either in the heart itself or in the great venous trunks; this is a very fatal condition, and not unfrequently causes death after operations. Heart clots may kill the patient directly, by mechanically impeding the cardiac action, or portions of a clot may become detached and be carried by the circulation into other parts of the body, where they may prove fatal by plugging important vessels, such as the branches of the pulmonary artery, the internal carotids, etc. This process is called embolism, and the fragments of clot are called emboli or embola. Embolism by particles of fat, is an occasional cause of sudden death in cases of injury to the bones involving the marroAV, as pointed out by Wagner, Busch, Czerny, Boettcher, Dejerine, Duret, and other surgeons; and a remarkable case of embolism of the pulmonary artery by a portion of the liver, folloAving rup- ture of that organ, has been reported by Marshall, of Nottingham. Fat- embolism from rupture of a fatty liver, has been noted by Hamilton, of Edinburgh, and from a simple flesh Avound of the thigh, by Dr. W. H. Bailey, of New York. There are other obscure constitutional conditions which result from injuries, often probably through secondary lesions of the central nervous system. In other cases, again, from some local change, the general nutrition of the body may be affected through the medium of the blood. The neuralgic condition which sometimes follows injuries, and Avhich has been particularly studied by Verneuil, may often be relieved by large doses of quinia. Local Effects of Injuries. These may be classified as the effects of violence, embracing contusions, wounds, fractures, and dislocations, and the effects of chemical agents (espe- cially heat and cold), embracing burns, scalds, frostbite, etc. There are like- wise certain remote local effects of injuries, which have not as yet been thoroughly traced out; thus many chronic affections of bones and joints origi- nate from injuries, while external violence must be considered as at least the exciting cause of the development of many morbid growths, whether inno- cent or malignant. CONTUSIONS. 139 Contusions.—In a contusion the skin is not broken. There is ahvays, however, laceration of the subcutaneous tissues, sometimes very slight, as in the ordinary bruise, but sometimes causing complete disorganization of a limb or other portion of the body. When all the tissues of a part are completely crushed, it is sometimes said to be pulpefied. The skin itself, though not broken, may be so much injured as to lose its vitality, and slough. Every contusion is attended with more or less extravasation of blood; if in small amount, this constitutes ecchymosis, the blood undergoing certain changes in the process of absorption, which gives rise to the " black and blue" appearance of an ordinary bruise. If the extravasation of blood be in larger amount, it constitutes a thrombus (Avhen clotted), or a hozmatoma when remaining as a tumor containing fluid blood. Beside the extravasation of blood, a contusion is ahvays accompanied by the exudation of a serous fluid; this may be very slight and superficial, as seen in the wheal or elevated ridge produced by the stroke of a whip, or it may arise from deep-seated injury, when it makes its appearance in the form of vesicles and bullae, as is especially seen in parts in Avhich the bones are subcutaneous, as over the tibia and ulna. The subcuta- neous hemorrhage or extravasation which accompanies a contusion is seldom productive of serious consequences, unless from rupture of a large artery. Mr. Erichsen has, however, recorded an autopsy in the case of a boy beaten to death by his schoolmaster, in which the fatal issue appeared to have been principally due to this cause. The amount of extravasation varies Avith the part affected ; where the areolar tissue is of loose structure, as in the eyelids, it is very great, and the swelling correspondingly Avell marked. The causes of contusion are simple pressure, blows, and falls, or, in other words, direct and indirect violence. The symptoms are local pain and tenderness; swelling (from extravasation and exudation), preceded perhaps by a temporary depres- sion or indentation from the force of the blow; momentary loss of color, fol- lowed by increased redness, and subsequently by various modifications of hue OAving to the changes in the extravasated blood; increase of temperature, etc. In cases of severe contusion, vesications make their appearance in the course of from twelve to twenty-four hours, and by their size and number indicate the extent of subcutaneous injury. The diagnosis of contusion is usually easy. In some cases, however, the appearances are almost identical Avith those of incipient traumatic gangrene (which may indeed result from con- tusion), and then the nature of the case must be determined by negative evi- dence, by the absence of the characteristic gangrenous odor, by the tempera- ture of the affected part, the constitutional symptoms, etc. In some situations, as in the scalp, difficulty of diagnosis arises on account of the extravasation, which in this position imparts to the surgeon's fingers very much the sensation of a depressed fracture. There is a ring of hard tissue Avith a soft central depression, which often deceives the hasty observer; by firm pressure the bone can be usually felt in its natural position, at the bottom of this depres- sion, and the surrounding hard tissue may be observed to be really elevated above the normal level. A thrombus is sometimes mistaken for a solid tumor, and a hozmatoma for an abscess; the diagnosis under these circum- stances must be made from the history of the case, from the absence of inflam- matory symptoms, etc. Though extravasated blood is usually absorbed, it occasionally becomes encysted, remaining fluid for an indefinite period and thus becoming a starting-point for the development of a tumor, or it may coagulate and remain as a clot, or after coagulation become again liquid (Baker, St. Bartholomew's Hosp. Reports, vol. ii., pp. 201-223); according to Paget and others, the blood extravasated in contusion may actually become organized, acquiring more or less the characters of connective tissue, but it more frequently acts as a foreign body, exciting inflammation around, and 140 EFFECTS OF INJURIES IN GENERAL. being eventually discharged Avith the products of the resulting suppuration. The prognosis of contusion, unless some vital organ be involved, is usually very favorable. Provided that the skin be uninjured, the severest laceration will commonly be recovered from without difficulty; but if the atmosphere be admitted to the injured tissues by the smallest wound, or by secondary sloughing of the skin, the characters of a subcutaneous injury are lost, and wide destruction of parts may ensue. Contusions of bones and joints, and of nerves, are, as we shall see hereafter, often followed by secondary conse- quences of the gravest nature. The treatment of ordinary bruises is best conducted by the application of slightly stimulating embrocations, such as the soap liniment of the Pharma- copoeia, the tincture of arnica, or simply diluted alcohol. The absorption of extravasated blood may be assisted by gentle friction or kneading—a mode of treatment Avhich the French have systematized under the name of massage. In severer cases, the part should be wrapped in some warm and soothing dressing, such as lint soaked in oil, Avith laudanum, or in lead-Avater and lauda- num, in order to keep up the natural temperature, and prevent, if possible, the occurrence of gangrene. All tight bandaging or firm pressure should be strictly avoided. If gangrene should occur, the question of amputation may arise, and should be decided on the principles laid down in Chapter V. If a thrombus form, the surgeon may endeavor to promote its absorption by moderate pressure and gentle friction; all rough handling should be avoided, lest suppuration be induced. In case of a collection of fluid blood persisting in spite of treatment, a puncture may be made, and, after the escape of the blood, pressure employed, with a view of inducing the walls of the cavity to adhere; if this fail, or if suppuration occur, a free opening must be made, and the case treated as one of ordinary abscess. Strangulation of Parts.—SomeAvhat analogous to the condition of a part which has been severely contused, is that of a part which has undergone strangulation, from the pressure of a tight bandage or other cause of constric- tion. Strangulation is often intentionally employed by the surgeon in the treatment of \Tarious affections, such as nsevus, vascular tumors, hemorrhoids, etc. In such cases the strangulated part becomes mortified, and is removed by the formation of granulations in the line of constriction. The fingers occasionally become accidentally strangulated by being carelessly thrust into tight rings. The ring can generally be removed by soaking the finger in iced water, which causes the part to shrink, or by the use of a silk cord, tightly wrapped around the finger and slipped under the ring, which is then worked off in the process of unwrapping. If these expedients do not avail, a director should be insinuated under the ring, which must then be divided be a file or by cutting-pliers. The penis is sometimes strangulated, either by being introduced into a ring, or, as has occasionally happened in the case of children, by the nurse tying a tape around the organ to prevent the child from wetting its bed. Unless the constriction be promptly removed, the most serious consequences will probably ensue, sloughing of the part being almost inevitable, and even death having occasionally followed this accident. Wounds. A wound is a division or solution of continuity of the soft tissues, pro- duced by violence; an open wound is one in which the division of the' skin is as free or nearly so as that of the deeper tissues, while a subcutaneous wound is one in which the opening in the skin is comparatively very small. Wounds are further classified by surgeons, according to their nature and INCISED AVOUND S. 141 causes, into incised, lacerated, contused, punctured, and poisoned wounds. Gun- shot wounds, and the peculiar form of injury known as brush-burn, are vari- eties of contused wounds. Incised Wounds.—As its name implies, an incised wound is one made by a clean cut with a knife, razor, or other sharp instrument. These wounds are constantly intentionally inflicted by the surgeon, in amputating limbs, removing tumors, cutting for stone, etc. They are also frequently produced by accident, from the careless use of penknives or razors, or, among farm- laborers, from that of scythes or axes; many of the wounds produced by broken glass are incised, though these may also partake of the nature of lacerated wounds; the cut-throat of the suicide is an incised wound; the sabre-cuts met with in war, being inflicted Avith a heavy blow, approach to the nature of contused wounds. The pain of an incised wound varies ac- cording to the nature of the instrument Avith which it is inflicted, the part in which it is situated, and the manner in which it is produced. The sharper the knife, the less the suffering which it causes; wounds of the face or hands are more painful than those of the trunk; wounds made from within, less painful than those from without. The reason of these differences is very apparent: a clean cut with a sharp knife produces less dragging and tearing of sensitive parts than a haggling incision with a dull one; those parts which are most abundantly furnished with nerve filaments are most sensitive to pain; and by first dividing the trunks of nerves, their branches are para- lyzed, and there will then be less suffering than under opposite circum- stances; hence the advantage (before the days of anaesthesia) of the trans- fixion operation over other forms of amputation. It is well knoAvn that a wound rapidly inflicted is less painful than one more deliberately produced, and it has therefore been suggested by B. W. Richardson, and by Andrews, of Chicago, to use a blade connected Avith a rapidly revolving wheel, and it has been claimed that in this way operative surgery might be rendered painless; it seems to me, however, that such a contrivance Avould in practice be unmanageable, not to speak of the erroneous principle involved in its conception, which would endeavor to substitute mechanical ingenuity for the immediate personal attention and responsibility of the operator. The amount of hemorrhage from an incised wound varies of course with the number and size of the vessels cut. Wounds of the face bleed more freely than those of the extremities, and wounds of the scalp are attended with very profuse hemorrhage, not only from the vascularity of the part, but because, on account of the denseness of the surrounding structures, there is not the same opportunity for contraction and retraction of the vessels, as m parts of looser texture. The existence of inflammation or other circum- stances may cause the vessels of a part to be much enlarged; hence an in- cision into inflamed tissue will bleed more freely than one into normal structure In some peculiar cases, in which what is called the hemorrhagic diathesis exists, the slightest wound—even that caused by lancing the gums of children—may cause fatal hemorrhage. Beside the pain and bleeding which attend an incised wound there is always more or less retraction of its edges or lips, which constitutes the gaping of the wound. The amount of this retraction depends upon the nature of the tissue involved, its condition at the time when the wound is inflicted, and the direction of the wound itself. Tissues which are elastic or which contain muscular fibres retract more than fibrous tissues; the following is given by Nelaton as the order in which the soft parts gape when wounded, viz., skin, elastic tissue, cellular tissue, arteries, muscles, fibrous tissues, nerves, carti- lages A wound of a part in which there is much tension, from inflammation 142 EFFECTS OF INJURIES IN GENERAL. or from any other cause, Avill gape more than one in the same part under ordinary circumstances. Thus an incision into an erysipelatous limb, or over the female breast during the process of lactation, will gape more than if those parts were not in a state of tension. Again, the direction of a Avound affects the degree of retraction of its lips; an incision in the direction of the mus- cular fibres of a part Avill gape less than one Avhich crosses that direction at right angles, and in general terms Ave may say that longitudinal Avounds gape less than those Avhich are transverse. Process of Healing in Incised Wounds.—Incised Avounds may heal in one of three Avays, or, as more frequently happens, partly in one and partly in another of the three. The modes in Avhich incised Avounds heal are—1, by immediate union, or by the first intention; 2, by adhesion; and 3, by granula- tion, or by the second intention. Healing by scabbing, or incrustation, is a variety of the first or second methods, according to circumstances; Avhilethe so-called secondary adhesion (third intention, or union of granulations), is a mere modification of the third method—the union by granulation, or by the second intention. 1. Immediate Union, or Union by the First Intention (Hunter).—To under- stand the processes concerned in the healing of Avounds, the reader must bear in mind Avhat Avas said in the first chapter as to the nidritive and formative changes due to the inflammatory process. It is by means of these changes that the repair of wounds is in every instance effected. For a short time, varying from a few minutes to an hour or two, after the reception of a Avound, it remains inactive; its edges then become somewhat red, Avarm, swollen, and painful—it has, in fact, become the seat of the inflammatory process. Now, if the Avound be a clean cut, if it contain no foreign body nor clotted blood, if its lips be in close and accurate approximation, and if the tissues concerned be homogeneous (that is, if skin be apposed to skin, cellular tissue to cellular tissue, etc.), under the most favorable circumstances of gene- ral health and hygienic surroundings, the inflammatory process may stop in its first stage, that of temporary hypertrophy. The parenchyma in both lips of the wound is distended with nutritive material, a feAV wandering cells per- haps pass across the line of incision, the apposed surfaces adhere together, and the wound is healed by immediate union, or the first intention, without the formation of lymph, and, of course, without any resulting scar. This mode of healing is very seldom met with, at least in this country. I believe that I have seen it in cases of very slight cuts of the fingers, inflicted by the sharp blade of a penknife, and once in the face, in at least a portion of a clean incised wound. Sir James Paget has seen this mode of union in a case of excision of the breast. The cases Avhich we read of every day in the journals, of union by first intention after amputation, are, I believe, really instances of the second method by which wounds heal, that by adhesion. 2. Union by Adhesion.—In the accomplishment of this process, the inflam- mation reaches its second stage, or that which is accompanied by the first formative change, viz., lymph production. This is what Paget calls union by adhesion (the name which I have adopted), or by adhesive inflammation —that distinguished surgeon and pathologist considering that the first mode of union is accomplished without any inflammation Avhatever ; it is, however, I think, more consonant with the modern vieAvs of the inflammatory process, to look upon that process as necessary for the repair of wounds under all cir- cumstances, and to regard immediate union, as I have done, as effected by inflammation limited to its first stage, that of temporary hypertrophy without lymph production. For union by the mode which we are now considering, lymph is essential. Whether this lymph be the result of cell proliferation, or whether it originate in the escape of Avhite blood cells from the vessels, can- INCISED WOUNDS. 143 not at present be considered as determined ; in its appearances, physical prop- erties, and other characters, it is identical Avith the inflammatory lymph described in Chapter I. To obtain union by adhesion, the patient must be in good condition, the Avound healthy, and containing no foreign body or blood, its lips not bruised or otherwise injured, but accurately adjusted, and the cut surfaces strictly in apposition and excluded from the air. The inflam- mation must not pass beyond its second stage, or this form of union cannot be obtained. Perhaps the fairest examples of this mode of healing are to be seen in cases of plastic operation, as for harelip, lacerated perineum, etc. It is possible that in these cases immediate union may be sometimes obtained, but the presence of a slight scar after healing shows that, at least in the immense majority of cases, the union has been by adhesion or through the medium of lymph. Union by adhesion should ahvays be aimed at in the treatment of stumps and of most operation Avounds, and may be generally secured throughout the greater part of the incision. Scalp Avounds, and wounds of the face and neck, commonly unite in this Avay, as do also, though more rarely, incised Avounds of other parts of the body. Superficial Avounds, Avhen their edges are brought together, often unite without difficulty under a scab, formed by the hardening, over the line of incision, of effused blood and serum, intermingled with hair, dust, and other foreign particles ; the healing under such circumstances may be by immediate union, though it is more often by adhesion. In either case, this healing under a scab constitutes what has been called healing by scabbing, by incrustation, or by subcrustaceous cicatrization. It is a mere variety of one or other of the methods already described. Some confusion is often created by the appli- cation of the phrase " union by the first intention," by modern writers, to that process Avhich I have described under the name, proposed by Paget, of " union by adhesion." The latter name is, I think, more correct, and more expressive of the process which actually occurs in the ordinary primary union of wounds, and the term "first intention" should, I think, be reserved for those rare cases of immediate union without lymph, to Avhich it Avas applied by the illustrious John Hunter, though that surgeon erroneously believed that the union in such cases depended on the organization of an interposed layer of effused blood. 3. Union by Granulation, or by the Second Intention.—In this mode of healing, the inflammatory process reaches its third stage, that attended by the second formative change, or the production of pus. The cut surfaces become covered Avith granulations, precisely identical in structure and char- acters to those met Avith in a healing ulcer (see page 47), and the free sur- face is bathed Avith pus. The granulations gradually fill up the gap, and, Avhen they have reached the level of the surrounding skin, cicatrization occurs just as in the repair of ulceration, Avhich has already been fully described. The union by secondary adhesion, or by the third intention, is identical Avith the mode of union now under consideration, except that the granulating sur- faces are so apposed that they unite and grow together, thus expediting the healing process. Union by granulation is that commonly met with in large wounds, such as those produced by amputation, or Avhere, from excessive inflammation, from a large number of ligatures acting as foreign bodies, or from other causes, union by adhesion cannot be obtained.1 1 D. J. Hamilton, of Edinburgh, has recently advanced an ingenious theory, according to which the lymph which is found on the surface of a recent wound is an exudation from the divided lymphatic vessels, acts merely mechanically in favoring the adhesion of the cut surfaces, and is soon reabsorbed; the repair of the wound is due exclusively to proliferation of the connective-tissue corpuscles in its immediate vicinity; while the leucocytes, which escape from the bloodvessels, act as foreign 144 EFFECTS OF INJURIES IN GENERAL. Treatment of Incised Wounds.—The object of the surgeon, in the manage- ment of every incised Avound, should be to obtain, if not immediate union, at least union by adhesion. The credit of establishing the rule Avhich is now universal, at least in England and in this country, to attempt to get primary union Avhenever possible, is due, in great measure, to the teachings of the British surgeons of the last century, especially Sharp, Alanson, Hey, the Bells, and Hunter, although it is probable that such a course was occasionally pursued in much earlier times. Its advantages are obvious; not only is the time occupied by the healing process much shorter Avhen adhesion is obtained than Avhen union occurs by granulation, and the resulting scar less conspicuous and disfiguring, but the patient is saved the exhausting consequences of pro- longed suppuration, and is, in a great measure, preserved from the risk of the secondary affections which often complicate wounds, such as erysipelas, vari- ous forms of blood poisoning, etc. In making the attempt to procure primary union, there are three principal indications presented to the surgeon ; these are (1) to arrest and prevent hemorrhage, (2) to remove all foreign sub- stances, and (3) by suitable dressings to adjust the cut surfaces closely and accurately, to prevent the access of atmospheric air, and to prevent the in- flammatory process from passing beyond its second stage, or that of lymph formation. (1.) If the hemorrhage be of the nature of general oozing from small ves- sels, it may be commonly controlled by position, or by the use of cold, of pressure, or of various styptics, as will be described in another chapter; if the bleeding be from larger vessels, these must be treated by ligature, by acupressure, or by torsion, the comparative merits of Avhich plans will be fully discussed when Ave come to speak of Avounds of arteries. (2.) Hemorrhage having ceased, the surgeon must carefully but gently cleanse the wound, so as to remove all foreign substances Avhich may have lodged betAveen its lips. This may be conveniently done by means of a stream of running water (as supplied by the "ward carriage," Fig. 10); or if sponges be used they should be new and soft, and very gently handled. As Sir James Paget well puts it, " Wounds should not be scrubbed, even Avith sponges." Mr. Callender employed camel's-hair brushes. To determine the freedom of a wound from foreign bodies, the surgeon may put in service his hands as Avell as his eyes, it being sometimes possible to detect with the finger a grain of sand or spicula of bone, which, embedded in muscle and tinged with blood, might escape ocular observation. (3.) Dressing of Incised Wounds.—As a rule, wounds should not be dressed until all oozing has ceased. A great deal used to be said about the glazing of a Avound, and it was supposed that this glazing consisted in the exudation from the bloodvessels of a fibrinous material (lymph), which formed the bond of union. But Avhatever be the origin of this lymph (a question of purely theoretical interest), there is no reason to suppose that it is formed more readily or of a better quality, before than after the closing of a wound; hence, as soon as hemorrhage has ceased, the sooner the lips of the wound are ap- proximated the better. In closing Avounds, the surgeon makes use of sutures, plasters, and bandages. The various materials employed for sutures have bodies, and are either reabsorbed or discharged as pus. According to the same writer, granulations are not new formations, hut consist of capillaries which are dis- tended into the form of loops on account of the removal of the restraining pressure of the integument. Hence, Mr. Hamilton regards what is known as unionby granula- tion as really the same as union by adhesion. Mr. Hamilton also recommends, under the name of "sponge-grafting," the introduction into wounds, when there is much loss of substance, of a carbolized sponge, to act as a framework for the support of the granulations. INCISED WOUNDS. 145 Mounted needle, armed with a ligature. Fig. 69. been already described in previous chapters, and it will be sufficient to say here, that, for ordinary purposes, lead or malleable iron Avire is the most suitable and convenient. The needles used by surgeons are of various sizes and shapes, as shown in Fig. 38 ; it is occasionally advantageous to have a strong needle mounted in a handle (Fig. 68), and with an eye at its point, like the " nievus needle," for use in situations diffi- Fig. 68. cult of access, or when the tissues to be pene- trated are unusually dense. Various needles have been devised for special use Avith Avire, but present no particular ad- vantages over those gen- erally employed. The various forms of suture commonly used by the surgeon may be enumerated as the interrupted suture, the continued or glover's suture, the twisted or harelip suture, and the quilled suture. The interrupted sidure (Fig. 69), which is that most frequently used, con- sists, as its name implies, in a number of single stitches, each of Avhich is entirely independent of those on either side. In applying it, the surgeon holds one lip of the Avound Avith the fingers of the left hand, or with forceps, and introduces, Avith a quick thrust, the needle previously threaded, about two lines from the cut edge; he then takes the opposite lip in the same way, and passes the needle, in this case from within outAvards, taking care that there shall be no undue tension or uneven dragging of the wound. Some surgeons employ two needles, passing both from Avithin outAvards ; but this causes unnecessary delay, and offers no ad- vantage over the common mode. Each stitch may be secured as it is introduced, or all may be passed, their ends being left loose to be fast- ened subsequently. If silk be employed, it is tied in a reef-knot; if Avire, it is simply tAvisted. If the mounted needle (Fig. 68) be employed, it must be thrust through both lips of the Avound before being threaded (the suture being thus passed as it is AvithdraAvn), and must, therefore, be re-threaded for each stitch. The distance betAveen the points of the interrupted suture, and the depth to Avhich each stitch is passed, vary Avith the nature and extent of the wound ; as a rule, the skin and superficial fascia only should be included in the stitches, and there should be an interval of from half an inch to an inch betAveen the consecutive points of introduction. The continued or glover's suture (Fig. 70) is principally used for wounds of the intestines, though it is occasionally employed in other situations Avhere the tissues are of loose structure, as in the eyelids. It is made Avith silk or with a fine thread, which passes across the Avound continually in the same direction ; it is the stitch employed in the manufacture of gloves, whence it derives its name. The twisted or harelip suture (Fig. 71) is an excellent method of uniting 10 The interrupted suture. 146 EFFECTS OF INJURIES IN GENERAL. wounds Avhere great accuracy and firmness are desirable. It consists of metallic pins or needles, thrust through both lips of the wound, the edges being kept in contact over the pin by figure of 8 turns with silk thread or Fig. 70. Fig. 71. Fig. 72. The continued, or glover's suture. The twisted suture. India-rubber suture. with Avire, according to the fancy of the surgeon. For the figure of 8 turns may be substituted delicate rings of India-rubber, constituting the " India- rubber suture" of M. Kigal (Fig. 72), which was used in this city by the late Dr. W. L. Atlee, in dressing cases after the operation of ovariotomy. The tAvisted or harelip suture, as its name implies, is principally used after the operation for harelip. The pins should be of steel, which may be gilded to prevent oxidation, and, after the complete adjustment of the suture, the points of the pins should be cut off with suitable forceps or pliers, to prevent their hurting the patient, or they may be protected by bits of cork, or by the ingenious "needle guard" devised by Tyrrell, of Dublin. The quilled suture (Fig. 73) is seldom employed at the present day, except in the treatment of lacerations of the perineum. It consists of a number of double threads or wires, passed through the lips of a wound so that the loops shall be on the same side; through these loops is passed a quill or piece of bougie, and the sutures being tightened, the free ends are secured around another quill, deep and equable pressure being thus made along the whole line of the wound. Various ingenious modifications of the quilled suture have been introduced, among others by Lister, and by Will, of Aberdeen, and are principally useful in plastic operations. The clamp and button sutures of Dr. Sims and Dr. Bozeman will be again referred to in speaking of the treatment of vesico-vaginal fistula. Except in very extensive Avounds, or where the tension is unavoidably very great, it is, I think, better to rely upon sutures alone, without using plasters, at least in the early dressings. Even in amputation wounds, I am not in the habit of employing plaster, except after the sutures have been removed, to give support to the line of union of the flaps. The common machine-spread adhesive plaster of the shops is a very good article for general use; it should be cut into strips, of widths varying from half an inch upAvards, and, if firmness be desired, the strips should be cut lengthwise from the roll of plaster, as the cloth on which it is spread stretches more transversely than in a longitudinal direction. To prepare them for use, the strips are heated by applying their unspread side to a bottle or can filled with hot water; or by passing them through the flame of a spirit lamp; they are ad- INCISED AVOUNDS. 147 justed so that the Avound comes opposite to the middle of the strip (Fig. 69), and they should be applied with care and neatness, so as to support the edges of the Avound Avithout dragging or undue pressure. In removing them, the same care must be used not to drag apart the edges of the wound by rough manipulation. It is, perhaps, scarcely neces- sary to say that the surface to Avhich the Fig. 73. plaster is applied should be thoroughly cleansed and dried to insure adhesion, and that the hair, if there be any on the part, should be shaved off, as otherwise the removal of the plaster w ill give the patient consider- able pain. Isinglass plaster is a very neat and efficient substitute for the ordinary adhesive plaster, and is, I think, preferable for superficial wounds, especially in private practice. An excellent article has been introduced under the name of " American surgeon's adhesiAre plaster;" it contains India-rubber, and has the great advantage that it will adhere Avith- out artificial heat. Wet strips of muslin are employed instead of adhesive plaster by Porcher, of Charleston. The use of sutures is occasionally undesir- able, particularly in localities where it is wished to avoid any needless mark, as in the face ; or in the scalp, AAdiere the use of stitches is believed by many surgeons to expose the Quilled suture. patient to the risk of erysipelas. Hence it becomes important to possess an article Avhich Avill be more permanent than the ordinary plaster, and yet Avhich Avill not cause the disfiguration, inevita- ble Avith sutures. Such a material is collodion, Avhich was first employed in surgery by Dr. Maynard, of Boston, and Avhich may be most com^eniently used in the form of the gauze and collodion dressing, introduced into this city by the late Dr. Paul B. Goddard. The gauze and collodion dressing is thus employed. Strips of fine tarlatan, or, Avhich is better, of " Donna Maria gauze," about an inch Avide by four or five long, are laid across the approximated lips of the wound, previously AArashed and dried, and are secured by the application, Avith a camel's-hair brush, of collodion, first to one end, and, Avhen that is firmly adherent and dry, then to the other. With neatness and care, a superficial wound can thus be closed as accurately and as firmly as by the use of sutures. The strips will stay on as long as may be desired, the collodion being impermeable to water, and the dressing may be hermetically sealed, if thought necessary, merely by spreading the collodion over the Avound itself as well as on either side. The " svptic colloid " of Dr. Richardson, Avhich is essentially a solu- tion of tannin in collodion, may be advantageously substituted for the ordi- nary collodion in cases in which there is a tendency to oozing, or a combina- tion of these substances with carbolic acid, as suggested by an Italian physi- cian, Dr. Paresi, might be employed with the view of obtaining the antiseptic effect so much insisted on by Prof. Lister and his folloAvers. Lead ribbon has been substituted for the gauze in this mode of dressing, and has been satisfactorily used by Dr. HeAvson, at the Pennsylvania Hos- pital ; my oAvn experience has, however, not been favorable to this modifica- tion. 148 EFFECTS OF INJURIES IN GENERAL. Serre-fines (Fig. 74) may be used for slight and superficial wounds, either alone or in addition to other measures, Avhen very close and accurate union is desired. Sutures and plasters Avill only serve to approximate the edges of a Avound; its deep surfaces should be brought into contact by the use of compresses (of lint, oakum, or charpie) and appropriate bandages. The bandage of Scul- tetus and other still more complicated devices Avere formerly much used by surgeons for this purpose, but are uoav almost universally sup- Fig. 74. planted by the common roller bandage, Avhich in skilful hands can be made to meet every indication. Ordinary incised Avounds should be dressed as lightly as pos- sible ; a piece of lint, Avet or dry, or an oiled or greased rag, held in place by a feAV strips of plaster or turns of a roller, Avill com- monly be sufficient. Guerin, Warren Greene, and others com- mend the use of cotton-wool, Avhich they believe acts as a filter to prevent the access of deleterious germs to the wound; and Hew- son, of this city, has reported very favorably of the employment of dry earth as a primary dressing; Avhile Prof. Hamilton, of Xew York, is equally en- thusiastic in his praise of the continuous warm bath, a mode of treatment Avhich, I believe, originated Avith Langenbeck, and Avhich has been modified by Duplay, who plunges the limb in an " antiseptic bath " containing one per cent, of carbolic acid. In scalp wounds, it is generally right to apply a firm compress, so as to check oozing and prevent bagging of serous and other discharges. Sutures may be removed about the fourth or fifth day, or sooner if they ha\Te become loosened, and the edges of the wound should then be supported by strips of plaster till union is complete. If the wound become inflamed and painful, it must be treated on the principles laid doAvn in previous chapters. Lacerated and Contused Wounds.—These two varieties of wound may be considered together, as they generally coexist in the same cases, and require essentially the same treatment. As their names imply, a lacerated wound is one of Avhich the edges are torn and not sharply cut, and a contused wound is one of Avhich the edges are bruised. These Avounds are inflicted by bloAvs from dull instruments, as stones or clubs, by machinery accidents, by injuries from railway trains, etc. Gunshot Avounds are likeAvise included under this head, but are of such importance as to demand a separate chapter for their consideration. Lacerated and contused wounds present several peculiarities of character and appearance. Thus, their edges are irregular and jagged; the pain is duller and less acute, though more lasting, than that of incised Avounds ; there is less tendency to gaping, and there is less bleeding. This arises from the mouths of the vessels being tAvisted and crushed, rather than evenly divided. More or less sloughing ahvays attends these Avounds, and they are peculiarly liable to be followed by erysipelas, secondary hemorrhage, and tetanus. As a rule, and universally in this part of the Avorld, lacerated and contused Avounds heal only by granulation, or by second intention; in certain rare cases, hoAvever, and under peculiarly favorable climatic influences, it is said that they occasionally unite by adhesion. When a limb is entirely torn off from the rest of the body, the tissues of the part give way at different levels. The skin usually separates at the highest point; the muscles protrude, and appear to be tightly embraced and almost strangulated by the skin; the tendons,1 vessels, and nerves hang out of the Avound, of variable lengths, 1 In some cases the tendons give way at a point much higher than that at which the other tissues separate. LACERATED AND CONTUSED WOUNDS. 149 while the shattered bone forms the apex of the ragged conical stump. There is usually comparatively little hemorrhage under these circumstances, as in Cheselden's Avell-knoAvn case of avulsion of the whole upper extremity, but occasionally the bleeding is very profuse, and proves directly or indi- rectly fatal. In a case of this kind, in Avhich a child's thigh, being caught between the spokes of a carriage-AArheel, Avas torn off at the middle, I found the great sciatic nerve hanging fifteen inches from the stump, having given Avay below its division in the ham; a curious fact in this case Avas, that, Avhile the cutaneous surface of the stump Avas acutely sensitive to the touch, there Avas no manifestation of pain evinced upon handling the exposed nerve. The principal danger attending lacerated and contused wounds, is the occurrence of gangrene. This may be of three kinds:— (1.) Sloughing of the injured tissues, to a greater or less extent, may be considered inevitable in any seAere lacerated or contused Avound. This is the ordinary form of the affection, and demands no special consideration. The parts which have lost their vitality will be thrown off by the efforts of nature, and the Avound will then heal by granulation, or, if the sloughing be extensive, amputation may be required. (2.) There may be gangrene from arterial obstruction at a point above the apparent seat of injury; this form of gangrene is principally met Avith in cases of gunshot injury, and is often a cause for amputation (see page 92). (3.) The most fatal form of gangrene is the true traumatic or spreading gangrene,1 Avhich is ahvays of the moist A'ariety, from implication of the venous system, and is usually met with in connection Avith severe compound fractures or other destructive lacerations produced by raihvay and machinery accidents. The most rapidly fatal case Avhich I have ever seen Avas in the person of a professional lion tamer, whose thigh was frightfully lacerated by the teeth and claAvs of the animal Avith Avhich he Avas in the habit of per- forming. Traumatic gangrene occasionally, hoAvever, follows comparatively slight local injuries, and this circumstance has led many authorities to attribute its occurrence to constitutional causes. Certain it is that those are especially apt to be attacked by traumatic gangrene who are in a depraved state of health, and particularly such patients as suffer from organic disease of the kidneys. The symptoms of traumatic gangrene are sufficiently charac- teristic. The limb swells and becomes tense, and a dusky-red or purplish color supervenes, attended Avith a deep-seated burning pain. Soon the dusky hue gives Avay to a dark mottled appearance, vesications and bullae are formed, the surface becomes soft and boggy, and emphysematous crackling, running along the deep planes of cellular tissue, gives evidence of the forma- tion of gases as the result of decomposition. Below the seat of gangrene, the limb has a cadaveric appearance, Avhile above, oedema and discoloration rapidly extend, especially along the planes of areolar tissue on the inside of the limb, reaching and invading the trunk in perhaps a few hours from the period of commencement, While the gangrene spreads upAvards, the part first attacked falls into the condition of a disorganized, black, and pultaceous mass. The general symptoms indicate from the first a state of extreme con- stitutional depression.' Death is almost inevitable in these cases, and follows shortly after the gangrene has reached the trunk; or it may occur at an earlier period, as pointed out by Perrin, from gases entering the circulation and proving fatal, as Avhen air enters the veins in an operation. 1 This grave aifection has also been described under the names of putrid pneumo- hccmia (Maisonneuve), bronzed erysipelas (Velpeau), gangrenous emphysema, traumatic poisoning (Chassaignac), acute purulent oedema (Pirogoff), acute putrid infection (Per- rin), and acute gangrenous septicemia (Terrillon). 150 EFFECTS OF INJURIES IN GENERAL. Treatment of Lacerated and Contused Wounds.—Small portions of the body, especially of the face, even if entirely separated, will occasionally reunite when replaced and carefully supported; hence, as a rule, all lacerated or partially detached flaps of tissue should be gently cleansed and readjusted, for even if sloughing eventually take place, the attempt to preserve the injured part will at least have been attended by no harm. Great caution should, however, be used in any case of lacerated or contused Avound as to the employment of sutures. These Avounds are always followed by a good deal of inflammation and consequent SAvelling, and if the parts be closely stitched up, there will probably be so much tension as seriously to endanger the vitality of the already bruised and torn tissues. lam confident that I have seen extensive sloughing of integument, due quite as much to the over- zealous use of sutures, in these cases, as to the effects of the original injury. A few stitches may be proper, if the wound be large and there be much tendency to gaping; but it is best to rely chiefly upon the support afforded by plaster and judicious bandaging. For lacerated wounds Avithout much contusion, especially about the face, Avhere the tissues are very vascular, cold Avater, or glycerine and water, is an excellent primary dressing; it may be applied simply by wetting pieces of lint, or by irrigation. When the edges of the Avound are contused as well as lacerated, warm dressings are usually more grateful, and here warm Avater, or, still better, diluted alcohol or diluted laudanum, answers a very good purpose. Cotton-wool, dry earth, and the warm bath, are recommended by their respective advocates, as in the case of incised Avounds. Chloral in solution (gr. v.-|j.) is recommended by W. W. Keen, Marc See, and other surgeons. When the slough is about to separate, poultices, especially those containing yeast or porter, may be advantageously substituted for the alcoholic dressing, to be replaced in turn, Avhen the wound is fairly granulating, by lime-water or such other substance as the appearance of the part or the fancy of the surgeon may dictate. At each dressing, disinfectants, such as the preparations of chlorine, dilute carbolic acid, or the permanganate of potassium, should be freely used; the latter agent is that which I am myself in the habit of employing, and it is certainly the most elegant of all the preparations that have been mentioned. Amputation in Lacerated and Contused Wounds.—In many of the worst cases of lacerated and contused wound, no treatment will avail, short of removal of the injured limb. Thus, if an arm or leg be entirely torn away, or if all the soft parts and bones be crushed together into a pulp-like mass, there can be no question as to the propriety of amputation. Those cases, however, in which the soft tissues are alone involved, the bones escaping injury, present more difficulty; there is a popular notion that cases of this kind do not require amputation; it is a mere flesh wound, it is said, and the surgeon ought to be able to cure it. I am well convinced, however, that when the skin and muscles are extensively torn and separated, even if the bone be Avhole, especially in the lower extremity, amputation is more often necessary than is commonly supposed. It must be remembered that the appearance of the skin often gives an imperfect idea of the amount of injury beneath; I have not unfrequently found the skin apparently healthy and uninjured, Avhen by insinuating the finger beneath the surface, all the deeper- seated tissues, muscles, vessels, and nerves, were found pulpefied, as it Avere, and crushed into an almost indistinguishable mass. If amputation be required, it should be done as soon as sufficient reaction has occurred; the advantages of primary over secondary amputation were fully considered in Chapter V., and need not be referred to here. If an attempt be made to save the limb, however, secondary amputation may become necessary from the occurrence of hemorrhage, or from the onset of one of the forms of gangrene described ANTISEPTIC TREATMENT OF WOUNDS. 151 •on page 149. If the true traumatic gangrene should occur, amputation must be at once performed, though the chances of a successful issue are, it must be confessed, under these circumstances, very doubtful. It is, perhaps, scarcely necessary to give the caution not to be deceived into amputating for a mere superficial slough, an error Avhich can be avoided by carefully Avatching the case for a feAV hours, Avhen, if mortification have really taken place, the occurrence of putrefactive changes in the part will sufficiently clear up the diagnosis. AVhen amputation is resorted to under these circum- stances, it should be done at a point sufficiently removed from the seat of gangrene, to avoid, if possible, the recurrence of disease in the stump. Brush-bum is a name used by Mr. Erichsen for the form of contused Avound Avhich is produced by violent friction. It is frequently caused in manufacturing districts, by portions of the body being caught by rapidly revolving straps of leather or other material. Brush-burn may vary in severity from a mere superficial abrasion to absolute destruction of the skin and subjacent tissues. It is a very painful injury, but not dangerous, unless very extensive and severe, and it presents no peculiar indications. The part is to be protected from the air, the separation of sloughs promoted by poultices, etc., and the resulting ulcer treated on general principles. Gunshot wounds will form the subject of the next chapter. Antiseptic Treatment of Wounds.—Under the name of the "antiseptic method," Prof. Lister, formerly of Edinburgh, but noAV of King's College, London, has urged the employment of carbolic or phenic acid as a dressing in surgical cases, and the practice has, both in his hands and those of others, no doubt met Avith a large measure of success. At the same time, other surgeons equally competent and careful, and who have endeavored consci- entiously to carry out Prof. Lister's instructions, have utterly failed in ob- taining the promised results, Avhile results quite as good as those of Prof. Lister's folloAvers are obtained by surgeons Avho rely simply upon enforcing cleanliness and attending to the constitutional hygienic condition of their patients, without adopting any exclusive mode of dressing. Other substances, such as boracic and salicylic acids, thymol, etc., have been also employed, but carbolic acid is upon the whole preferred by Prof. Lister himself,1 and by most of his disciples. The theory of the method is founded on the ob- servations of Pasteur, and supposes that animal decomposition is due to the presence of organic germs floating in the atmosphere, and carbolic acid is used on account of its known destructive effects upon low forms of organic life. To carry out the " antiseptic system " in dressing a wound or performing an operation, there are needed : two solutions of carbolic acid, one containing one part of the acid to forty of water, and the other one to tAventy; an " atom- izer," or steam-spray apparatus2 (Fig. 75), with a very large flame produced by burning the vapor of alcohol—the solution of carbolic acid to be atomized containing one part to thirty, and being diluted by the steam to the strength of one to forty; a " protective," consisting of oiled silk covered on both sides Avith copal varnish, and then Avith a mixture of dextrine starch and carbolic acid; " antiseptic gauze," which is simply loose cotton-cloth thoroughly im- bued Avith a mixture of one part of carbolic acid, five of paraffine, and seven of common resin;3 Mackintosh cloth; drainage-tubes; carbolized silk sutures; 1 In the British Medical Journal for May 'IS, 1881, Prof. Lister is reported to have said that he had found the oil of eucalyptus to be "a perfect substitute for carbolic acid." 2 Kichardson, of Dublin, has devised a spray-apparatus to be worked by the foot. 8 Or, which Mr. Lister has since recommended, oil of eucalyptus, one part, dam- mar gum, three parts, and paraffine, three parts. 152 EFFECTS OF INJURIES IN GENERAL. and carbolized catgut ligatures, made by soaking catgut in a mixture of car- bolic acid, glycerine, chromic acid, alcohol, and water. If adhesive plaster is to be used, it is to be rendered antiseptic by dipping it in a hot solution of carbolic acid. All the instruments, sponges, drainage-tubes, etc., to be used, Fig. 75. "Atomizer," or steam-spray apparatus. must be kept lying in the 1-40 solution of the acid; and if an instrument is laid down for an instant, it must be re-dipped before it is again employed. Before beginning an operation, the part is to be shaved, and thoroughly washed Avith the 1-20 solution of carbolic acid. (In the case of an accidental wound, this solution should be not only applied to the surface, but should also be carried into all the recesses of the wound.) The spray is then made to play over the part, and kept in action until the whole operation is completed; if the surgeon's hands, or those of his assistants, pass beyond the limits of the spray, they must be re-dipped in the 1-40 solution before again approaching the wound. All vessels are to be tied with the antiseptic catgut-ligatures, both ends of which are cut short, and the drainage-tubes are to be placed deeply in the wound and cut on an exact level Avith the surface,1 being held in place by means of pieces of carbolized silk. The wound having been closed with the antiseptic sutures (and adhesive plaster, if necessary), a small piece of the " protective," dipped in the 1-40 solution, is applied, so as to protect the raw surface from the irritating effects of the remainder of the dressing. The wound is next covered with a layer of the " antiseptic gauze," dipped in the 1-40 solution, and there are then successively superimposed six layers of dry gauze, one of Mackintosh, an eighth layer of gauze, large enough to cover in all that have preceded, and finally a bandage of the same material. When- ever the dressings are changed, this is to be done under the spray, and special precaution is to be taken not to admit any uncarbolized air. The outer dress- ings are not changed until the discharge has begun to soak through, while the inner dressings may in some cases be allowed to remain for weeks without renewal. As has been already indicated, the alleged superiority of the " antiseptic method" cannot be said to have been as yet demonstrated. Prof. Lister, though repeatedly challenged to do so, has not thought proper to publish any detailed statistical account of his results, and most of the reports which have come from other sources have been accounts of isolated cases, or of the general impressions of the writers. 1 Chiene, of Edinburgh, employs instead of the ordinary drainage-tubes, hanks of carbolized catgut, which act by capillary absorption and are finally dissolved in the discharges. McEwen, of Glasgow, employs decalcified chicken bones as drainage- tubes, steeping them in a solution of chromic or carbolic acid, and introducing them threaded with horsehair, which is withdrawn in a few days. PUNCTURED WOUNDS. 153 Failure on the part of other surgeons to attain the expected results, is at- tributed by the advocates of the plan to some mistake or neglect in the ap- plication ; and such may doubtless be the case. But it is obvious that any mode of treatment which is so intricate and complicated as to elude the skill of such excellent surgeons as have failed with the antiseptic dressing, is not likely ever to be adapted for general employment. Punctured Wounds.—These, as their name implies, are such wounds as are inflicted with the point, rather than with the edge, of a weapon. If the point be sharp, the wound approaches somewhat the character of an incised wound; if dull, the injury more resembles a contused Avound. Punctured wounds are always painful, and are apt to be followed by a good deal of swelling and inflammation. If deep, and especially if they penetrate an im- portant cavity, they are attended by much risk to life. The form of punc- tured Avound most frequently met with in civil practice is that produced by the common seAving-needle, Avhich easily penetrates the flesh, and then is broken off, the point remaining in the tissues. These wounds may be met with in any part of the body, but are, for obvious reasons, most often found in the hands, feet, knees, and buttocks. If the surgeon see such a case shortly after the introduction of the needle, he should, if possible, at once remove the foreign body. Its position can usually be detected, even if it cannot be seen, by a sensation of limited resistance offered to the surgeon's fingers on careful palpation. If it be necessary to cut doAvn upon the needle (Avhich operation may be much facilitated by using Esmarch's tube and bandage), the incision should be made somewhat obliquely to the position of the foreign body, so that it may be reached with suitable forceps a short distance beloAV the point at which it is broken; it is occasionally more convenient to push the needle onwards, thus making its point emerge by a counter-opening at a little distance. If the case be not seen for some hours after the introduction of the needle, Avhen swelling has already occurred, or if unskilful efforts at extraction have only served more deeply to imbed the foreign body, it is often impossible for the surgeon to satisfy himself as to the position of the needle. In such cases it is usually better to wait until the establishment of suppuration has dislodged the foreign body, Avhen it will gradually work its way towards the surface. The presence or absence of a needle might, in case of doubt, be determined by the magnetic test of Mr. Marshall, holding a poAverful magnet upon the part for fifteen or twenty minutes, so as to influence the fragment, the presence of which would then be revealed by the deflection of a polarized needle delicately suspended above it. Very serious consequences sometimes result from the prick of a needle; I have known necrosis of the entire shaft of the humerus, due to a Avound of the periosteum thus inflicted. After the removal of the foreign body, cases of needle wound are to be treated on general principles. If an important part, such as the knee-joint, is involved, entire rest and the local use of dry cold Avill be particularly indicated. Bayonet Wounds form almost the only class of punctured wounds now met with in civilized warfare. They are very rare, only 143 cases being recorded in Circular No. 6, S. G. O., 1865, compared with over 85,000 wounds of other descriptions; of these 143, only six proved fatal. Formerly, when duelling was very frequently resorted to by soldiers, the small-sword was the Aveapon usually employed, and punctured wounds were thus constantly inflicted; they were treated by the drummers of the regiment, who sucked the part dry from blood, and then applied a piece of chewed paper or wet cloth to the Avound, which frequently healed under this treatment in a remarkably short space of time. This mode of practice is said by Percy and Laurent to have origi- nated among the Romans (who employed suction as a remedy for poisoned 154 EFFECTS OF INJURIES IN GENERAL. wounds), and to have been introduced into military surgery by Cato, who would not allow doctors in his army, disliking them because they were usually of Grecian birth. Arrow Wounds are frequently met Avith on our Avestern border in conflicts with the Indians. They are very serious injuries, being particularly fatal when they involve the abdominal cavity. The following tables, taken from an excellent paper by Dr. J. H. Bill, in the American Journal of the Medical Sciences for October, 1862, show the relative fatality of arrow wounds in dif- ferent parts of the body, and the causes of death in fatal cases: Head. i o a s c '5. w 1 Chest. X Abdomen. >> E X O) V a. a. !=> 6 u % o *1 OT3 C V .5 t= «s 5 L* o pa £ ■6 c"2 ^ S M o ■s Ma s = 1-1 & £1 2 • » a S 3 C '5 0 B 3 O S -n ° 5-| Total. PM u W H a, Number of cases, . 7 13 2 2 1 1 1 1 l 29 Dr. Otis has, in Circular No. 3, S. G. O., 1871, published 83 additional cases of arrow wound, of which 26, including nearly all in which the great cavities of the body or the larger bones and joints were involved, proved fatal. The great danger in cases of arrow wound is, as shown by Dr. Bill, from the head of the weapon becoming detached from the shaft, and remaining in the wound as a foreign body of the worst description. Hence the importance of not hastily pulling the shaft away while leaving the head, and the equal importance of careful but persistent efforts to remove the latter. This may often be done by catching the head of the arrow in a strong wire loop, as recommended by Dr. Bill, or it may be sometimes better to make a counter- opening, and in case of a chest wound, if necessary for this purpose, even to cut through the rib with a trephine. It is commonly believed that the Indian tribes make use of poisoned arrows; it would appear, however, from the reports of Dr. Bill and other army surgeons, that in reality this is very seldom done; I am, however, in- formed by Dr. Schell, who was stationed for some time at Fort Laramie, that it is the universal custom to dip the arrows in blood, which is allowed to dry on them, and it is not improbable, therefore, that septic material may thus be occasionally inoculated through a wound. Tooth Wounds.—Quite severe injuries are occasionally inflicted by bites, 1 One of these perished from a gunshot wound. POISONED WOUNDS. 155 even Avhen there is no evidence of the introduction of any morbid poison. Prof. Gross bas met Avith cases in which great inflammation and suffering followed abrasions of the hand received in striking another person on the mouth, and I have myself seen a bite of the thumb folloAved by fatal tetanus. The treatment of punctured wounds consists in the use of simple anodyne dressings, and in the adoption of means to prevent the development of ex- cessive inflammation. Poisoned Wounds.—The Stings of Insects are seldom productive of serious consequences, in this country at least. In tropical climates, the insects ap- pear to be more venomous, and, according to the reports of African and other travellers, death not unfrequently results from such a cause. Even in this part of the world, hoAvever, death, sometimes preceded by gangrene, has occasionally resulted from the sting of a bee or the bite of a mosquito, prob- ably oAving to idiosyncrasy on the part of the patient. The pain of a sting may be relieved by the application of spirit of hartshorn (aqua animonise), and the subsequent inflammation should be treated on general principles. Snake Bites are often productive of serious symptoms, and not unfrequently of death. All snakes, hoAvever, are not venomous; and even in the case of those Avhich are known to be poisonous, if by the action of biting a feAv times they have exhausted their stock of venom (Avhich in the instance of the rat- tlesnake is contained in a small pouch under the upper jaAv), the Avounds Avhich they can then inflict, until the venom re-accumulates, may be no more serious than other punctured wounds of similar characters. The bite of the rattlesnake is usually attended Avith much pain, though this is not always the case ; there is sometimes free external bleeding, and ahvays rapid interstitial hemorrhage, causing great swelling of the affected part, which is usually one or other extremity. In cases which terminate unfavor- ably, the SAvelling rapidly ascends the limb, which is deeply discolored; vesi- cations make their appearance, and the part falls into a gangrenous condi- tion. In favorable cases, the swelling and other local symptoms disappear almost as rapidly as they came. The constitutional symptoms of rattlesnake poisoning are those of extreme prostration, the mind often remaining clear until "within a feAv minutes of the fatal issue. Death may take place in a very short time (forty minutes only in a case reported by Dr. Shapleigh), from the direct effect of the poison on the nervous system, or after the lapse of several days or Aveeks, from extensive sloughing and suppuration resulting from the local injury. The coagulability of the blood appears to be much impaired by the effect of the poison, this fact accounting for the great inter- stitial hemorrhage, and consequent swelling and discoloration. Various substances have been proposed as antidotes to snake poison, those which have attained most reputation being the eau de luce (containing am- monia), the Tanjore pill (of which arsenic is a principal ingredient), Bibron's antidote (containing corrosive sublimate, bromine, and iodide of potassium), and the liquor potassse, recommended by Dr. John Shortt. Prof. Halford, of Australia, has proposed the direct injection into the veins of dilute aqua animonise, and has reported several cases in Avhich the treatment was followed by recovery. The use of ammonia in this Avay might doubtless prove effi- cient as a cardiac stimulant, but the treatment has completely failed in the hands of Prof. Fayrer, and there seems to have been a doubt as to the venom- ous nature of the snakes, in some of those cases in Avhich success followed the use of the remedy. The hypodermic use of ammonia has been successfully resorted to by Dr. Semple, in a case of spider bite attended with grave symptoms, and by Dr. Elder in four cases of poisoning by the bite of the copperhead or red viper. 156 EFFECTS OF INJURIES IN GENERAL. There is no evidence of advantage from the use of any of the antidotes above mentioned in cases of rattlesnake poisoning; the remedy attributed to Prof. Bibron, which was highly esteemed a few years ago, is noAV, I believe, abandoned even by those Avho most highly extolled its virtues. The treat- ment recommended by Dr. S. W. Mitchell, who is one of the highest living authorities on this subject, consists in the internal administration of alcoholic stimulus, of course not pushed to the point of producing deep intoxication, with suction by means of a cupping-glass, the application of carbolic acid, diluted Avith half its weight of alcohol, and the local use of the intermittent ligature. The intermittent ligature consists of a tourniquet applied above the injured part, so as to interrupt the blood current, except when momen- tarily relaxed by the surgeon; by the use of this means a small portion of the venom can be admitted at a time into the general circulation, and the enemy, as it were, met and fought in detachments. The warmth of the body should be kept up to the normal standard, by the use of external heat; and, should it be found impossible to produce sufficient stimulation through the stomach, the inhalation of the fumes of warm alcohol, or even of ether, might be resorted to. Fayrer recommends in the treatment of Avounds inflicted by the cobra, or by other poisonous serpents of India, the application of a tight ligature, with amputation, excision, or cauterization of the part, followed by the internal administration of hot spirits and water, Avhich he considers preferable to am- monia, and by the use of external heat, galvanism, and perhaps the cold douche. Should the breathing fail, artificial respiration should be resorted to, in hope that life may be thus prolonged until elimination of the poison has been effected. Bites of Rabid Animals, especially cats, dogs, and, according to Drs. Janeway and Wolf, skunks, sometimes prove fatal through the occurrence of Hydrophobia. The peculiar poison which produces this frightful affection appears to be communicated by means of the saliva, though whether it orig- inate in that secretion or be merely mixed with it, coming from other struc- tures of the mouth, is uncertain. The proportion of cases of hydrophobia to the number of persons bitten by dogs or other animals supposed to be mad, is very small, only 71 deaths from this affection having occurred in London in twenty-nine years, an annual average of less than 2h After the reception of a bite, the poison may remain latent for a variable period, the limits of which have been placed at as short a time as one day, and at an interval as long as forty years. The truth appears to be that the stage of incubation may vary from about four weeks to eleven months, sometimes, hoAvever, un- doubtedly surpassing the latter limit. This difference is supposed, by Mr. Forster, to depend on the part bitten, and the circumstances under which the bite is received. If the face be the seat of injury, the period of latency Avill probably not exceed four or five weeks, and if the disease have not appeared in that time, the patient may be considered safe. When the hand is the part affected, the period of latency varies from five Aveeks to a year; and Avhen the clothes have been bitten through before the skin is injured, several years may elapse before the development of the disease. An apparently au- thentic case has been recently reported by Fereol, in Avhich the period of in- cubation Avas tAvo and a half years, and Colin has recorded a case in which it was said to have been nearly five years. The wound is usually healed long before any manifestations of hydrophobia occur, and the invasion of the latter is often unattended by local symptoms, though occasionally shooting pains and twitchings are felt at the seat of original injury. The development of hydrophobia is usually preceded for some days by a feeling of general malaise, together with chills, flushes, and giddiness' The most characteristic POISONED WOUNDS. 157 special symptoms of the disease, and those Avhich Mr. Forster considers in themselves sufficient for diagnostic purposes, are intense pain and cutaneous sensibility, and spasms of the pharyngeal muscles, rendering it almost im- possible to swallow anything, but especially liquids. To these there is usually added a feeling of great anxiety and a sense of impending danger, together with delusions alternating Avith the wildest delirium. There may be general convulsions, Avhile there are almost ahvays spasmodic movements of the mouth and of the laryngeal muscles, Avith expectoration of viscid and very tenacious mucus and saliva ; hence the popular notion that the patient barks and tries to bite. Hydrophobia has, until recently, been thought an invariably fatal affection, but instances of recovery under the hypodermic use of woorara have been lately recorded by Offenburg, Polli, and B. A. Watson. Death may occur in one day, or life may be prolonged for nearly a Aveek. As a preventive measure, excision of the part bitten is usually recommended. Mr. Youatt had great confidence in cauterization with nitrate of silver, and I may add that I was told by a negro, Avho had been for many years chief " dog- catcher" in this city, that he himself had been bitten many times by dogs suspected of being mad, and had never suffered any unpleasant consequences, having ahvays used this remedy. I am disposed, however, to question (Avith Mr. Forster) Avhether either of these plans is really productive of benefit; the immense majority of bites will not be folloAved by hydrophobia under any circumstances, and, on the other hand, hydrophobia has occurred even after free excision of the injured part. Duboue, of Pau, suggests the daily administration of large doses of bromide of potassium during the whole period of incubation. When the disease occurs, the patient must be kept quiet in a darkened room, and free from all avoidable sources of irritation; his strength must be supported by such concentrated food and stimulus as can be taken, or by nutritious enemata, Avhile an ice-bag may be placed to the spine, as recommended by Dr. Todd and Mr. Erichsen, and the violence of the spasms relieved by the inhalation of ether, or nitrite of amyl (Forbes), or by the use of large doses of bromide of potassium. Bouisson speaks very favorably of the employment of a hot-air bath. Dr. Hammond recommends the persistent employment of a primary current of electricity, one pole being applied to the head, and the other to the feet. SkinkAvin, of Cork, advises transfusion, and Culver, of Jersey City, following a hint of Majendie's, in- tra A'enous injections of saline solutions; bromide of potassium, administered in this manner, is recommended by Duboue; as already mentioned, several cures have been recently reported from the administration of woorara, and others are said to haA'e been obtained by inhalations of oxygen and by the use of the monobromate of camphor, and of cannabis indica. The only post- mortem appearance visible to the naked eye, Avhich can be considered as characteristic, is, according to Mr. Forster, dilatation of the pharynx ; but in cases recorded by Clifford Allbutt, Hammond, GoAvers, and Cheadle, there Avere found decided changes in the medulla, spinal cord, and other nerve centres, consisting in congestion, softening, localized effusions of blood and serum, and, in some parts, granular degeneration. Inflammatory changes in the brain have been observed by Benedikt, of Vienna, and AVassilief, of St. Petersburg.1 Congestion of the nervous structures in the vicinity of the wound, and inflammatory changes in the salivary glands, have been noticed by Nepveu, as haATe hypera3mia and an accumulation of Avhite corpuscles in the kidneys, by Coats, of GlasgoAV. 1 The changes noted in the brain and spinal cord in cases of hydrophobia, are, however, according to Middleton, of Glasgow, by no means characteristic of that disease, but may be met with in any cases in which there has been great cerebral ex- citement. 158 EFFECTS OF INJURIES IN GENERAL. Dissection Wounds are less frequently productive of unpleasant conse- quences at the present day, Avhen anatomical subjects are prepared Avith anti- septic agents, than formerly; it is indeed much oftener from making autop- sies, especially in cases of erysipelas, puerperal peritonitis, etc., than from the dissection of ordinary subjects, that this form of poisoned wound is met with. Even in performing surgical operations, surgeons are occasionally exposed to this form of injury: Avitness the melancholy case of the late Mr. Collis, of Dublin, Avho died from the effects of a slight Avound received in excising an upper jaw. A cut received in dissecting or in operating may act merely as any other Avound, producing an inflammatory condition, Avhich will of course be aggravated if the person be in a depressed state of health Avhen the injury is inflicted. Under such circumstances, the Avounded part will SAvell, becoming hot and painful, and the neighboring lymphatics will proba- bly become involved, Avith enlargement of the axillary glands, and a condition of general febrile disturbance. The inflammation may end in resolution, or may run on to suppuration, pursuing very much the same course as a severe whitloAV. In other cases there is a positive inoculation of septic material, followed by diffuse cellular inflammation, or by phlegmonous erysipelas, in- volving a considerable part of the body, and attended by extensive suppura- tion, and perhaps sloughing; the general symptoms are those of extreme depression, and the patient dies of pysemia or septicemia, or recovers after a long and tedious convalescence, Avith his health, perhaps, permanently im- paired. The first symptom of this more serious form of the affection is usually a small vesicle, Avhich appears at the seat of the injury, sometimes within twelve hours, but usually on the second or third day. If a wound is received in dissecting, it is proper to tie a ligature around the part to encourage bleeding, and to Avash the Avound thoroughly with soap and Avater; after Avhich suction should be practised, provided that there be no abrasion about the mouth. The benefit of cauterization in these cases is someAvhat doubtful, but if it be thought proper to employ it, strong nitric acid or the acid nitrate of mercury will probably prove the best agent. If, in spite of these precautionary measures, the wound give further trouble, the treatment must vary according to the form Avhich the symptoms assume. The simple inflammatory affection Avhich Avas first described,'should be treated on general principles, poultices or other soothing applications being made to the injured part, and laxatives and diaphoretics administered internally. In the more serious form, in which there is evidence of blood-poisoning, more active measures must be adopted : the vesicle and adjacent parts should be freely incised, and the Avound washed Avith diluted tincture of iodine. Ano- dyne fomentations may be then applied, and the strength of the patient must be kept up by the free use of stimulants and food, with quinia, camphor, and ammonia. If abscesses form, they should be opened as soon as fluctuation is detected. The proportion of recoveries from this form of the affection is stated by Travers to be but one in seven : if the case terminate favorably, the patient should be sent as soon as possible to the country, to recruit his shattered health by change of air and scene. CHARACTERS OF GUNSHOT WOUNDS. 159 CHAPTER VIII. GUNSHOT WOUNDS. It is not my intention, nor, indeed, would it be possible, within the limits of this chapter, to attempt a full description of gunshot injuries, and of their modes of treatment. American surgeons have had ample opportunities for the study of this class of injuries during the last twenty years—more ample, it is to be hoped, than will again be afforded for a very long period ; still, injuries from firearms are often enough met with in civil practice to render it impor- tant for every surgeon to be familiar with their more prominent features and peculiarities, and to be prepared to perform any of the operations Avhich their treatment especially demands. Characters of Gunshot "Wounds.—These vary according to the nature of the projectile by which the Avound is inflicted, and the force Avith which it produces its effect. The momentum of a gunshot projectile is an important matter for the surgeon's consideration. This depends upon two factors— the mass or weight of the projectile, and the velocity which it possesses at the moment of striking the body ; thus, if a cannon-ball and a musket-ball, moving Avith the same velocity, strike at the same moment, the cannon-ball, from its greater mass, will have a greater momentum, and will produce the greater injury. A charge of powder alone, Avithout any ball, or the Avadding of the gun, if the latter be fired at short range, may produce a serious or even fatal injury, the great velocity making up for the slight mass. A charge of small shot, if the gun be discharged in close proximity to the person struck, may enter the body en masse, as it were, and produce a large, ragged wound ; or if the hand be struck, as occasionally happens to sports- men from the premature discharge of a foAvling-piece, may absolutely bloAV off a portion of the member as effectually as would be done by a piece of shell or a round shot, fired at a greater distance. When small shot scatter before they strike, they produce slighter wounds, though even then a single shot may destroy the'eye, or cause fatal hemorrhage by wounding a large artery or vein. . Bullet wounds have increased greatly in severity since the introduction of rifled muskets and of conoidal balls. The old round musket-ball, fired from a smooth bore, produced a comparatively slight Avound ; thus I have on several occasions seen patients who had what might be called " button-hole fractures " of the tibia, caused in this Avay: simply a round aperture in the front of the bone, the ball sometimes lodging, and sometimes going completely through the limb, but causing no splintering, and no great laceration of the soft tissues. The peculiar shape of the modern conoidal ball causes it to meet with much less resistance from the air, while the spiral rotatory motion which is imparted to it by the grooves of the modern rifled firearm enables it to re- tain much more of its initial velocity, and thus to strike with much greater momentum than the old form of musket-ball; moreover, from its centre of gravity not coinciding with its centre of figure, in its passage through the air it acquires a peculiar dip, causing it to strike obliquely, making a large wound, ploughing and tearing up the soft parts, and splintering the bones in all directions. *" Thus, it is not uncommon for a long bone, such as the 160 gunshot avounds. tibia or humerus, when struck by a conoidal ball, to be splintered and split both upAvards and downwards, to the epiphyseal lines, or even into the ad- joining articulations.1 Round shot or cannon-balls, unless moving Avith very slight velocity, are apt to tear off an entire limb, or Avhatever part of the body they may happen to strike ; even when almost spent, and rolling along the ground Avith no more apparent force than a ten-pin ball, they are capable of producing most frightful injuries, as it is said foolhardy soldiers have occasionally learnt to their cost, in attempting to stop such a spent ball Avith the foot. The reason is obvious : though the velocity is slight, the mass and, therefore, the momentum are very great. On account of the great elasticity of the skin, it Avill oc- casionally escape injury from the bloAvs of spent shot, while the parts beneath, bones, muscles, vessels, and nerves, may be frightfully torn or completely pul- pefied. Such are the injuries Avhich used to be attributed to the effects of the wind of a ball, passing close to, but apparently not coming in contact with, the person wounded. These injuries are apt to be followed by gan- grene, which often seems to be due to rupture of the main artery, at a point higher than the seat of apparent lesion. Shell wounds are among the most fatal injuries met Avith in modern war- fare. The explosion of a single shell may kill or mortally wound quite a number of persons; the injuries most analogous to these which are met with in civil life, are such as are produced by accidents in blasting and mining, portions of metal or stone, or splinters of Avood, being hurled violently by the force of the explosion against the bystanders, and often inflicting most serious and even fatal lacerations. Nature of Gunshot Wounds.—In whatever way inflicted, gunshot wounds partake of the nature of contused wounds, and are often, as we have seen, attended by great laceration, while in certain cases, especially in the slighter forms of shell wound, the soft parts may be split to some distance from the point of contact of the projectile, and in these cases a portion at least of the wound may be clean cut, and approach therefore to the nature of an incised wound. Whatever part is, however, directly touched by the ball, is almost invariably so contused as to be deprived of vitality, and hence it may be laid doAAm as an axiom, which holds good in this part of the world at least, that every gunshot wound must of necessity be followed by more or less sloughing. Indeed it is often said that every portion of the track of a ball must slough, and that in the case, for instance, of a perforating flesh wound of the extremities, a tubular slough will be separated, representing exactly the course of the ball. I believe, however, that this rule is not invariable; in the early part of our late war, when buckshot were occasionally used in the form of " buck and ball cartridges," I saw several cases of very small perforating flesh Avounds thus produced, in which, although undoubtedly both the apertures of entrance and of exit sloughed, the deep parts of the wound apparently healed Avithout the occurrence of sloughing; and to sup- pose that such might be the case is not at all unreasonable, for the swelling of the tissues Avould measurably convert the deeper portion of the Avound into a subcutaneous injury, placing it thus in a condition which, as we know, will allow of great laceration Avithout inevitable loss of vitality. The sloughing of gunshot wounds is not due, as Avas formerly supposed, to any 1Prof. Middleton Michel, of Charleston, maintains that the splintering caused by the conoidal bullet is less than is commonly supposed, and that when fired at short range it produces comparatively little injury, its destructive effects being inversely proportionate to its velocity. WOUNDS OF ENTRANCE AND EXIT. 161 poisonous qualities of the projectile, nor to its temperature,1 nor to any fancied development of electricity, but simply to the excessive degree of contusion inflicted by the ball, which, though usually of small mass, strikes with great momentum. Wounds of Entrance and Exit.—Most gunshot wounds have two apertures, one where the ball came in2 and the other where it went out. If there be but one Avound, it is primd-facie evidence that the ball has lodged and re- mains in the part; though more rarely a spent ball may drop out by the same opening as that by Avhich it entered, or striking some prominent part, as the larynx or a rib, may be deflected from its course, and, restrained by the elasticity of the skin, may make a complete circuit around the chest or neck, as the case may be, coming out at last at the same point at Avhich it went in. Well-attested illustrations of these statements may be found in Avorks on military surgery. On the other hand, the existence of tAvo Avounds is not positive evidence that there is no ball in the part; for a ball may split on a ridge of bone or other projecting object, one portion passing out and making an aperture of exit, Avhile the other lodges; or, Avhich comes to the same thing, two balls may enter at one opening, one passing out and the other remaining. Again, there may be more than two Avounds. I had under my care, after the battle of Antietam, a Confederate soldier Avho had three Avounds in the fleshy part of the thigh; they Avere all in a line, super- ficial flesh wounds, almost identical in appearance, and Avith nearly equal intervals between them. Either tAvo balls had entered together, and, sepa- rating in the tissues, had come out by different apertures, or, AA'hich from the position of the Avounds seemed more probable, two balls had entered by dis- tinct openings, and, meeting in the limb, had come out together. Not un- frequently a ball perforates both loAver extremities, thus making four Avounds, and I have even seen five wrounds, evidently made by the same ball. Thus, I remember a soldier Avho had apparently been struck by a ball passing obliquely upAvards, Avhile his arm Avas flexed at the elboAv and somewhat elevated; the ball had grazed the forearm, perforated the upper arm (just missing the brachial artery), and then entered the chest, superficially wound- ing the lungs, and ultimately emerging below the scapula. The apertures of entrance and exit present somewhat different appearances; these were better marked when round balls Avere in common use than at the present time, Avhen gunshot Avounds are usually inflicted by conoidal bullets. The entrance Avound is usually smaller than that of exit, and, indeed, from the elasticity of the skin, often appears smaller than the ball Avhich made it; its edges are rather imrerted than everted, and, if the Aveapon has been dis- charged at a very short distance, the skin may be blackened by the explosion of the poAvder. The exit Avound has everted edges, is ragged and more irregular than that of entranee, and is usually larger. These differences are OAving to several circumstances, among Avhich may be enumerated the reduced velocity of the projectile at the moment of exit, the diminished degree of resistance offered by the soft parts, which at the point of exit are unsupported, and therefore more liable to laceration, and the actual increase in bulk of the projectile from carrying portions of tissue before it—a similar explana- 1 Hagenbach, Socin, and Busch, however, have lately adduced experimental proofs to show that balls in passing through the tissues of the body undergo an actual in- crease of temperature sufficient to cause partial melting of the projectiles. 2 Dr. Skae has reported a case in which a lunatic shot himself with a pistol ball through the ear, thus producing a fatal injury without any wound which could be recognized during life; and a curious case occurred during our late war, in which an officer was mortally wounded through the anus. 11 162 GUNSHOT WOUNDS. tion to that given by Mr. Teevan for the larger size of the exit than of the entrance wound in cases of punctured fracture of the skull. The statement above given may be considered as generally, though not invariably, correct; thus, it is easy to understand how a conoidal ball, strik- ing with its long axis corresponding to the surface, might make a large and ragged wound, and, undergoing partial rotation from the resistance of the tissues, might emerge point forwards, thus making the exit Avound smaller and more regular than that of entrance. Again, the distinctive appearances of the apertures may be obliterated, or their characters reversed, by the proc- esses of sloughing and suppuration. There is most sloughing at the point of entrance, for here the momentum of the projectile was greatest, and hence, in the subsequent stages of a gunshot wound, the aperture of exit may be absolutely smaller than that by which the ball entered. Direction of Ball.—The direction taken by a ball in traversing a part is usually in a straight line from aperture to aperture. To this rule there are, as already stated, exceptions, from deflection of the ball by means of a ridge of bone, tendon, fascia, etc. Still, the rule holds good in the immense ma- jority of cases, and the surgeon may often derive valuable information by bearing it in mind; thus, it has happened that in cases of secondary hemor- rhage it has been impossible to discover the source of bleeding, till by placing the patient in the exact position which he occupied when shot, and looking along the line which the ball must have taken, it has become obvious that a certain vessel was in the way of being wounded, and the proper point for the application of a ligature has been thus made at once evident. A familiar instance of the value in another respect of this mode of examination, is that which occurred to Sir Astley Cooper, who, by resorting to this plan in a case of murder, determined that the fatal shot could only have been fired by the left hand, a point of circumstantial evidence which eventually led to the detection and conviction of the criminal. Symptoms of Gunshot Wounds.—The symptoms of gunshot Avounds vary with the part affected, the nature of the missile, and other circumstances. The amount of shock is, according to Drs. Mitchell, Morehouse, and Keen, apt to be greater in wounds about the upper third of the body than in other parts. The attitude assumed by the person shot, immediately on receipt of the wound, varies with the locality of the latter; a man shot in the head usually falls forwards, while one shot about the shoulder often involuntarily turns round, making a half revolution, or a complete or even two revolutions, before falling. The first stage of shock may be very evanescent, the patient when first seen being in a state of wild excitement, delirious, or even maniacal; this is said to be particularly noticeable in wounds about the genital organs. The behavior of men when shot in battle is influenced by a variety of circumstances; thus, marked differences have been observed in accordance with the race of the person wounded. The Anglo-Saxon is usually calm and philosophical; the Celt sometimes gay and merry, and at other times depressed and gloomy; the Teuton phlegmatic. The negro soldiers during our late war were, according to the testimony of Dr. Brinton and other army surgeons, the most patient and enduring of all our wounded; another pecu- liarity was that, while the white troops of all races almost invariably threw away their muskets when shot, the negro soldier as regularly brought his into hospital with him, and was not satisfied to have it taken from his sight. The pain of gunshot wounds is sometimes very slight; indeed, in the heat 01 action, a soldier is often unaware that he is wounded, till he feels the trickling of blood, or sees its stain upon his clothes. When the shot is felt TREATMENT OF GUNSHOT WOUNDS. 163 the sensation is variously described as that of a bloAV from a cane or sharp stone, as a burning rather than a pain, or as an electric shock. In some cases, Avhen nerve trunks are in\^olved, there is most distressing pain referred to other and occasionally far different parts of the body; in other cases a still more curious phenomena is observed, viz., local temporary paralysis of motion and sensation, caused by concussion or commotion of a large nerve, from a ball passing near Avithout directly injuring it. Primary hemorrhage, contrary to Avhat might be supposed, is not a promi- nent symptom of gunshot wounds, but, when it does occur to any great extent, usually proves almost instantly fatal. Even Avhen.a limb is carried off by a shell or round shot, the peculiar way in which the vessels are torn asunder alloAvs contraction and retraction to occur, and there is much less bleeding than Avould be anticipated. In ball wounds of the extremities, the natural elasticity and resiliency of the vessels seem to enable them to elude the pro- jectile, and Ave often find the track of a wound apparently crossing directly the line of a main artery Avhich yet has entirely escaped injury. In other cases, as in wounds of the lung, there is a sudden gush of blood, which induces fainting, and before the patient recovers consciousness, a clot forms, and the bleeding may not be reneAved. Hence, death from hemorrhage on the battle-field is a rarer occurrence than is generally supposed; the cases which do prove fatal in this Avay, are usually those of wound of the heart itself, or of one of the large internal arteries, such as the aorta or pulmo- nary artery, or of wound at the root of the neck, A\diere arterial retrac- tion and contraction cannot occur, and where the condition may be addi- tionally complicated by the entrance of air into the great veins in that situation. The secondary symptoms of gunshot wounds do not materially differ from those of other lacerated and contused Avounds of the same severity. There is always a good deal of inflammation, with perhaps more swelling than in ordinary contused Avounds, attended by constitutional disturbance, fever, and perhaps traumatic delirium. The slough begins to separate about the sixth day ; and, when it has entirely come away, the extent of destruction is often found to be much greater than was at first supposed. During the whole period of separation of the slough, there is great risk of secondary hemor- rhage ; this usually takes place from the tenth to the fifteenth day, though it may occur as early as the fifth or as late as the thirtieth. Secondary hemor- rhage may, of course, be caused at a still later period by some accidental cir- cumstance, such as the puncture of a large artery by a spicula of necrosed bone, as in a case recorded by Dr. Chisolm, in Avhich bleeding occurred on the 328th day, or in the still more remarkable case recorded by Dr. William Hunt, in which fatal secondary hemorrhage similarly occurred nearly three years after receipt of the injury, Avhich Avas not, hoAvever, in this instance, a gunshot Avound. Erysipelas, pyaemia, hospital gangrene, and tetanus, may each prove a cause of death after gunshot injury, but do not, under such circumstances, present any different phenomena from those Avhich they exhibit when occurring after the lesions met Avith in civil life. Treatment of Gunshot Wounds.—All gunshot injuries may be divided, as regards the question of treatment, into those Avhich do, and those which do not, require amputation or excision. The latter division is by far the more numerous, embracing most of those which are known as flesh Avounds, together Avith all of the more serious class of penetrating wounds of the great cavities of the body. Thus, there Avere registered at the office of the Sur- geon-General U. S. A., up to Sept. 30, 1865, only 8825 gunshot fractures of 164 GUNSHOT WOUNDS. the extremities, as compared Avith 46,400 simple flesh Avounds of the same parts. The immediate indications for treatment, in a case of gunshot Avound in which the question of operative interference does not arise, are three in number, viz., (1) to promote reaction, (2) to arrest hemorrhage, and (3) to remove all foreign bodies. The first point has already been sufficiently con- sidered in previous chapters, and need not be again referred to. Hemorrhage.—With regard to the arrest of hemorrhage, from Avhat was said above it will be seen that there are comparatively feAv cases in which the surgeon has the opportunity to treat primary bleeding. Of over 17,000 operations tabulated in Circular No. 6, S. G. O., 1865, there Fio. 76. were but 404 ligations of arteries, and most of these were for secondary, not primary, hemorrhage. Still, cases are occasion- ally met Avith in which patients die from avoidable bleeding on the field of battle, as is said to have happened in the case of a distinguished officer in the Confederate service, Avho bled to death from a wound of the posterior tibial artery, and Avhose life might not improbably have been saved by prompt ligation of the wounded vessel. For temporary control of the bleeding artery the surgeon may use the ordinary tourniquet, or may im- provise one in the form of the common Spanish windlass (Fig. 25), tAvisting the knot with a clrum-stick or the handle of a sword. It has been recommended to distribute field tourniquets to soldiers on the eve of a battle, with instructions for their use; but it is the general opinion of military surgeons, that the cases of serious primary hemorrhage are really so rare, and the risk of producing injurious venous congestion by the improper use of the tourniquet so great, as to render the distribution of these instruments among troops more apt to be productive of harm than of benefit. Suppose a surgeon to find a man who has evidently lost a great deal of blood, Avith a deep wound filled by a recent clot Avhich has for the moment checked the hemorrhage, what course should be pursued ? If the wound were in a situation in which it would be difficult or even impossible to apply a ligature, as in the chest or abdomen, there can be no question that the proper course would be to allow the clot to remain, in hope that under its protection the wounded vessel would close by the natural processes which will be considered hereafter; and even if the Nelaton's wound were in one of the extremities, it Avould probably be right probe. to wait until full reaction had occurred before running the risk of provoking fresh bleeding by handling the wound. If, on the other hand, the wounded vessel were in an easily accessible situation, and the patient not much exhausted, it Avould be better to remove the clot as any other foreign body, and apply the proper treatment directly to the wounded artery. Removal of Foreign Bodies.—Bleeding having ceased, and the patient having reacted sufficiently to bear examination of the wound, the surgeon should proceed to remove all foreign bodies, the ball, if it have not passed out, and any portion of wadding, clothing, etc., that may have entered the wound. The finger constitutes the best probe for all parts Avithin its reach, but for exploration of the deeper portions of the wound, various bullet-probes may be employed. Nelaton's probe differs from the ordinary form of the instrument, in being capped with unglazed porcelain, which, by receiving a metallic streak, surely indicates the presence of a leaden ball, if the latter TREATMENT OF GUNSHOT AA'OUNDS. 165 come in contact Avith it.1 It was by means of this probe that the eminent French surgeon, Avhose name it bears, was enabled to demonstrate the pres- ence of a ball in the Avound of the celebrated Italian General, Garibaldi. Longmore speaks favorably of Lecompte's " stylet-pince," or "probe-nippers," by which the surgeon can withdraw a minute portion of the foreign body for examination. Culbertson, of Ohio, has devised a meerschaum probe which serves the purpose of Nelaton's instrument, and is besides provided with a roughened surface to catch and Avithdraw filaments of clothing, etc., Fig. 77. Bullet-forceps. which may be in the wound. Electric probes, containing two insulated Ayires, have been devised by Favre, of Marseilles, and others, for the detec- tion of balls, the effect of the metallic contact being to complete the circuit, and thus indicate the nature of the foreign body. Dr. Bill has invented an ingenious magnetic probe, employing the audient of a telephone as an indicator. An older instrument is the drum or reverberating probe of L'Estrange, an Irish surgeon, Avhich is provided Avith a small sounding- board to indicate to the ear the nature of the body struck. Deneux suggests the use of a probe carrying a mass of charpie dipped in dilute acetic acid; by contact Avith the ball the acetate of lead is formed, and the presence of Fig. 78. Screw Extractor. the metal may then be demonstrated by means of suitable reagents. Uhler, of Maryland, injects dilute acetic or dilute nitric acid, and then tests the in- jected fluid for lead and iron respectively.2 If the course of the ball be very circuitous, advantage may be derived from the use of flexible probes, such as those of Sayre, Steel, Sarazin, and other surgeons. For the extraction of balls, forceps of various kinds may be employed, or if the ball be imbedded in bone, it may sometimes be removed by the tirefond, or screAV extractor (Fig. 7.S); while if superficial, it may often be readily turned out with a scoop, or Avith the extremity of an ordinary grooved director. In other 1 Dr. Highaway, of Cincinnati, is said to have employed for this purpose, during the Mexican war, the stem of a clay tobacco pipe. 2 The same surgeon suggests that the presence of a splinter of wood might be recog- nized by detecting tannic acid in the discharges. 166 GUNSHOT AVOUNDS. cases, again, a ball is most conveniently reached by means of a counter- opening. Beside the information afforded by the finger or probe as to the presence and position of foreign bodies, the surgeon can thus obtain valuable knowledge as to the condition of the wound itself, and, in case the bone have been injured, as to the extent of its comminution. The splinters of bone produced by gunshot injuries were classified by Dupuytren into primary, secondary, and tertiary splinters or sequestra. The primary are such as are entirely detached, and should be immediately extracted, as they will other- wise produce irritation, acting as foreign bodies; the secondary sequestra are partially detached, and if very loose should be removed, but if pretty firm may be pushed back into place; the tertiary should always be preserved, as their vitality is not much impaired, and they serve a most useful purpose in assisting recovery by strengthening the new-formed callus. Dressing.—The wound being freed from all foreign bodies, loose splinters, etc., the surgeon proceeds to dress it. It was formerly the almost universal custom to enlarge gunshot wounds with the knife, and this practice, under the name of debridement, is still pursued by many European surgeons. It is doubtless useful in some cases, when there is much swelling, especially in the suppurative stage, to make more or less free incisions to relieve excessive tension, just as would be done in the case of any other wound, in which the original opening did not give sufficient vent; but in the immense majority of cases of gunshot injury this treatment is not at all necessary. Gunshot wounds are to be treated on the ordinary principles which guide the surgeon in the management of other injuries, and require no special or exclusive dressing. Cold water was most extensively employed during our late war, and as a primary application answers very well; if too long con- tinued, however, it produces a depressing influence on the part, the granula- tions becoming pale and flabby, and shoAving an indisposition to heal. In civil practice I have found the best primary dressing to be laudanum, pure or diluted, as Avith other contused and lacerated Avounds; changing it for poultices or warm fomentations when the sloughs begin to separate, and again using more stimulating dressings, such as lime-water, etc., when the process of granulation is fairly established. During the period of separation of the sloughs, if, from the position of the wound, there is reason to fear the occur- rence of secondary hemorrhage, it is well to apply a tourniquet loosely around the limb above the seat of injury, and to instruct an attendant in its use, that it may be screwed up on the first onset of bleeding. By the employ- ment of this provisional tourniquet, as it is called, many lives may be saved that would otherAvise inevitably be lost. Amputation and Excision in Gunshot Injuries.—Amputation may be rendered necessary m cases of gunshot injury by various circumstances; thus, if part of a limb be entirely carried away by a round shot, or by a fragment of a shell, there is nothing for the surgeon to do but to improve the form of the stump thus made, and endeavor to promote its healing. Many cases of gunshot fracture require amputation, either from extent of lesion of the bone itself, or from the concomitant injury to the soft parts. Especially do wounds of the main arteries and nerves of a limb, in conjunction with fracture, demand amputation. Even if the bone itself be not injured, it may be so extensively denuded that removal of the limb becomes the sur- geon's only recourse. When it is evident that, from the severity of the injury, amputation will be required, it should, in accordance with the prin- ciples enunciated in Chapter V., be performed as soon as possible after the occurrence of reaction. It may, however, even in cases which at first promise AMPUTATION AND EXCISION IN GUNSHOT AVOUNDS. 167 well, be required, as Avill be seen hereafter, as a secondary operation, on account of the occurrence of hemorrhage, of acute suppurative osteo-myelitis, or of extensive necrosis. The introduction of Excision of Bones and Joints as a substitute for am- putation in military practice, is comparatively an affair of modern times; the operation has, however, been so successful, at least in the upper extremity, that it may hoav be said that in most cases of injury of this part of the body, excision should be the surgeon's first thought, and should be preferred to amputation Avhenever the destruction of parts does not manifestly render the latter operation imperative. Shoulder.—Gunshot fractures involving the shoulder-joint very often re- quire excision, the operation having, apparently, been first employed by Percy in 1792. The statistics of the operation during our late war, as re- corded by Dr. Otis, give a total of 1086 cases. The results are known in all but 135. The mortality was 31 per cent, for primary, 46 per cent, for intermediate, and 29.3 per cent, for secondary cases. This proportion is less favorable than that of shoulder-joint amputation, of which the mortality during our Avar Avas, according to the same authority, 29.1 per cent. Ex- pectant treatment (reserved of course for selected cases) gave a death-rate of only 27.5 per cent. Gurlt's tables embrace 1661 cases of excision, with 5()7 deaths, a mortality of 34.7 per cent. In spite of its slightly greater fatality, excision should, I think, be preferred to amputation in any case admitting of a choice between the two operations. Even if the humerus be split for a considerable distance downwards through its shaft, excision may still be practised, not a few instances having occurred during our war, in Avhich very large portions of the humerus were removed by excision, a useful hand and forearm being thus preserved. Elbow.—Excision of the elbow, introduced into military practice by Percy, Avas frequently performed during our war,1 764 cases being noted in Dr. Otis's Surgical History. In 716 of these cases, in Avhich the results are known, there Avere 165 deaths, a mortality of 23 per cent. The death-rate, according to these figures, Avould appear to be slightly less than that of am- putation of the lower third of the arm, 25.9 per cent., and hence excision should be preferred in all suitable cases. The secondary Avere more successful than the primary excisions, while the intermediate operations Avere much the most fatal. According to Dominik, secondary excisions are also the most favorable as regards the utility of the limb. The same writer considers partial more successful than total excision of the elboAV, and his view is adopted by Hueter, Langenbeck, and Gurlt; but the experience of our war, as given by Dr. Otis, is decidedly in favor of the more SAveeping operation. Gurlt's tables give 1438 cases of elbow excision Avith 349 deaths, a mortality of 24.87 per cent. Wrist.—Excision of the wrist-joint has not been much practised in mili- tary surgery; the results of such operations as are recorded have been suffi- ciently satisfactory as regards life, but rather unsatisfactory as regards the utility of the preserved limb. Dr. Otis records 90 cases, of Avhich 15, or 16.67 per cent, terminated fatally. Gurlt gives 133 cases with only 20 deaths. Hip.—Gunshot injuries of the hip-joint are universally regarded as among the gravest injuries met Avith in military practice. The comparative advan- tages of excision,2 amputation, and expectant treatment in these cases, have 1 The first case in American military surgery is attributed to Dr. Otis Hoyt, during the .Mexican war (1817). 2 First adopted in military practice by Oppenheim, in 1829. 168 GUNSHOT AVOUNDS. been fully and ably investigated by Dr. Otis, U. S. A., in Circular No. 2, S. G. 0., 1869, and the statistics Avhich bear upon the question are exhibited in the following tables: Excisions. Primary, . . . Intermediate, . . Secondary, . . . Aggregate, Cases. 39 33 13 85 > 36 30 11 77 Recovered. Death-rate 92.3 90.9 84.6 90.6 Amputations. Cases. Died. Recovered. Doubtful. Death-rate. Intermediate,.... Secondary,..... Ke-amputations, . . . 79 76 20 8 75 70 13 4 1 6 7 4 3 98.68 92.10 65.00 50.00 Aggregate, . . 183 162 18 3 90.002 Gurlt's statistics shoAV very much the same mortality, 139 cases having given 122 deaths, or 88.40 per cent. The mortality in cases treated during our war by expectancy was 93 per cent., or, including cases in which the acetabulum Avas involved, 96 per cent. During the late Franco-Prussian war, as reported by Kichter, 33 cases of wound of the hip, treated by expectancy, furnished 31 deaths, and 21 treated by excision 18 deaths, Avhile 11 hip-joint amputations all terminated fatally. From these facts the conclusion is fairly drawn that, in any case of gunshot injury of the hip-joint, primary excision should be preferred to any other mode of treatment, and this simply to increase the chance of life, Avithout reference to the utility of the preserved limb. Of course there may be such extensive destruction of parts as to put excision out of the question, and in such cases the surgeon must still have recourse to Avhat Hennen called the "tremendous alternative" of hip-joint amputation, an operation which may also be required secondarily, after an unsuccessful attempt to save the limb. The accompanying illustration (Fig. 79), from a photograph, shows the con- dition of the bone in a case in which I performed (unsuccessfully) secondary amputation at the hip-joint, for gunshot fracture of the head and neck of the femur. The specimen is now in the museum of the Episcopal Hospital. Knee.—"Wounds of the knee-joint," says Guthrie, "from musket-balls, with fracture of the bones composing it, require immediate amputation." Unfortunately, this rule still holds good. The statistics of excision of the knee-joint, for gunshot injury (first performed by Fahle, in 1851), have been particularly investigated by Cousin, Chenu, Lotzbeck, Kiister, Culbertson, and Gurlt. Cousin finds that 33 cases of total excision have given 5 re- coveries and 28 deaths (85 per cent.), while 11 cases of partial excision have given but one recovery and 10 deaths (91 per cent.). Of the whole 44 cases, 1 One (fatal) case should be omitted, as not strictly an excision, which would lessen the death-rate. 2 Doubtful cases omitted in computing percentages. AMPUTATION AND EXCISION IN GUNSHOT AA'OUNDS. 169 Fig. 79. 38 proved fatal, a mortality of over 86 per cent. Chenu's figures, derived from the records of the Franco-Prussian Avar, show a still larger death-rate, 37 complete excisions having giA'en 33 deaths (89 per cent.), and 65 partial excisions 62 deaths (95 per cent.), or the whole 102 cases 95 deaths, a mor- tality of over 93 per cent. Lotzbeck's and Kiister's statistics, though somewhat more favorable, are still suf- ficently gloomy, 66 cases collected by the former writer giving 48 deaths (nearly 73 per cent.), and 101 cases collected by the latter giving 66 deaths, a mortality of over 65 per cent. Culbertson gives 44 complete excisions with 33 deaths, and 16 partial excisions with 12 deaths, a mortality for either category of 75 per cent., Avhile Gurlt's tables give 146 cases with 111 deaths, a mortality of 77.08 per cent. When we compare the above figures with the death-rate of amputation in the loAver third of the thigh (55 per cent, according to Legouest, 50 per cent, according to Macleod), the conclusion is surely irre- sistible that excision of this joint should be banished from the practice of military surgery, and that the rule should still be regarded as imperative, that every gunshot fracture of the knee-joint is a case for amputation. Ankle.—Fifty cases of complete excision of the ankle (first employed in military practice by Langenbeck, in 1859), are reported by Grossheim as having occurred during the late Franco-Prussian Avar; of these, 26 termi- nated in recovery, and 20 in death, the result in 4 cases not having been ascertained; partial excisions (including operations upon the tarsal bones) Avere more successful, 47 cases having given 33 recoveries and only 14 deaths. Gurlt's figures embrace 150 cases Avith 51 deaths, a mortality of 34 per cent. Gunshot Fractures of Shafts of Long Bones very commonly require ampu- tation. The preservation of a limb which is the seat of such an injury can less often be effected now than formerly, on account of the great severity of the bone lesions produced by the use of the conoidal bullet and of the modern improved forms of firearm. The results of excision in such cases, during our war, are shown in the folloAving table taken from Circular No. 6, S. G. O., 1865, and the second volume of Dr. Otis's Surgical History: Gunshot fracture of hip. Excisions in continuity. Died. Recovered. Undeter-mined. Total. Mortality, per cent. Humerus, .... 191 109 10 32 27 5 4771 856 104 6 112 26 28 21 2 24 37 2 696 986 116 62 1852 33 28.5 Bones of forearm, Metacarpal bones, Femur, .... 11.2 9.6 84.2 Bones of leg, . . Metatarsal bones, . 19.4 16.1 Comparing these figures, Avhen the number of cases is sufficiently large to justify their being used for statistical purposes, with the results of amputa- tions of the same parts, as gi\ren in previous chapters, Ave may conclude that—(1) excision in the continuity of the bones of the forearm is permissible in faA'orable cases ; (2) excision in the continuity of the humerus is more fatal than amputation of the corresponding parts, and is so often folloAved by non-union as to be in most cases an undesirable operation; (3) excision in 1 In 164 cases bony union did not occur. 2 Subsequent amputation in nine cases. 170 GUNSHOT WOUNDS. the continuity of the femur is a bad operation, and should be definitively rejected from military practice; (4) excision in the continuity of the bones of the leg is less fatal than amputation, and might, therefore, be resorted to in selected cases, though the number of undetermined results at the date of issue of Circular No. 6 was still so large that this conclusion may very probably be ultimately reversed ; (5) excision in the hand or foot is not an operation to be recommended. Judging from my individual experience, which is, of course, limited, I should say that except in the case of the radius or ulna separately, and per- haps of the fibula, excision in the continuity of the long bones was an unde- sirable operation. Those cases of resection of the shaft of the humerus or tibia, which I have observed, have either required subsequent amputation, or have preserved limbs of very Fig. 80. questionable utility: the case is very different from one of necrosis or ununited fracture, and, I believe, there is as yet no instance on record, of useful reproduction of bone, in a case of excision in continuity, for gunshot or other traumatic injury. In the case of the separate bones of the forearm, however, most ex- cellent results may be obtained by excision. I have myself tAvice ex- cised considerable portions of the radius, in cases of gunshot fracture, one being a primary (Fig. 80), and the other a secondary operation; both patients made good recoveries. Of 7888 completed cases of gun- shot fracture of the humerus, re- corded in Dr. Otis's Surgical His- tory of the War, amputation or ex- cision was practised in 4928, and conservative treatment was adopted in 2960, with a ratio of mortality of 24.1 per cent, in the former, and 15.2 per cent, in the latter category. These statistics show that in the upper extremity, at least, gunshot fracture may very often, though in a numerical minority of cases, be recovered from Avithout operation. In the lower extremity, the case in somewhat different. The mortality of gun- shot fracture of the upper third of the thigh is, indeed, less when treated by expectancy than after amputation, Avhich, in this situation, is an ex- tremely fatal operation ; in the middle of the thigh the mortality is about the same under either mode of treatment; but in the lower third, or in gunshot injury of the knee-joint, amputation gives much the best results. These points will appear from the following table, condensed from one in Circular No. 6: Result of partial excision of radius for gunshot in jury. (From a patient in the Episcopal Hospital.) Statistics of Gunshot Fractures. Mortality per cent. tt J.V j * j? Amputation. Upper third of femur,.....75 00 Middle " " " . . . . . 54.83 Lower " " " ..... 46.09 Wound of knee-joint, witb or without fracture, 73.23 Expectation. 71.81 55.46 57.79 83.76 ENCYSTED BALLS. 171 In gunshot fracture of the leg, if the splintering of the bones be not very great, and if the vessels and nerves have escaped injury, an attempt may be made to preserve the limb, the mortality, according to Circular No. 6, being but 24 per cent, under all modes of treatment. Remote Consequences of Gunshot Injury.—There are certain indirect or remote consequences of gunshot Avounds Avhich may demand the attention of the surgeon. These are principally manifested in the bones, the vessels, and the nerves. Bones.—The vitality of a bone may be seriously impaired by a gunshot wound, Avhich, at first, is supposed to have inflicted no injury upon it. The subjects of contusion and of contused Avounds of bone, have been ably inves- tigated by Dr. John A. Lidell, formerly surgeon in the IT. S. Volunteer Corps, Avho has published his vieAys in an elaborate paper in the American Journal of the Medical Sciences for July, 1865. Dr. Lidell has traced seven distinct conditions, Avhich may result from contusion of bone, and each of which is fraught Avith more or less danger to the patient; these are: 1. Ecchy- mosis of the osseous tissue ; 2. Ecchymosis of the medullary tissue ; 3. Simple osteo-myelitis (attended Avith production of new bone, both from the perios- teum and from the medulla); 4. Necrotic osteitis, or an inflammation of bone so severe in character as to terminate in necrosis; 5. Suppurative osteo- myelitis; 6. Gangrenous or septic osteo-myelitis (both this and the last- named condition are almost certain to terminate fatally); and 7. Necrosis produced directly by the contusion of bone, without the intervention of either ecchymosis or inflammatory irritation. If the bone which is contused be in the neighborhood of an articulation, the latter may undergo serious or fatal disorganization; or if an important organ, as the brain, be adjacent, secondary visceral disease may ensue. Vessels.—Traumatic aneurism of the circumscribed variety, occasionally, though rarely, folloAVS a gunshot injury; the diffused traumatic aneurism is a more frequent result of these Avounds, and constitutes a most serious affec- tion. I have seen one case of arterio-venous A\ound, resulting in aneur- ismal varix, produced by a musket-ball passing directly between the femoral artery and vein. Nerves.—Very curious nervous affections are occasionally observed as con- sequences of gunshot wounds. These affections may consist of paralysis of either motion or sensation, or both, of hyperesthesia, of choreic movements, etc. This subject has been particularly investigated by Drs. Mitchell, More- house, and Keen, of this city, Avhose labors in this department will be again referred to in a subsequent chapter.1 Encysted Balls.—Balls sometimes become encysted, that is, surrounded by a layer of dense cellular tissue, Avithin Avhich they may remain without producing any irritation, for a very long period. There are Avell-attested cases on record in Avhich encysted balls haAre remained harmlessly in the tissues for forty or even fifty years; in other cases, again, after a variable interval, they excite inflammation by acting as foreign bodies, and may pro- duce serious or even fatal consequences. Especially when lodged in the lung or pleural cavity is this apt to be the case, so that it is given as a rule by many authorities, that any gunshot Avound of the thoracic cavity, in AA'hich the ball remains lodged, will sooner or later cause death. 1 See also remarkable cases reported by Dr. J. H. Brinton (Am. Journ. of Med. Sciences, Oct., 1870. p. 435;, and by Dr. B. Ehett (Ibid., Jan., 1873, p. 90). 172 INJURIES OF BLOODVESSELS. CHAPTER IX. INJTJKIES OF BLOODVESSELS. Injuries of Veins. Subcutaneous Rupture of Veins occasionally occurs as a consequence of external violence, and is manifested by the extravasation of a large quan- tity of blood, which is, hoAvever, usually absorbed again in the course of a feAv days; or the blood may coagulate, the clot subsequently exciting sup- puration, or possibly becoming organized, as pointed out in Chapter VII. More rarely, the blood may become encysted in a fluid state, constituting what is sometimes called a venous aneurism. Open Wounds of Veins are not unfrequently met Avith in civil practice, and occasionally give rise to most serious consequences. Hemorrhage from a Wounded Vein is marked by the even and rapid flow, and the dark1 color of the effused blood. In certain situations, as at the root of the neck, or under peculiar circumstances, as when veins are affected by varicose disease, the hemorrhage may be so profuse as to endanger life. Wounds of the internal jugular vein are indeed extremely fatal acci- dents, eighty-five cases collected by Dr. S. W. Gross having been followed by death in no less than thirty-seven instances. Hemorrhage from super- ficial veins can usually be readily controlled by pressure, or even by position. Thus the most profuse bleeding, from rupture of a vein in a varicose ulcer of the leg, may often be checked, simply by elevating the limb. The large superficial veins on the back of the hand are often wounded by accidents from broken glass; in such cases I have found it a good plan to transfix both ends of the bleeding vessel with a metallic suture, thus arresting the hemorrhage and closing the Avound at one and the same time. In any case in Avhich pressure cannot conveniently be applied, the surgeon should not hesitate to use a ligature. There was formerly a great prejudice against the practice of tying veins, from the supposition that it was liable to induce pyasmia, but now that modern researches have shown that there is no necessary connection between that process and inflammation of the veins, or phlebitis, the theo- retical grounds for opposition are removed, and it is established by clinical observation that the risks of tying veins are much less than Avas formerly believed The lateral ligature, Avhich Avas first practised by Mr. Travers in a case of Avound of the femoral vein, consists in pinching up the bleeding orifice, and throwing around it a delicate ligature, so as not to obliterate the calibre of the vessel; this plan, which has theoretical merits, is found in prac- tice to be very apt to be followed by secondary hemorrhage, so that it is now generally abandoned, the vein being tied as an artery, above and below the bleeding point. The process by which nature arrests bleeding from a vein is essentially that which will be presently described in speaking of wounded thltDtbPHML^0tter' °/ Gen6Va' ^ \> haS observed in eiffht cases of spinal injury, nofwn 5 « 7k T & Vem 1S °f arterial hue: this observation has, however not been confirmed by others. ' ENTRANCE OF AIR INTO VEINS. 173 arteries, a clot forming in the vessel, and the cut edges subsequently uniting through the development of local inflammatory changes. After ligation, which corrugates but does not divide the coats of the veins, a clot forms on the distal side of the ligature, which gradually cuts its Avay through, as in the case of an artery, though in a shorter time in proportion to the size of the vessel. Phlebitis may follow a wound of a vein, and Avas formerly supposed to be the cause of pyaemia, which occasionally occurs and proves fatal after such an injury: this subject will be fully discussed in another part of the volume. Entrance of Air into Veins.—The most frightful and fatal consequence of venous wounds, though fortunately one which is rare, is the entrance of atmospheric air, and its transfer to the heart. This accident is princi- pally met with in cases of wound of the internal jugular, or of the other large veins situated at the root of the neck, or in the axilla, and this part of the body is accordingly often spoken of by surgeons as the " dangerous re- gion." It has, hoAvever, occurred in other parts of the body; thus, in a case of the late Prof. Mott's, serious though not fatal symptoms followed the en- trance of air into the facial vein where it crosses the lower jaAV, Avhile this accident occurring in the femoral vein is supposed to have been the cause of death in a case of thigh amputation during the Crimean Avar.1 The mode in Avhich air is pumped into the veins is easily understood: during the act of inspiration, a vacuum is created in the thorax, to supply Avhich air rushes through the trachea or through any other opening into the interior of the chest; thus, in the case of wounds of the pleura, air is sucked in during in- spiration, to such an extent as often to induce collapse of the lung and pneumo- thorax, and in the same way, if a large vein in the neighborhood of the thorax be Avounded, and be prevented from collapsing by the natural connec- tions of the part, by the position of the patient, or by a structural change in the Aressel itself (to which the French give the name of canalization), the act of inspiration will mechanically and necessarily pump air into the open vein, precisely as it does through any other aperture into the chest. The local signs of entrance of air into a vein, consist in a peculiar sound, variously described as of a hissing, gurgling, sucking, or lapping character, and in the appearance of frothy bubbles in the Avound. The constitutional symptoms are equally well marked. The patient cries out, impressed Avith a sense of certain and rapidly impending death, and falls almost instantly into a semi- collapsed state, moaning and perhaps struggling; the pulse is almost imper- ceptible, the action of the heart tumultuous but feeble, and the respiration difficult and oppressed. Death may occur immediately, but more commonly after an interval varying from a feAv minutes to an hour or more; or, if the quantity of air introduced be but small, recovery may gradually ensue, partial paralysis sometimes continuing for several hours or even a much longer time subsequent to the accident. The cause of death in these cases is somewhat obscure; Mr. Erichsen be- lieves it to be the frothy condition of the blood, produced by the action of the heart, Avhich prevents the due transfer of the circulating fluid through the pulmonary tissue, and thus secondarily causes a deficient supply of blood to the brain and nerve centres, inducing death by syncope. Sir Charles Bell believed that death was caused by the direct transference of air to the base 1 It is probable, also, that the entrance of air into the uterine veins is an occasional cause of sudden death after delivery, and after various operations upon the womb. (See an able paper by Dr. Greene, of Dorchester, in Amer. Journ. of Med. Sciences for Jan., 1864, pp. 38-65.) 174 INJURIES OF BLOODVESSELS. of the brain, and, in confirmation of this vieAv, Prof. Gross's observation may be referred to, viz., that animals may be rapidly killed by the injection of air into the carotid artery. Dr. Cormack attributed the fatal result directly to paralysis of the right side of the heart from gaseous distention, Avhile Mr. Moore maintained that death Avas due to the entrance of air to the heart, impeding the action of the cardiac valves and thus stopping the circulation, a ATieAy which has recently received experimental confirmation from M. Couty. Other experiments also, by Kowalewsky and Wyssotsky, show that frothy blood accumulates in the right side of the heart, mechanically hindering the normal circulation, and thus causing death by anaemia of the aortic system. Treatment.—As a preventive measure, the surgeon should exercise extreme caution in all operations about the root of the neck, or deep in the axilla, using as much as possible the handle instead of the blade of his knife. It might also be desirable to have the large veins compressed by an assistant, or protected by serre-fines, between the seat of the operation and the heart, and care should be taken not to place the veins in such a position as will prevent them from collapsing if Avounded, whether by stretching the patient's head to the opposite side, by hastily elevating the shoulder, or by incautiously lifting a tumor from its bed. Mr. Erichsen recommends that the patient's chest should be swathed by a firm and broad bandage, as a precautionary measure, so as to limit as far as possible the depth of the inspirations. Should a large vein in the " dangerous region" be Avounded during an operation, or should the surgeon find such a wound in a case of cut-throat, etc., measures should instantly be taken to prevent the entrance of air, by the application of liga- tures above and below the aperture. When this alarming accident has actually occurred, the first indication for treatment is obviously to prevent any further ingress of air, by making instant compression and then quickly applying a ligature. The lateral ligature was successfully employed in a case recently recorded by Lange, of New York. The subsequent treatment must consist chiefly in endeavoring to keep up the action of the heart by appropriate means. Of these, the most promising appear to me to be arti- ficial respiration and the administration of stimulants. The patient should be in the recumbent position, and the extremities elevated so as to retain as much blood as possible in the central organs; to accomplish the same pur- pose, Mercier advised the application of tourniquets and compression of the abdominal aorta. Artificial respiration may be practised Avith suitable bellows, or simply by the surgeon's mouth. Sylvester's or Hall's method would scarcely be applicable in these cases, on account of the situation of the wound. The administration of oxygen gas by inhalation is recommended by Walsham and Couty, the latter of whom also advises venesection. Vari- ous other plans have been suggested, among which may be mentioned—(1) an attempt to suck out the air by means of a canula introduced into the wounded vein, into the right jugular vein, or even into the heart itself; (2) bleeding from the right jugular vein or from the temporal artery; (3) tracheotomy; and (4) the injection of Avarm Avater into the heart. I am not aware, however, that there are any cases on record which prove the effi- ciency of any of these methods. Galvanism might rationally be applied to the cardiac region, though I should be disposed to trust more to the use of stimulants and to artificial respiration. Remote Consequences of Injuries of Veins.—A clot may form in a vein as the result of injury (thrombosis), and may subsequently undergo disinte- gration, the fragments being carried to the right side of the heart and thence to the lungs, plugging the minute pulmonary arteries (embolism), and thus giving rise to the formation of what are commonly but incorrectly called AVOUNDS OF ARTERIES. 175 metastatic abscesses. This condition, Avhich is in no degree necessarily con- nected with phlebitis, Avill be again referred to in the chapter on pyaemia. On the other hand, a clot in a vein may undergo a process of gradual contraction, induration, and decolorization, becoming finally calcified, and constituting Avhat is called a phlebolite, or vein-stone. These phlebolites, hoAvever, usually result from clots due to stagnation, without external vio- lence, and are consequently chiefly met with in the veins of the pelvis, genital organs, and loAver extremities. Injuries of Arteries. Contusion of an Artery may exist, without giving at first any evidence of its occurrence. The secondary results of arterial contusion depend upon the severity of the injury; if this have been very great, a portion of the Avail of the vessel may slough, and cause secondary hemorrhage or extrava- sation ; if the violence have been less, the vessel may undergo obliteration, or in very slight cases may recover without evil consequences. The oblitera- tion of an artery, occurring some hours or days after the reception of an injury, is usually attributed to the effect of inflammation ; I believe, however, that it is more commonly due to the plugging of the vessel, either by embol- ism (fragments of clot being carried from another part of the circulation), or more rarely to an actual thrombosis in situ, clotting taking place in the in- jured vessel itself. As a result of this obliteration, or infarctus as it is called by French Avriters, gangrene or serious visceral degeneration may occur, ac- cording to the size and situation of the vessel. Thus, in two cases of injury in the lumbar region, Dr. Moxon found complete thrombosis of the renal arteries, with corresponding incipient degeneration of the kidneys. Rupture or Laceration of an Artery may be either partial or complete; partial laceration generally occurs without external wound, and involves the two inner coats of the artery, the elasticity of the outer coat preserving it from injury. This accident may form the starting-point for the develop- ment of an aneurism at a subsequent period ; or the torn inner coats of the vessel, curling upon themselves, may furnish a nidus for the occurrence of coagulation, which, as in the case of contusion, may cause gangrene of the part below the seat of injury; or, again, the lacerated inner coats may turn doAvnwards, and by their mechanical valvular action produce gangrene, by directly interfering with the circulation. Finally, a partial laceration may, after a longer or shorter interval, become complete, when death from inter- nal hemorrhage may follow, as in a case of rupture of the external iliac artery observed by myself at the Episcopal Hospital. (Fig. 81.) Complete rupture may occur subcutaneously, or in an open wound. In the latter case, the nature of the accident may be obvious from the profuse arterial bleeding, though in other instances, if the coats of the vessel are tAvisted upon themselves, there may be scarcely any hemorrhage, the artery, perhaps, hanging out of the wound and pulsating, and yet no blood escaping. When an artery is torn across subcuta- neously, there may be wide-spread extravasation, or the development of one or other form of traumatic aneurism, according to the size and position of the vessel. Wounds of Arteries.—Non-penetrating wounds of arteries occasionally, but very rarely, occur. In these, the external coat is divided, with, perhaps, a portion of the middle coat. There is no primary hemorrhage in these cases, but the inner coat almost invariably yields after a feAv days, when 176 injuries of bloodvessels. fatal bleeding may ensue. Hence, a partially divided artery should always be ligated, as a precautionary measure. Penetrating wounds of arteries, if very small (consisting of a mere punc- ture with a fine needle), may not be productive of evil consequences; but if the puncture be larger, as Avith a tenaculum, secondary, if not primary, hemorrhage Avill almost certainly follow. Incised Avounds of arteries bleed Fig. 81. Rupture of External iliac Artery. (From a specimen in the Museum of the Episcopal Hospital.) A. Common iliac artery. B. External iliac artery. C. Internal iliac artery. D. Position of rupture. E. Clot overlying common trunk. F. Clot protruding from distal end of external iliac artery. more or less freely, according to the size and direction of the wound; thus, a longitudinal wound will, in consequence of the anatomical arrangement of the arterial coats, gape less, and consequently bleed less, than one which has an oblique direction, Avhile a transverse Avound will bleed more than either. An artery which is completely cut across bleeds less, other things being equal, than one which is only partially divided; for the complete section of the vessel allows partial retraction and contraction to occur, and thus meas- urably lessens the size of the stream. A wound of an artery at the bottom of a narrow and tortuous passage through muscular or other tissue, approaches to the nature of a subcutaneous laceration, and extensive extravasation may then occur with very little external bleeding; or the outer wound may ac- tually heal, while the opening in the vessel remains patulous, in which case a form of traumatic aneurism may be developed. Hemorrhage from a Wounded Artery may usually be recognized by the bright vermilion hue of the effused blood, and by the fact that it is thrown out in jets corresponding to the pulsations of the heart, and does not flow in an even stream, as in cases of hemorrhage from veins. To this rule there are, however, exceptions; the blood from the proximal end of a divided constitutional effects of hemorrhage. 177 artery ahvays, I believe, presents the characters Avhich have been described, but from the distal end, for at least an hour after the infliction of the wound, or until the collateral circulation has been established, the floAV of blood resembles that from a Avounded vein. In other cases, hoAvever, if the anastomosis be very free, as in the palmar arch, both ends of the cut vessel Avill bleed in jets, and pour out blood of a bright red color. The force of the jet varies Avith the size and position of the artery and the strength of the heart's action. A small branch wounded in close proximity to a main trunk, may bleed more furiously than a larger vessel divided at a more distant point, and, in general terms, the nearer a cut vessel is to the centre of circulation, the more profusely will it bleed. As the pulsations of the heart become weaker, the jet of blood has less force, and may finally cease with the occur- rence of syncope, or may be arrested by the natural processes of contraction and retraction which are set up in the wounded vessel. As already indicated, there may be profuse bleeding without any external loss of blood. When bleeding occurs into one of the cavities of the body, as the peritoneal, it constitutes internal or concealed hemorrhage; when into the areolar tissue of a part, it is known as extravasation. Extravasation may prove directly fatal, by the amount of blood abstracted from the general circulation, may cause gangrene by pressure, especially upon the neighbor- ing venous trunks, or, if circumscribed, may give rise to a form of traumatic aneurism. Constitutional Effects of Hemorrhage.—These are the same in kind, though differing in intensity, whether the bleeding proceed from arteries or veins, and whether the hemorrhage be apparent or concealed. The first effect of profuse hemorrhage is shown in the blanching of the surface; the cheeks and lips become pale, and the conjunctiva unnaturally Avhite. The pulse becomes small and rapid, the heart endeavoring by increased action to compensate for diminished poAver. The patient feels languid; the res- piration assumes a sighing character; the senses of sight and hearing are perverted, being sometimes preternaturally acute, but more often dulled; the temples throb, the skin becomes cold, and at last, rather suddenly, the patient faints. During the state of syncope, the heart's action is very feeble, and the breathing almost entirely diaphragmatic. Death may occur in this con- dition from a continuance of the hemorrhage, but more commonly coagulation takes place in and around the mouth of the wounded vessel, and Avhen con- sciousness returns, the bleeding is found to have spontaneously ceased. Vom- iting frequently occurs as syncope passes off. All the tissues of a patient who has lost much blood appear soft and flabby, probably from the loss of the natural fluids of the part, Avhich are rapidly absorbed into the depleted bloodvessels. Profuse or repeated hemorrhage, beside the symptoms AAdiich have been above described, often gives rise to distressing nervous phenomena, such as amaurosis, delirium, convulsions, or even hemiplegia; I have known death attributed to a cerebral clot, which the autopsy shoAved did not exist, the fatal result being simply and altogether owing to profuse and repeated secondary hemorrhages. In recovering from the effects of loss of blood, the patient sometimes passes through a condition of constitutional irritation, with extreme restlessness and delirium, to which the name of " hemorrhagic fever" has not been inaptly applied. The amount of blood which can be lost without serious consequences ensuing, varies greatly in different individuals. Infants and very old persons are, as a rule, more injuriously affected by hemorrhage than those in middle life. The amount of blood lost in ordinary childbirth might produce serious consequences under different circumstances, Avhile, on the other hand, the 12 178 injuries of bloodvessels. mental state of a patient, as of one who has attempted suicide, or who believes himself to be bleeding to death, may actually cause a fatal result after the loss of a really insignificant quantity of blood. Habitual or Periodic Hemorrhage may be met Avith in either sex. In the female it may take the place of, or alternate with, the natural menstrual flow, when it constitutes what is called vicarious menstruation. In the male sex, bleeding from the hemorrhoidal veins sometimes occurs at certain periods of the year, and seems to be occasionally beneficial by relieving a state of plethora. Some persons bleed habitually from the nose, without any apparent solution of continuity having taken place; and Mr. Moore mentions an apparently authentic case, in which a young woman had severe spontaneous hemorrhages from the skin of the finger. In these cases the blood seems to ooze from numerous minute orifices, and subsequently to collect in the form of drops, which then flow over the surface. Hemorrhagic Diathesis; Haemophilia.—These are the names used in England and in this country for the remarkable affection which the French call Hemophylie, and the Germans Hamophilie or Bluterkrankheit. Its chief manifestation, and that from Avhich its name is derived, is a disposition to profuse bleeding, which may be spontaneous, or may follow upon the slightest wounds. It is often hereditary, and those in whom it exists are in childhood often subject to affections of the joints, and to inflammations of the lungs. It affects almost exclusively persons of the male sex, the female members of a family, though transmitting it to their posterity, being themselves usually exempt. The disease appears to depend on a peculiar condition of the blood (not mere want of plasticity, for it coagulates readily when removed from the body), and on a defective contractility of the arteries and capillaries. P. Kidd has observed, after death, great proliferation of the epithelioid cells lining the small vessels, with degeneration of their muscular coat. Ac- cording to Wachsmuth, the spontaneous hemorrhages may often be averted by smart purging with Glauber's salts, and, when they occur, may best be arrested by the administration of an infusion of arnica, or ergot in doses of five grains every half hour. The hemorrhages which follow wounds do not yield so readily to constitutional measures, and in these cases long-continued pressure, and the use of the actual cautery, appear to be the most promising modes of treatment. The existence of the hemorrhagic diathesis would of course be a contra-indication to the performance of any operation involving the use of the knife; it is somewhat remarkable, however, that cases which have proved fatal, from this cause, have almost invariably been those of trivial accidental wounds, or of such slight surgical procedures as the ex- traction of a tooth, or lancing the gum—the only recorded instance, as far as I know, of the hemorrhagic diathesis having caused death after an im- portant operation, being in a case of lithotomy reported by Mr. Durham. Process of Nature in Arresting Hemorrhage.—Before entering upon the subject of the treatment of arterial hemorrhage, it will be necessary to con- sider briefly the process adopted by nature in closing wounds of these vessels, a process which the surgeon endeavors to imitate by the appliances of art. The natural means by which arterial wounds are healed have been experi- mentally and very thoroughly investigated by Dr. J. F. D. Jones, whose monograph on the subject was published more than sixty years ago, since which time very little, if anything, has been added to our information con- cerning the matter. The temporary means employed by nature to arrest hem- orrhage are twofold: (1) the formation of a clot, and (2) the contraction and retraction of the cut end of the vessel itself. The formation of a clot, which PROCESS OF NATURE IN ARRESTING HEMORRHAGE. 179 is greatly facilitated by the diminished force of the heart's action (one of the constitutional effects of hemorrhage, as Ave have already seen), Avas first noticed and its importance pointed out by the celebrated French surgeon Petit, in 1731. This distinguished Avriter described an external clot Avhich he called couverck, and an internal clot which he called bouchon. The in- ternal clot is someAvhat conical in form, its base adhering to the sides of the vessel near its cut extremity, and its apex reaching upAvards, usually as high as the origin of the first anastomosing branch. It is formed gradually, and having served its temporary purpose, undergoes contraction and partial ab- sorption, and eventually appears to form a portion of the fibrous cord into which a closed artery is converted. The contraction of a divided artery, and its retraction within its sheath, begin immediately upon its division;'this step of the process was first indicated by Morand, in 1736, Avho did not deny, as some of his followers have done, that the formation of a clot is of tem- porary utility, though he clearly declared his conviction that the permanent closure of the vessel must depend upon the cicatrization of the artery itself. The retraction of the vessel Avithin its sheath allows the blood to come in contact with the irregular surface of the latter, and thus facilitates the for- mation of the external coagulum, Avhile its contraction as regards its calibre diminishes the size of the stream, and thus tends to assist the formation of the internal clot, of which it likeAvise determines the shape. This contrac- tion, as shown by Kirkland, extends to the origin of the nearest anastomos- ing branch. The permanent means by Avhich a divided artery is closed, con- sist in the union of the cut edges by the development of local inflammatory changes, the continued contraction of the walls of the vessel upon the in- ternal coagulum, and the final conversion of the lower end of the vessel into a dense, fibrous, impervious cord, into the construction of Avhich a certain portion of the internal clot appears usually to enter. The exact mode in which the cicatrization of the cut extremity of the vessel is effected, is vari- ously described by authors, according to the several views entertained as to the nature of the inflammatory process (see Chap. I.). Most surgical Avriters, following Dr. Jones, have attributed the healing of divided arteries to the effusion of plastic matter from the rasa vasorum; the advocates of the cellu- lar pathology consider the process to be one of cell proliferation from the vessel's Avails, a vicAv Avhich is sustained by careful experiments made by Dr. Shakespeare, of this city ; Prof. Beale and Mr. Lee consider the union to be due to the development of germinal matter, derived from the Avhite corpus- cles of the blood, Avhile Billroth (practically returning to the old doctrine of Petit), attributes the healing of Avounds of both arteries and veins to the organization of the internal coagulum, through the multiplication of the white blood-corpuscles, aided, perhaps, by the entrance of Avandering cells from the surrounding tissues. Without entering into a discussion of this question, which must be con- sidered to a great degree one of purely theoretical interest, I may say that whatever be the method by Avhich injuries of other tissues are repaired, by the same method, in all probability, are Avounds of arteries united ; and this method, as I have endeavored to shoAV in previous chapters, is in all cases by means of that natural process Avhich for Avant of a better name Ave call in- flammation. We may, however, from what has been said, derive this prac- tical lesson : that as the repair of an artery after injury appears to require the co-operation both of the Avails of the vessel and of the contained blood, no means of arresting hemorrhage can be looked upon as philosophical^ which ignores the^ efficiency and attempts to dispense Avith the aid of either of these agents. The application of this remark will be seen directly, when I come to speak of the local means of treating arterial hemorrhage. 180 INJURIES OF BLOODVESSELS. The changes Avhich have been above described are best marked in the closure of the proximal or cardiac end of a divided artery. Those Avhich take place in the distal extremity are the same in kind, though less in degree ; especially is this the case as regards the internal coagulum, Avhich in the dis- tal end of the vessel is smaller than in the proximal, and indeed in some cases entirely deficient; a circumstance which, as pointed out by Guthrie, may probably account for a fact which has long been recognized by sur- geons, that secondary hemorrhage usually occurs from the distal extremity of a wounded vessel. In the case of partially divided arteries, the process is essentially the same; a clot forms between the sheath and the vessel itself, and congresses the latter ; this pressure may likewise be aided by the formation of a clot in the external wound. The permanent closure of the arterial incision is effected, as in the case of complete division, by the inflammatory process. Very slight wounds, especially if longitudinal, may close Avithout the calibre of the artery being obliterated; if, however, the size of the wound be equal to one-fourth of the circumference of the vessel, the latter will almost inevitably be con- verted into an impervious cord at the seat of injury, and it is probable that, in these cases, the healing process is assisted by the formation of an internal, as well as an external, coagulum. When such a Avound heals without the obliteration of the calibre of the artery, the inner coats of the latter do not unite very firmly, and an aneurism is apt to be subsequently developed. In an artery as large as the axillary or femoral, it may be stated, in general terms, that a wound of one-fourth of the circumference of the vessel will, if untreated, either cause death by hemorrhage, or give rise to a traumatic aneurism; in the rare instances in which neither of these consequences ensues, the vessel will, in healing, be converted into an impervious fibrous cord. Treatment of Arterial Hemorrhage. The treatment of arterial hemorrhage should be both local and constitu- tional. The constitutional treatment consists in keeping the patient quiet in a recumbent position, and in avoiding any sudden elevation of the head or of the arms, which might induce fatal syncope. Food and stimulants should be cautiously administered in small quantities at a time, and, if there be vomiting, may be given by enema. Hypodermic injections of ether have been successfully used by Hecker, Macan, and others, in the collapse of post- partum hemorrhage, and I have myself employed them with advantage in cases of profuse bleeding during operations. Opium should be freely used, and is a most valuable remedy in these cases. Drugs adapted to increase the plasticity of the blood, such as the muriated tincture of iron or the acetate of lead, may be administered, or ergot may be used, as recommended by Wachs- muth in cases of the hemorrhagic diathesis. As a last resort transfusion of blood should certainly be tried, in the manner and with the precautions re- commended in Chapter IV. The statistics of this operation in cases of hem- orrhage, as given by Landois, are very favorable, 99 cases having afforded not less than 65 recoveries, while 11 of the 31 fatal cases (the result in 3 Avas doubtful) Avere moribund at the time transfusion was practised. Strieker recommends vigorous kneading of the abdomen, so as to force the blood from the abdominal veins to the heart, and thus keep up the action of that organ. For the anaemia left after recovery from the primary effects of hemorrhage, a long course of tonics, and especially of the preparations of iron, may be required. The loss of blood in some cases is never entirely repaired during life, the patient remaining permanently blanched, though otherwise appar- COLD, POSITION, AND PRESSURE. 181 ently in good health; or the debility resulting from hemorrhage may act as a predisposing cause for the occurrence of tuberculosis or other morbid con- dition. The local treatment of arterial bleeding consists in the adoption of various measures, which may be either of a temporary, or of ^permanent nature. Hemorrhage from a wounded artery may be temporarily checked by pressure. This may be applied directly at the seat of injury, or indirectly upon the main artery of the part, at a point between the wound and the centre of the circulation. In the latter case compression is usually best exercised by the application of the tourniquet, the various forms of, and the modes of using, Avhich instrument have been sufficiently described in a previous chapter. In dealing with certain arteries, as the subclavian, to Avhich a tourniquet cannot be applied, effectual pressure may be made with the handle of a large key (previously Avrapped, so as to protect the skin), or other suitable implement; or if the clavicle be much displaced-—as by an aneurismal tumor—Syme's plan might be employed, Avhich consists in making an incision in the line of the artery, upon Avhich direct pressure is then made by introducing the finger through the Avound. For the permanent arrest of arterial hemor- rhage, the surgeon may have recourse to the use of—1, cold; 2,position; 3, pressure; 4, styptics; 5, cauterization; 6, torsion; 7, ligation; or 8, acupressure. 1. Cold is an efficient means of arresting hemorrhage from many vessels of small calibre. In some cases the presence of clotted blood in a Avound ap- pears to encourage further bleeding by acting just as a Avarm poultice would do, and the surgeon often finds that, upon sweeping away the clots and ex- posing the wound to the air, the hemorrhage ceases spontaneously. Hemor- rhage from small vessels may often be arrested by pouring a stream of cold water over the part, or if the bleeding come from one of the mucous outlets of the body, as the mouth, nostrils, rectum, or vagina, by introducing small pieces of ice. Care must be taken, however, in the use of cold, not to con- tinue its application too long, lest injurious depression or even sloughing should ensue. The application of hot water has been successfully employed in cases of capillary hemorrhage by Keetley, C. T. Hunter, and other surgeons. 2. Position may often be usefully employed to arrest, or, at any rate, to assist in arresting arterial hemorrhage. If the wound be in the loAver limb, the part should be elevated by means of pilloAvs or an inclined plane, so that, by the laAvs of hydraulics, the force of the circulation in the injured part may be diminished, and an opportunity given for the occurrence of the natural processes of repair. The same plan may be adopted for Avounds of the upper extremity; while in treating Avounds of the arteries of the fore- arm or of the palmar arch, it will be found advantageous to forcibly flex the elbow—a modification of Hart's method of treating aneurism, Avhich has afforded good results on more than one occasion. 3. Pressure, which, as we have seen, is the common mode of temporarily checking hemorrhage, may be also efficiently used for its permanent arrest. It may be applied directly to the bleeding point by means of the graduated compress, or by the use of serre-fines, or of small forceps; or indirectly, by bandaging the limb and flexing the proximal joint OArer a roller, or, in the case of bleeding from cavities, by plugging the part Avith lint or compressed sponge. Sometimes pressure may be efficiently applied by means of a Aveight, as a bag of shot, or even loose shot, as A\as done in Dr. Smyth's remarkable case of successful ligation of the innominate artery, which will be again re- ferred to. The graduated compress is made by laying together a number of 182 INJURIES OF BLOODVESSELS. pledgets of lint of gradually increasing dimensions, so that Avhen completed the mass has the form of an inverted cone about an inch in height; the apex of this cone is applied directly upon the bleeding point, all clots having been previously removed from the wound, and the compress is held in place by adhesive strips, Avhile firm pressure is made upon it by means of a piece of cork or metal, secured Avith a bandage. In positions Avhere the proximity of a bone gives a firm substance against which the vessel may be compressed, as in the case of wounds of the temporal artery, this will be found a very efficient mode of controlling hemorrhage. 4. Styptics.—These agents, Avhen employed alone, are not of much use, except in checking capillary oozing or the bleeding from very small vessels. The simplest and most convenient is ordinary diluted alcohol, the employ- ment of Avhich in operations has already been adverted to. The styptic of Pagliari, Avhich has a good deal of reputation, particularly among French surgeons, contains alum and benzoin, and certainly seems in some cases to answer a very good purpose. Among the more poAverful styptics may be especially mentioned the perchloride of iron, in substance, in solution, or in the form of the muriated tincture, and the persulphate, or Monsel's salt. The latter, in particular, is undoubtedly a very powerful agent, and, when prop- erly used, capable of serving a very good end; its indiscriminate employment in all cases of surgical hemorrhage has, however, been productive of a great deal of harm, not only on account of its effect in hindering primary union, but because the rapidity of its action, and the facility Avith which it can be applied, have often induced inexperienced practitioners to neglect less easy but more trustAvorthy means of suppressing arterial bleeding. In conjunction with pressure, styptics are more valuable than by them- selves ; by applying the styptic upon the apex of the graduated compress, or, in the case of hemorrhage from deep fistulous wounds, or from the mucous outlets of the body, by plugging the cavity with lint or sponge soaked in the styptic, a very powerful impression may be produced. In a very interesting if inconclusive paper, published in the American Journal of Medical Sciences for October, 1865, Dr. J. M. Holloway advocates the employment of styptics, with pressure, in cases of consecutive hemorrhage from gunshot Avounds, as often preferable to the use of the ligature; and though, of course, a practice founded on universal experience is not to be revolutionized by the record of a feAv exceptional cases met Avith by any individual, still the instances men- tioned by Dr. Holloway are of much interest, as showing that these means may occasionally prove successful even in dealing with such a large artery as the axillary. For bleeding after the extraction of a tooth, ]\ loreau recommends plugging the cavity Avith cotton saturated with tincture of benzoin, and com- pression by means of a piece of cork fixed betAveen the neighboring teeth. 5. Cauterization with a hot iron was, until within a comparatively short period, the principal means of arresting arterial bleeding at the command of the surgeon. Although the ligature a\ as re-invented and powerfully ad- vocated by the illustrious Pare, in the middle of the sixteenth century, it was not generally adopted for a long time subsequently, and we learn from the writings of Sharpe, of Guy's Hospital, only a little more than one hun- dred years ago, that even in his time the cautery and styptics were still preferred to the ligature by many surgeons, not only on the Continent, but even in some parts of England. Although no surgeon at the present day, probably, Avould use the hot iron in any case in Avhich a ligature could be applied, there are some circumstances under which the cautery must still be resorted to; in some operations about the jaws, and in other cases in Avhich TORSION. 183 from the position of the bleeding vessel, or from the condition of the sur- rounding tissues, other modes of controlling hemorrhage are not awailable, or fail upon trial, the hot iron is a valuable application. The various forms of the cautery have already been described and figured in the chapter on Minor Surgery, and it Avill be sufficient to add here that Avhen used for hemorrhage, as it is the coagulant and not the destructive effect that is needed, the temperature of the iron should not be raised above a black heat. 6. Torsion, as a means of controlling the hemorrhage from cut arteries, was knoAvn to the ancients, but subsequently passed through a long period of oblivion, having been revived in the early part of this century, principally by the efforts of French and German surgeons, among Avhom may be specially named Amussat, Velpeau, and Fricke. Since then torsion has been occa- sionally used by surgeons, generally in dealing with small arteries; but the practice has Avithin a few years received a fresh impulse, and is now strongly advocated by several Avriters as a mode of treatment applicable to vessels of all sizes; this movement has been most actively participated in by Prof. Syme, of Edinburgh, Prof. Humphry, of Cambridge, and Messrs. Bryant and Forster, of Guy's Hospital, London. Torsion may be practised in several Avays: Syme, Humphry, and Tillaux, following Amussat, draAv the extremity of the artery out from its sheath, and twist it until it is twisted off; the sur- geons of Guy's Hospital, on the other hand, adopt Velpeau's plan of leaving the tAvisted end attached, that it may give additional security by acting as a mechanical plug. Free torsion (that is, Avith a single pair of forceps) is recommended by Bryant for vessels of moderate size, and for all vessels in the extremities; limited torsion (in which the vessel is grasped Avith one pair of forceps and tAvisted with another) for such arteries as are large and loosely connected. An ingenious torsion-forceps has been devised by Dr. Hewson, Fig. 82. Speir's artery constrictor. of this city. When it is not intended to twist off the end of the vessel, the number of turns should vary from six to eight, according to the size of the artery. The mechanism of torsion is as folloAA's: the inner and middle coats are lacerated and curl upon themselves, forming a nidus for the coagulation of blood, just as after ligation, or in the ordinary natural process of repair already described; the external coat is tAvisted into a cord, Avhich serves tem- porarily as a mechanical plug, and is eventually surrounded by lymph and incorporated with the adjoining tissues, or more commonly separated and throAvn off by sloughing, just as the end of a vessel Avhich has been submitted to the ligature. The artery is permanently closed by the inflammatory proc- ess, at the point at which the middle and inner coats have giA^en Avay. Tor- sion has now been so often successfully applied, even to large vessels, that it cannot, I think, any longer reasonably be doubted that it is an effectual mode of controlling hemorrhage; it is, according to Forster and H. Lee, even more applicable to large vessels than to small. I do not see, hoAvever, that it is at all a better mode than ligation, nor, I think, does it equal the latter in safety; this point Avill be again referred to after I have described the remaining modes 184 INJURIES OF BLOODVESSELS. of controlling hemorrhage, ligation, and acupressure. A modification of the ordinary mode of effecting torsion has been recently suggested by Dr. S. Fleet Speir, of New York, who employs an instrument Avhich he calls the " artery constrictor" (Fig. 82) ; its action somewhat resembles that of the ecraseur, and it is designed to sever the internal and middle coats of the artery, thus allowing their invagination Avithin the external coat, which is corrugated but not divided. The instrument is removed as soon as this has been accomplished. 7. Ligation.—The use of the ligature, though apparently known to the ancients, was aftenvards completely forgotten, so that its introduction into surgery by Pare, in the sixteenth century, has all the merit of an original discovery. It was not, however, until long after Pare's time that the use of the ligature became universal, or indeed general; and the reason for this appears to have been not so much on account of innate obstinacy on the part of surgeons, as because the natural process by which hemorrhage is arrested not being understood, and ligation being consequently practised in a very defective manner, its results Avere correspondingly unsatisfactory. The liga- ture, as now used, is, I believe, Avhen applicable, the very best method of checking arterial hemorrhage. The form and structure of the ligature, and its mode of application to the open ends of vessels, have already been de- scribed (page 98), and need not be again adverted to. When it is necessary to secure an artery in its continuity, the ligature may be most conveniently passed beneath the vessel by means of an aneurismal needle (Fig. 83), or Fig. 83. Aneurismal needle, armed with a ligature. even an ordinary curved needle, or an eyed probe. The mechanism of the ligature in controlling hemorrhage is noAV well understood (thanks to the investigations of Dr. Jones), and the rules for its application thoroughly established. The illustrious John Hunter, even, did not appreciate the mode of action of the ligature, and accordingly we find that in his operations for aneurism he did not draw the noose tight, fearing to weaken the coats of the vessel—thus, as Dr. Jones subsequently showed, defeating the very object sought to be attained. The ligature should be applied with sufficient force to divide, smoothly and evenly, the inner and middle coats of the artery, while the outer coat is constricted Avithin the noose. In tying the larger vessels, the giving Avay of the inner tunics of the artery is sometimes distinctly per- ceptible to the surgeon. The divided inner coats curl upon themselves, and assist the formation of an internal coagulum, while the artery is permanently sealed by the occurrence of inflammatory changes, just as in the natural haemostatic process already described. The noose of the ligature is gradually loosened by ulceration, and finally cuts its way through, or comes out bring- ing with it the constricted portion of the external arterial coat. The clot which is formed on the distal side of the ligature is usually smaller than that on its proximal side; in some cases one or even both clots may be absent, RULES FOR LIGATING WOUNDED ARTERIES. 185 and yet the artery be securely closed, Avhich shoAvs that the formation of a clot, though of great assistance, is not in all cases absolutely essential for the success of the ligature. Dr. B. HoAvard, of Is eAv York, has published some experiments to show that it is not invariably necessary to draAV the ligature so tight as to diA^ide the inner coats, but that mere narroAving of the arterial tube Avith a loose ligature is sufficient sometimes to secure obliteration of the vessel. This (Avhich is a revival of the teaching of Scarpa) Avas indeed knoAvn from the cases of Hunter, who, as Ave have seen, did not tighten his ligatures in operating for aneurism; but I am not aAvare of any clinical facts which show that a loose ligature has any superiority over a tight one, while the universal experience of surgeons is that it is less safe, and that it has the additional disadvantage of not coming away as readily as one Avhich is tightly drawn. The best material for a ligature is, as has been already said, ordinary fine Avhip-cord or silk. Various attempts have been made from time to time to substitute other materials Avhich it has been supposed would produce less irritation and might become encysted or absorbed. Thus Sir Astley Cooper and Dr. Physick made use of animal ligatures, catgut or some similar sub- stance, and this practice has since been occasionally adopted by others.1 Carbolized catgut has been recently extensively employed by Lister and other surgeons, but has not proved itself as certain a preventive of secondary hemorrhage as Avas at first anticipated. Its fault is, it seems to me, that it disappears without dividing the external coat of the artery, and thus does not securely occlude the vessel—in this respect being open to the same objection as acupressure. Metallic ligatures Avere employed in a series of experiments on the loAver animals by Dr. Levert, of Alabama, about forty years ago, and since then have been occasionally used in operations on the human subject. Dr. Levert found that Avire ligatures tightly secured around the arteries of dogs, produced obliteration of the vessels, and that, when both ends of the ligature Avere cut short, the loop became encysted, and remained in the wound an indefinite time Avithout producing irritation. Similar results have been since obtained by Sir J. Y. Simpson and others. Dr. HoAvard, on the other hand, finds that Avire ligatures, if draAvn tight, produce marked inflam- mation and suppuration around the seat of ligation, and therefore recom- mends the use of loose Avire ligatures. Metallic ligature threads have now been used a sufficient number of times in operations on the human subject, by Stone, Gross, Mastin, and other surgeons, to Avarrant the belief that they are safe agents, and may properly be applied in cases in which it is desirable to leaAre the noose in situ and close the wound over it, as in certain operations upon the abdominal cavity ; even in these cases, however, it is probable that the antiseptic short-cut ligature of Prof. Lister would ansAver a still better purpose. Rides for Llgating Wounded Arteries.—In the application of ligatures to wounded arteries, there are certain rules which should be indelibly impressed upon the surgeon's mind : these are— 1. In eases of primary hemorrhage, no operation should be performed upon an artery, unless it is at the moment actually bleeding. In cases of secondary hemorrhage, a different practice should be adopted, as Avill be presently seen; but in dealing with a recently wounded artery, if hemorrhage have ceased, the surgeon as a rule should not interfere, because (1) there is a fair 1 The late Prof. Eve employed ligatures made from the sinew of a deer, and Mr. Barwell recommends those taken from the middle coat of the ox's aorta. Mr. T. Smith, Mr. Croft, and Mr. Pollock have used carbolized ligatures made from the tendon of the kangaroo. 186 INJURIES OF BLOODVESSELS. prospect that the bleeding will not return; (2) the probability of discover- ing the source of hemorrhage is much less, when there is no stream of blood to point the surgeon's way, and (3) the incisions and manipulations which would be necessary in searching for the arterial Avound would be a positive injury A\hich Avould more than counterbalance any benefit that might prob- ably be obtained. In certain exceptional cases, however, the surgeon should not hesitate to apply a ligature even under these circumstances; for instance, if an artery were seen pulsating in a wound, it would be right to tie it even though it did not bleed, for in such a case the ligature could do no harm, and might prevent a great deal of subsequent mischief; again, if a patient were likely, for any reason, to be subjected to unusual risk of secondary hemorrhage, as, for instance, if it were necessary for him to be transported to a distance, or if he were threatened with the invasion of delirium tre- mens, it might be proper to choose the lesser evil, and search for the wounded vessel, that it might be secured by a ligature. Under any circumstances the patient should be constantly Avatched, and if the wound were in an ex- tremity, it would be right to apply a provisional tourniquet, so that, in case of secondary hemorrhage, all unnecessary loss of blood might be prevented. 2. In applying a ligature to a wounded artery, the surgeon should cut down upon it directly at the point from which it bleeds, and secure the vessel in the wound. This rule and the next were clearly laid down by John Bell, and most powerfully enforced by Guthrie, and yet, it is to be feared, are, even at the present day, too often practically ignored by operators. There are two principal reasons why this rule should be considered invariable: (1) be- cause it is often impossible to tell what vessel is Avounded, until it is exposed in the wound itself; and (2) because, even if this point could be determined, ligature of the main trunk above the wound would, in a vast number if not in the majority of cases, fail to arrest the bleeding. Thus it has happened that the superficial femoral artery has been tied for arterial hemorrhage from a wound of the thigh, and, bleeding continuing or recurring, it has been subsequently discovered that it was a branch of the profunda that was wounded; or the subclavian has been tied for supposed Avound of the axil- lary artery, when the hemorrhage really came from the long thoracic. Again, if the main trunk be tied, the collateral circulation being quickly established, secondary hemorrhage is extremely apt to occur from the distal side of the arterial wound; or if there be collateral branches given off be- tween the point of ligation and the wound, bleeding may occur even from the proximal side of the latter, when, if a second ligature be applied in the wound, the double obstruction will (at least in the lower extremity) almost invariably cause gangrene of the limb. Still further, deligation of the main trunk exposes the patient sometimes to additional danger; thus, Liston having tied the external iliac for wound of a small branch of the common femoral, the patient died of peritonitis, a cause of death, it will be observed, which was directly connected with the operation, and entirely independent of the original injury. For these reasons, then, viz., that by this method only can the actual source of hemorrhage be determined; that thus only can probable security be afforded against secondary bleeding; that if sec- ondary hemorrhage should occur, this plan does not put out of the question further treatment; and that this plan does not entail any additional risk upon the patient, the rule should be invariable, that, whenever practicable, a bleeding artery should be directly cut down upon, and tied where it bleeds. In doing this, the surgeon should usually take the original wound as the guide for his incisions; should, however, the wound be very deep, it may be more convenient to reach the source of hemorrhage by making a counter-incision in the course of the vessels, cutting upon the end of a probe introduced to RULES FOR LIGATING WOUNDED ARTERIES. 187 the bottom of the Avound. Hemorrhage during the operation should be guarded against by the use of a tourniquet, where this instrument is appli- cable, or by pressure made by an assistant on the main trunk; in situations where this is impracticable, the surgeon should introduce one or tAvo fingers into the Avound, so as to compress the bleeding vessel Avhile making the neces- sary incisions. This rule of tying an artery where it bleeds holds good for both primary and secondary hemorrhage; no matter Avhat the condition of the Avound may be, as long as there is a wound, it should be freely enlarged, and the vessel secured at the point whence the blood issues. This is often a difficult and tedious proceeding, particularly in Avounds that are SAVollen and granulating, but it is a proceeding that the surgeon should consider impera- tive when the occasion arises; and it is surely very reprehensible for any operator, in view of the vast accumulation of recorded experience on the subject from both civil and military practice, to persist in cases of arterial hemorrhage in tying the main trunk of a limb, merely because it is easier than to tie the vessel in the wound, or, still worse, because it enables him to perform what is considered a more important operation. 3. A third rule, and one closely connected Avith the preceding, is that two ligatures should be applied, one to each end of the.artery if it be completely di- vided, and one on each side of the wound, if the latter have not completely severed the coats of the vessel. The reason for this rule is obvious: in many parts of the body the arterial anastomosis is so free that a ligature to the proximal side alone will not even temporarily arrest the bleeding, the current of blood being immediately carried around to the distal extremity; in other cases, though a proximal ligature may serve to check the hemorrhage for a short time, as soon as the collateral circulation is fully established, bleeding will again begin from the distal end of the vessel. If, as sometimes happens, the distal extremity of the vessel be so retracted and surrounded by the adjoin- ing tissues, that it cannot be found even after long and careful search, the surgeon may plug the Avound with a graduated compress, the apex of which is imbued Avith the solution of the persulphate of iron, and good results may be hoped for from this proceeding; but, whenever it is practicable, the distal as well as the proximal end of the vessel should unquestionably be tied. If a large arterial branch be wounded immediately below its origin, it is safer to regard the injury as one of the main trunk, and apply ligatures immediately above and below the origin of the branch, as Avell as on the distal side of the Avound in the latter;1 so, on the other hand, if a large branch be given off immediately above or below an arterial Avound, it is proper, after tying the injured vessel in the usual Avay, to apply an additional ligature to the branch. If this should not be done, there would be risk of secondary hemorrhage from deficiency of the internal coagulum, Avhich, as has been mentioned, extends only as far as the nearest anastomosing vessel. There are, it is true, a certain number of cases on record, in which the proximal ligature alone, or even the ligature of the main trunk at a distance from the Avound, has arrested hemorrhage, which has not recurred; but such cases are quite exceptional, and in no degree invalidate the force of this and the preceding rule of treatment, Avhich might Avell be called golden rules. 4. HoAvever desirable it may be to tie a bleeding vessel in the wound, in certain situations it is impossible to do so ; thus, in the case of Avounds which penetrate the floor of the mouth, dividing branches of the external carotid, or in cases of hemorrhage into the mouth from the internal carotid, or Avithin the pelvis from branches of the internal iliac, it is manifestly impossible to 1 Dr. T. B. Wilkerson, of North Carolina, has recently reported a case in which this plan was successfully carried out in a case of wound of the profunda femoris just below its origin. 188 INJURIES OF BLOODVESSELS. reach the seat of the wound, and the surgeon's only resource is to tie the main trunk. Again, in cases of secondary hemorrhage from Avounds of the palmar arches, it may be necessary to deviate from the ordinary rule, and tie either the brachial, or the radial and ulnar arteries.1 Application of Ligatures in the Continuity of Arteries.—In applying a ligature in the continuity of an artery, whether at the seat of Avound or at a higher point, or in the Hunterian operation for aneurism, the surgeon is guided in making his incisions by the lines Avhich he knows to correspond with the general course of the vessel. If there be a wound, that should, of course, be the starting-point for the incision, but in other cases the operator must rely upon the pulsation of the vessel if that can be felt, and if not, upon his general anatomical knowledge as to the course of the artery. It is Avell, especially when the artery lies deeply, to make the incision, as recommended by Hargrave and Skey, somewhat obliquely to the course of the vessel, Avhich can thus be more readily found than if the incision Avere directly in its line. The skin and superficial fascia may be divided by the first stroke of the knife, but afterwards the surgeon should proceed Avith great caution, taking up each successive layer of tissue with delicate forceps, and making a slight notch for the introduction of a grooved director (Fig. 84), upon Avhich the layer is then Pig. 84. Grooved director. carefully divided from below upwards. When the sheath of the vessel is reached, the surgeon picks it up in the same way with forceps (Fig. 85, A), and makes an opening just sufficient to alloAV the passage of the needle which bears the ligature. This is then delicately introduced betAveen the artery and the vein, and very cautiously brought around the former so as to include nothing except the vessel itself. The point of the needle, which must be well ground down and rounded, is then teazed through the opening in the sheath (Fig. 85, B), a process which may be facilitated by a gentle touch with the knife, one end of the ligature drawn out, and the other draAvn backwards with the needle, Avhich must be withdrawn as gently as it was introduced. The operation is completed by tying the artery firmly and tightly Avith the reef-knot (Fig. 85, C), and bringing both ends of the ligature out of the wound, Avhich is closed with sutures and lightly dressed. If any small arterial branch should be cut during the operation, it should be twisted or tied, taking care to secure both ends ; the chief precautions to be observed in passing the needle are not to Avound the vein, and not to include the latter or any portion of it, or a nerve, in the noose of the ligature. Entanglement of the vein would be very apt to cause phlebitis or gangrene, while ligature of the nerve would at least give unnecessary pain, and might possibly expose the patient to the risk of tetanus. It would likewise cause paralysis of the parts below, which in some situations might be productive of very grave consequences. If, in passing the needle, there should be a gush of blood, more in quantity than could be accounted for by the separation of the sheath, making it probable that the vein had been punctured, the sur- 1 Ogston, of Aberdeen, has successfully tied the deep palmar arch by separating the abductor indicis from the radial side of the metacarpal bone of the index finger, through a dorsal incision. ACUPRESSURE. 189 A. Opening the sheath. B. Drawing ligature round the artery. C. Tying artery. (Bryant.) geon should either suspend the operation and apply pressure, or should extend his incision and reapply the ligature at a higher point. To allow a ligature to remain Avhich passed partially through a vein, Avould be equiva- lent to forming a seton through that vessel, and Avould certainly expose the patient to the risks of phlebitis, thrombosis, gangrene, and, possibly Fig. 85. embolism and secondary pyaemia. It is almost needless to say that the surgeon should be careful not to miss the artery, and tie instead a nerve or even a portion of con- densed fascia, an accident which has occasionally happened in the hands of the most skilful operators. If the artery be very superficial, the surgeon should be correspond- ingly careful not to go too deeply in his first incision, Avhich some operators, indeed, prefer to make by pinching up a fold of skin, trans- fixing, and cutting from within out- wards. In dividing the deeper structures, the side of the knife should be used rather than the point, and the edge should always be directed away from the artery. After tying an artery in its con- tinuity, the limb below should be kept warm until the collateral circulation is fully established; the ligature will usually drop betAveen the first and third Aveeks, according to the size of the vessel; should it remain too long, gentle traction and twisting may be practised, as in the case of ordinary ligatures on the cut ends of vessels. 8. Acupressure.—Acupressure, or the means of controlling arterial hem- orrhage by pressure Avith a needle or pin, was first introduced to the notice of the profession by Sir J. Y. Simpson, in December, 1859. It has since then been employed more or less extensively by a great number of surgeons, and, after having been alternately extolled and condemned, and having ex- cited in the city of its birth one of the most virulent professional controversies of modern times, has now gradually assumed its proper place as one of the modes, and, under certain circumstances, one of the best modes by which arterial bleeding can be arrested. Acupressure may be practised in several different ways, of which Prof. Pirrie and Dr. Keith, who have published a monograph on the subject, enumerate seven; though for practical purposes the number might be reduced to four. In the first two of Pirrie's and Keith's methods, the vessel is compressed between a pin or needle and the soft tissues of the part; in the third, fourth, and sixth, between a pin or needle and a loop of fine flexible Avire ; in the fifth (or Aberdeen method), the pressure is made by passing a pin or needle beneath the artery, which is then tAvisted upon itself by a quarter or half rotation of the pin ; and in the seventh, the vessel is compressed betAveen the pin and any bony prominence Avhich may be conveniently situated. The first method is thus described by Simpson: " It consists in passing a long needle twice through the flaps or sides of a wound, so as to cross over and compress the mouth of the bleeding artery or its tube, just in the same Avay as in fastening a flower in the lapel of our coat, 190 INJURIES OF BLOODVESSELS. we cross over and compress the stalk of it with the pin Avhich fixes it, and with this view pass the pin twice through the lapel.....When passing the needle in this method, the surgeon usually places the point of his left forefinger or of his thumb upon the mouth of the bleeding vessel, and with his right hand he introduces the needle from the cutaneous surface, and passes it right through the whole thickness of the flap till its point projects for a couple of lines or so from the surface of the Avound, a little to the right side of the tube of the vessel. Then, by forcibly inclining the head of the needle towards his right, he brings the projecting portion of its point firmly down upon the site of the vessel, and after seeing that it thus quite shuts the artery, he makes it re-enter the flap as near as possible to the left side of the vessel, and pushes on the needle through the flesh till its point comes out again at the cutaneous surface. In this mode Ave use the cutaneous Avails and com- ponent substance of the flap as a resisting medium, against which Ave com- press and close the arterial tube." The exact mechanism of the first method can be readily understood from the accompanying Avood-cuts (Figs. 86, 87). Fig. 86. Fig. 87. Acupressure; first method; raw surface. Acupressure; first method ; cutaneous surface. (Erichsen.) (Erichsen.) In the second method, " a common short sewing-needle, threaded with a short piece of iron wire, for the purpose of afterwards retracting and removing it, is dipped down into the soft textures a little to one side of the vessel, then raised up and bridged over the artery, and then finally dipped down again and thrust into the soft tissues on the other side of the vessel" (Fig. 88). In Fig. 88. Fig. 89. Acupressure; second method. (Erichsen.) Acupressure ; third method. (Erichsen.) the third method (Fig. 89), " the point of the needle is entered a feAv lines to one side of the vessel, then passed under or below it, and afterwards pushed on, so that the point again emerges a few lines beyond the vessel. The noose or duplicature of Avire is next thrown over the point of the needle; then, after being carried across the mouth or site of the vessel, and passed around the eye end of the needle, it is pulled sufficiently tight to close the vessel; and lastly, it is fixed by making it turn by a half twist or twist around the' stem of the needle." The fourth method is identical with the third, except that a long pin is substituted for the needle, the head of the pin remaining outside of the wound, Avhile the sixth differs from the fourth merely in the way of ACUPRESSURE. 191 fixing the Avire, the ends of Avhich are, in this method, " crossed behind the stem of the pin so as to embrace the bleeding mouth betAveen them, . . pulled sufficiently tight to arrest the hemorrhage, thereafter brought forward by the sides of the pin—one on each side—and finally fixed by a half tAvist in front of and close doAvn upon the pin " (Pirrie and Keith, Acupressure, p. 44). The fifth, or " Aberdeen method," consists in passing a pin or needle through the soft tissues close to the artery, giving the instrument a quarter or a half rotation, by which the vessel is twisted upon itself, and then fixing the pin or needle by thrusting its point deeply into the tissues beyond (Fig. 90). This method seems to me the best and most generally applicable; additional Fig. 90. security may be given by superadding the use of a wire loop, as in the pre- ceding methods. The .seventh and last method consists, according to Prof. Pirrie, "in passing a long needle through the cutaneous surface, pretty deep into the soft parts, at some distance from the Aressel to be acu pressed—mak- ing it emerge near the Vessel--bridging Acupressure; fifth method. (Erichsen.) over and compressing the artery, dip- ping the needle into the soft parts on the opposite side of the vessel, and bringing out the point of the needle a second time through the common in- tegument. In this method the soft parts are twice transfixed, and the artery is compressed betAveen the bone and the middle portion of the needle in front of the integument, between the first point of exit and the second point of entrance." Mode of Repair of Arteries after Acupressure.—This subject has recently been investigated by several writers, the results of Avhose observations may be stated as folloAvs: There is no direct adhesion of the apposed Avails of the vessel, as believed by Dr. HeAvson and others, but, on the contrary, the sole process of permanent repair takes place at the cut end of the vessel; the end subserved by the needle is merely to remove the pressure of the blood cur- rent until this repair is accomplished. If, however, the needle be allowed to remain so long as to destroy the structure of the lining membrane of the ves- sel, then closure takes place at the line of this destruction, just as after the use of a ligature. The actual repair Avhich goes on at the cut end of the vessel is due partly to changes in the Avails of the vessel itself, and partly to changes in the contained blood, in fact to the same changes Avhich Ave have already studied as taking place in the process of natural hsemostasis. A clot forms above the needle, and rests upon without adhering to the contracted portion of the artery below. The time during which the acupressure needle should be allowed to remain varies from tAventy-four to sixty hours, accord- ing to the size of the vessel. If it be removed before the repair of the cut end of the vessel is complete, there Avill be risk of dislodgement of the clot (Avhich is not adherent), and of hemorrhage; Avhile if it remain too long, it will excite suppuration in its track, just as any other foreign body. Modified Acupressure.—Under the name of "artery compressor," Mr. Porter, of Dublin, has described an apparatus for the temporary occlusion of an artery in cases of aneurism. It somewhat resembles Sir P. Crampton's "prcsse art ere," and consists essentially of a bent probe and a wire, betwreen which the vessel is compressed, and which are so arranged as to be with- drawn at Avill. Dr. L'Estrange's apparatus for the same purpose consists of a double aneurismal needle, the blades of A\Thich close like the jaAvs of a lithotrite. Instruments of various kinds for the temporary occlusion of 192 INJURIES OF BLOODVESSELS. arteries have likeAvise been devised by Desehamps, Desault, Assalini, Du- rest, Richardson, of Dublin, and others. Filopressure, or compression of a vessel by means of a wire, has been practised by various surgeons, among whom may be specially mentioned Mr. Dix, Dr. Pollock, and Prof. Langenbeck, and has been described as a modification of acupressure. It is, hoAvever, as shoAvn by Simpson, an old mode of treatment, and, I may add, appears to be inferior to both acupress- ure and the ligature. It is practised by surrounding a vessel Avith a loop of wire, the ends of Avhich are brought out separately through the flap or side of the Avound, and twisted over a compress Avhich serves to protect the skin. Uncipressure, or compression by means of a hook, is recommended by Vanzetti, of Padua, in cases of secondary hemorrhage from Avounds of the palmar arch, etc. Aerteriversion is a name employed by Prof. Weber, of Cleveland, Ohio, for a mode of arresting hemorrhage suggested by himself, Avhich consists in everting the cut end of an artery so as to invaginate the vessel Avithin its own extremity, and then fixing the parts by the introduction of a needle point or delicate metallic peg. Comparison between Acupressure, Torsion, and Ligature.—From what has been said Avith regard to the mechanism by Avhich each of these methods acts, and the pathological changes to which each gives rise, it will appear, I think, that the ligature is to be preferred, Avhenever the circumstances of the case allow the surgeon to choose between them. The objections urged against the ligature are, that (1) it acts as a seton, causing suppuration along its track; (2) it confines a minute slough in the Avound until it comes away itself; and (3) it may become prematurely detached and allow sec- ondary hemorrhage. These objections, though theoretically just, seem to me to be practically of little or no value, for (1) healing without any sup- puration is almost never met with (at least in this climate), in wounds of the size of those in Avhich ligatures are used, and no trustworthy evidence has yet been adduced to show that the use of ligatures increases the amount of suppuration; (2) the size of the slough embraced by the noose of the liga- ture, in cases that do well, is so minute as to be really not worth notice, and in cases where there is extensive sloughing, there is no reason to attribute that sloughing to the use of ligatures; and (3) though hemorrhage may occur upon the detachment of a ligature, it is (unless violence have been used in removing the ligature) due to a defect in the natural process of ha> mostasis, which, as we shall presently see, is quite as likely to occur with either torsion or acupressure as with the ligature. Torsion closes arteries just as the ligature does, and there is the same risk of hemorrhage on the separa- tion of the twisted extremity, if it has been twisted enough to impair its vitality, as on detachment of the ligature; while if it have been insufficiently twisted, there is the additional risk of the extremity of the vessel becoming untwisted, and thus alloAving bleeding at an earlier period; if, on the other hand, the end be twisted off, the vessel is in the same condition as if it had been tied, and the ligature immediately removed. If the acupressure pin be removed before it produces suppuration, the sole protection against hem- orrhage is an incomplete union at the cut end of the vessel, and an unacl- herent clot above the point of constriction; if it be allowed to remain long enough to cause inflammatory changes in the arterial coats at the point of constriction, it defeats its own object, and acts as a ligature wdiich has been tied and subsequently removed. That both acupressure and torsion are able to control hemorrhage from even large arteries is abundantly proved ; that either does so any better than the ligature is, it seems to me, not proved • COLLATERAL CIRCULATION. 193 while to give the same security that is afforded by the ligature, either must be pushed so far as to be open to the identical objection which is urged against the ligature, viz., that of introducing a foreign body into the wound, and, by so doing, impeding union by adhesion. I am not aware of any sufficiently extended statistics of torsion having yet been published, to warrant a numerical comparison of the results of this method, Avith those of the ligature. The reports of Messrs. Syme, Hum- phry, Bryant, Forster, and Hill, have certainly been favorable, yet the ex- perience of other surgeons who are equally eminent has been opposed to the general employment of torsion; and it is to be observed that Mr. Syme only recommended it in connection with the antiseptic method of Prof. Lister, while the whole number of cases in which it has been used in the human subject is as yet comparatively limited. As regards the statistics of acupress- ure, the most favorable series of cases yet published is that of Prof. Pirrie and Dr. Keith, and yet even this, when analyzed, shoAvs at least no better results than are obtained by the use of the ligature. Thus, twelve amputa- tions reported by Prof. Pirrie gave three deaths, and yet in all but one case the operation was done for disease, and eight of the twelve patients were children. The theoretical assumption that acupressure guards against the common causes of death after operation, is not borne out by fact—erysipelas, sloughing, and pysemia having occurred even in the very favorable experience of Messrs. Pirrie and Keith; while union by adhesion, except in Aberdeen, has been quite as rare Avith acupressure as Avith the ligature, and even in the few Aberdeen cases in which it is stated that not a single drop of pus was seen during the cure, it does not appear that the period of convalescence was any shorter than it is constantly found to be, when ligatures are used. What, then, are the real advantages of acupressure ? Simply and solely, I believe, that it is more easily and quickly applied than the ligature, and that in its use the surgeon needs no assistant: hence, in cases of emergency, especially of secondary hemorrhage, it is often the surgeon's most available resource, and as such its modes of employment should be familiar to every practitioner. Torsion, on the other hand, is confessed even by its advocates to be a more tedious and difficult proceeding than the application of a liga- ture, and, therefore, seems to me, although possibly safer than acupressure, even less desirable for general use. Collateral Circulation.—In whatever way an arterial trunk be occluded, whether by disease or by surgical interference, the vitality of the parts be- Ioav would be impaired but for the establishment of the collateral circulation. The immediate effect of a ligature, or other means of arterial occlusion, is to throw the force of the circulation into new channels, and hence, though the limb below the site of ligature is for a time less full of blood, the bal- ance is soon restored, and after a few hours the activity of the capillary circulation is so much increased, that the part is not unfrequently both redder and Avarmer than in its natural state. The action of the capillaries is, however, but temporary, the true collateral circulation being established through the inosculation of anastomosing branches, derived sometimes from the affected vessel itself, but more frequently from neighboring trunks on the same side of the body. Thus, if the superficial femoral be tied, the collateral circulation is established through the branches of the profunda, Avhile after ligature of the common carotid, it is principally through the infe- rior thyroid and vertebral arteries that the circulation is maintained. Even after occlusion of the abdominal aorta, the collateral circulation is estab- lished in quite a short time, pulsation in the femoral artery having returned in less than ten hours, in the case of ligature of the aorta, reported by Mr. 13 194 INJURIES OF BLOODVESSELS. Stokes. In old persons, or in those whose arterial system is affected by atheromatous or fatty degeneration, the collateral circulation is less readily established and less perfectly maintained than in the young and healthy, the reason of this obviously being that the arteries of the latter are more elastic, and dilate with greater facility to accommodate the increased Aoav of blood through them. On the other hand, in cases of chronic aneurism, the obstruc- tion has sometimes gradually caused the establishment of the collateral cir- culation before ligation is practised, so that under these circumstances surgi- cal interference may be even less resented than when employed for wounds of healthy arteries. This statement would appear to be contradicted by the well-knoAvn fact that gangrene is more frequent after ligature for aneurism than after that for traumatic causes, but, as will be seen hereafter, the gan- grene in the former case is usually from venous, not from arterial obstruction. Not only does anastomosis take place betAveen collateral branches, but an indirect communication is sometimes re-established betAveen the divided ends of the obliterated trunk. Finally the fibrous cord, Avhich connects the divided extremities of the artery, occasionally becomes itself pervious, allowing a narrow but direct channel of communication betAveen the proximal and distal ends of the vessel. The establishment of the collateral circulation is sometimes attended with pain, apparently from pressure of the enlarging vessels upon contiguous nerves ; this is most marked in cases of aneurism, in which additional press- ure is caused by the coagulation of the blood contained in the sac. Secondary Hemorrhage.—The most frequent accident after the use of the ligature or other artificial means of arterial occlusion, is unquestionably secondary hemorrhage. This may arise from a variety of causes, some of which are local and some constitutional. Among the local causes may be mentioned, (1) imperfect application of the occluding means; as when the vessel has been tied so near its cut extremity that the noose slips off prema- turely, when the knot has been carelessly made, when a large amount of ex- traneous tissue has been included in the noose of the ligature, so that this becomes loosened before the vessel is healed, or (which is especially apt to happen with acupressure) when the vessel has been compressed only enough to check bleeding while the force of the heart is diminished by shock or by the use of an anaesthetic, but not enough to occlude the artery Avhen reaction has occurred; (2) the giving off of a large collateral branch either imme- diately above or immediately below the point of occlusion, a circumstance which, though not necessarily a cause of secondary hemorrhage, is very apt to be so, from limiting the extent of the internal coagulum in the proximal, and more especially in the distal end of the vessel; and (3) a diseased con- dition of the coats of the artery itself; this may cause hemorrhage directly, either by allowing the ligature to ulcerate through the vessel prematurely, or by allowing rupture to take place above the site of the ligature, or more rarely indirectly, by giving rise to the formation, above the ligature, of an aneurism which subsequently bursts and permits the escape of blood. In other cases secondary, or rather consecutive, hemorrhage may occur from vessels which escape the notice of the surgeon during an operation, or (in case of ligation in the continuity) from small anastomosing branches, which, though wounded, do not begin to bleed until enlarged by the establishment of the collateral circulation. The constitutional causes of secondary hemor- rhage may be said to be any conditions of system which interfere Avith the natural processes which we have seen to be essential for the closure of wounded arteries. Thus, a Avant of coagulability in the blood itself, the " hemorrhagic diathesis," visceral disease (especially of the liver), an unusually severe attack SECONDARY HEMORRHAGE. 195 of ordinary traumatic or inflammatory fever, certain affections which are apt to occur after operations, especially erysipelas, pysemia, hospital gangrene, or even ordinary sloughing, may all be considered as causes of secondary hemor- rhage. In the case of pyiemia, the hemorrhage often consists of capillary oozing—the parenchymatous hemorrhage of Stromeyer and Lidell—and is apparently due to mechanical obstruction, from thrombosis of the venous trunks of the part. J. H. Porter has described an intermittent form of hemorrhage, which he thinks is due to malarial influence. Occasionally a single secondary hemorrhage may prove fatal, but more usually there are a number of successive gushes, of which the first may be comparatively slight, the patient being gradually reduced to a state "of extreme anaemia, and dying rather from repeated losses of blood, than from the quan- tity lost at any one time. When hemorrhage occurs after ligature of an artery in its continuity, it is almost invariably from the distal extremity of the vessel. The reasons for this appear to be (1) that, as already remarked, the distal clot is smaller and less firm than the proximal, and (2) that, from the constriction of the ligature interfering more Avith its vasa vasorum, the distal end of the vessel is more exposed to sloughing than the proximal. Secondary hemorrhage may occur at any time after the application of a ligature, though it is most common about the period of separation of the lat- ter ; Avhen it occurs earlier, it is usually owing to some defect in the mode of occlusion, to disease of the arterial tunics, or to some of the systemic condi- tions which have been referred to. Secondary hemorrhage is occasionally met with, weeks or months after the separation of the ligature; in these cases it is usually due to the occurrence of sloughing, or to the dissolution and reab- sorption, under the influence of constitutional causes, of the coagulum and inflammatory adhesions by which closure of the vessel was effected. Treatment of Secondary Hemorrhage.—The constitutional treatment of secondary hemorrhage does not differ from that already described as appro- priate to the primary affection; the most valuable medicines, in this condition, are, I think, opium and ergot, which may be freely administered; special care should be taken to prevent any straining in defecation or violent cough- ing ; quinia should be given if there is any malarial complication. The local treatment of secondary hemorrhage varies according as the bleeding proceeds from a stump, or from an artery ligated in its continuity. It should be pre- mised that the rule not to operate on an artery which has stopped bleeding, does not apply in either of these cases. As Mr. Erichsen puts it, the surgeon in these cases may after the first, and must after the second bleeding adopt determined measures to prevent a return of the hemorrhage. 1. Secondary Hemorrhage from a Stump may, if in only moderate amount, be often checked by the judicious application of pressure, position, and cold. Should, however, these means fail, or should the bleeding be so free as to render it probable that it comes from a large vessel, the proper course to be pursued depends upon the condition of the stump itself; if the process of cicatrization in the latter be not far advanced, or, under any circumstances, if its cavity appear to be stuffed and distended Avith clots, the surgeon should without hesitation break up the adhesions, and search for the bleeding artery on the face of the stump itself, applying a fresh ligature to whatever vessel is found to be in fault. If, on the other hand, the stump be nearly healed, and do not appear to be stuffed with clots, it is proper to attempt to secure the bleeding vessel, or the artery of which it is a branch, immediately above the stump: this may be done by cutting down and applying a ligature, or, pref- erably, by acupressiug the vessel by Simpson's first method; this is one of the exceptional cases in which acupressure seems to be particularly applica- ble, and there would be every reason to hope, under such circumstances, that 196 INJURIES OF BLOODVESSELS. the temporary occlusion of the artery by the pin Avould be sufficient to allow the completion of the natural process of repair at the cut extremity of the vessel. Ligation of the main artery of a limb, for hemorrhage from a stump, is in most situations a bad operation, and should only be resorted to Avhen prolonged search has failed to find the artery in the reopened Avound (an event which may occur from the sloughing and disorganized condition of the part), and when the vessel cannot be secured immediately above the stump. The reasons for this are, that in many cases the operation would fail to check the hemorrhage, that it Avould expose the patient to great risk of gangrene, and that it would superadd an operation, in itself serious, to the dangers Avhich already existed: hence, in some situations, even re-am- putation might be a safer and better procedure than ligation of the main trunk. In some positions, however, as after amputation at the shoulder- joint, or high up in the thigh, ligation of the main trunk may be the only resource available, and in such cases the vessels to be secured are the axil- lary for the upper, and the external iliac for the lower extremity. 2. Secondary Hemorrhage from an Artery previously Ligated in its Con- tinuity is an accident of the gravest nature. In its treatment the surgeon may properly first try the effect of pressure, adjusting accurately to the bleed- ing point a graduated compress, and keeping it in position with a ring tour- niquet, or arterial compressor. In the case of some arteries, as the subclavian or iliacs, and generally in the case of vessels situated about the trunk, no other means are applicable, and the use of pressure should then be persevered in, though it must often prove ineffective. In the case of the upper extremity, if pressure fail, the surgeon should treat the vessel as one primarily wounded, cutting down and tying the vessel above and below the source of hemorrhage; if hemorrhage again recur, or if the bleeding vessel cannot be found or se- cured in the wound, a ligature may be applied with fair hope of success to the main artery at a higher point. Should this fail, amputation at the highest point of ligature should be resorted to. In the lower ex- tremity, the case is somewhat different. If the bleeding be from the femoral artery, an attempt may be made to apply fresh ligatures in the wound, above and below the source of hemorrhage, and this course will occasionally suc- ceed, as in a case under my care at the University Hospital; though, as shown by Mr. Cripps's statistics, carefully applied pressure is often the most promising remedy in these cases. The tibial vessels lie so deeply that it would be almost hopeless to attempt a second ligation in case of secondary hemorrhage after tying one of them, though it might perhaps be tried, if the condition of the patient warranted the effort. Ligation of the main trunk under these circumstances in the lower extremity would almost inevitably cause gangrene, and should not be attempted. Amputation at or above the site of ligature would be a safer operation, and should, I think, in this sit- uation, undoubtedly be preferred. Gangrene after Arterial Occlusion, whether from disease or from surgical interference, is due to a deficiency in the collateral circulation; it is most often met with in the lower extremity, and in those whose arteries from age or other cause are in an inelastic condition, whether accompanied or not by positive degeneration. Among the exciting causes may be mentioned loss of blood (as from secondary hemorrhage), venous congestion (hence it is more frequent after ligations for aneurism than after those for wounds), erysipelas, the application of cold or of excessive heat, or the use of even moderately tight bandages. It is usually manifested from the third to the tenth day, and is commonly, on account of venous implication, of the moist variety; occasionally, hoAvever, it assumes the character of dry gangrene or TRAUMATIC ANEURISM. 197 mummification. These conditions have been already described, in discuss- ing the subjects of inflammation and of mortification as a cause for amputa- tion, and need not therefore be again referred to. Much may be done to prevent the occurrence of gangrene after ligation of an artery, by wrapping the limb in cotton-wool, so as to keep up its temperature and protect it from ex- ternal injury, and by placing hot bottles or hot bricks under the bedclothes, though not in contact with the limb. Should there be much venous conges- tion, gentle but methodical friction from below upwards might be practised, so as to assist in emptying the superficial veins. Should gangrene actually occur, amputation must be practised through the site of arterial occlusion, unless when, after injury of the femoral artery, the gangrene is limited to the foot, when, as pointed out by Guthrie, amputation below the knee will usually be sufficient. (See page 92.) Remote Consequences of Arterial Occlusion.—Even when everything goes well after the ligation of a main artery, the limb is sometimes left for a long while numb and weak. In the case of the lower extremity, it is often (ede- matous, and apt to become inflamed from apparently slight causes. In such cases the limb should be Avarmly clad, and supported with an elastic band- age, while care should be taken to avoid undue pressure, which might give rise to ulceration, or even gangrene. Traumatic Aneurism.—Under this name are included several distinct affections: 1. The Diffused Traumatic Aneurism (so called), is, as Prof. Gross justly remarks, no aneurism at all, but merely a collection of arterial blood in the tissues of a part, differing from an ordinary case of wounded artery simply by there being no communication with the external air. This condition of affairs may result either from an originally subcutaneous lesion of an artery, or from the external wound healing before the arterial aperture itself is closed. It not unfrequently is a consequence of gunshot injury, the arterial Avail being bruised though not severed by the contact of the ball, and giving way after an interval of perhaps several weeks,, during which the external wound may have completely healed. The diagnosis of this condition can usually be made with tolerable facility; there is an oblong, someAvhat pyriform swelling, more or less elastic and fluctuating, and, if the arterial wound be tolerably free, accom- panied by a distinct impulse, and often by a marked thrill and aneurismal bruit. The limb beloAV is oedematous, and the pulse very feeble or completely absent. As the disease advances, the skin covering the tumor becomes tense, thin, and discolored, and unless efficient treatment be adopted, the limb may become gangrenous, though more commonly the tumor will suppurate and open externally, alloAving profuse secondary hemorrhage to occur. The treat- ment is the same as for an ordinary case of Avounded artery. The circulation being temporarily controlled by pressure applied as already directed, the sur- geon lays open the tumor, turns out the clots, and applies ligatures to both ends of the affected vessel; this is most conveniently done by introducing a director into the mouth of the artery, dissecting it up for about an inch, and passing a ligature around it Avith an ordinary aneurismal needle. If the arte- rial wound be in such a situation that effective pressure cannot be made above it during the operation, the surgeon must proceed more cautiously, in the way recommended by Prof. Syme; in this case the incision should be at first merely large enough to admit one or tAvo fingers of the left hand, which may plug the wound as they are introduced, and thus prevent hemorrhage, until, guided by feeling the current of warm arterial blood, they reach the aperture in the vessel; having thus control of the bleeding orifice, the surgeon may noAv enlarge his incision, turn out the clots, and still keeping up pressure with 198 INJURIES OF BLOODVESSELS. the left hand, endeavor to pass a ligature Avith the right; in doing this, a mounted needle, eyed at the point (Fig. 68), or a short curved needle, held with suitable forceps, may prove of more service than the ordinary aneurismal needle. In some instances, especially in military practice, the safety of the patient will be more promoted by amputation, than by any attempt to secure the vessel by ligation; particularly is this the case when the brachial artery is wounded near its origin, the aneurismal tumor encroaching upon the axilla; under such circumstances I believe amputation at the shoulder-joint to be often the best mode of treatment. 2. There is another form of traumatic aneurism, of which the pathology is the same as of that which has been described, but in Avhich the extravasation is less extensive, and in which an adventitious sac has been formed by the condensation of the surrounding areolar tissue. This, which is, clinically speaking, a Circumscribed Traumatic Aneurism, commonly results from punctured wounds, and is rarely met with except in the course of the smaller arteries ; it may be treated by laying open the sac and tying the vessel above and beloAV; or, if in a position where this operation would be undesirable, as in the palm of the hand, the main trunk may be ligated Avith the prospect of a favorable result. When met with in connection with a large artery, a proxi- mal ligature may be applied as close as possible to the sac, without opening the latter. 3. Another form of circumscribed traumatic aneurism is that which has been called " Hernial," and which results from the protrusion of the inner coats of the vessel through a wound or laceration of the outer tunic. This form of aneurism is extremely rare, its existence indeed being doubted by many writers. 4. The True Circumscribed Traumatic Aneurism results from a punctured wound of an artery (generally a large one), which has healed, the cicatrix afterwards yielding, and a true sac being thus formed from the external coat of the vessel and its sheath. The treatment consists in compression or in ligation of the artery at as short a distance as possible above the sac. Should, hoAvever (in any of these forms of circumscribed traumatic aneurism), the sac burst, allowing the aneurism to become diffused, or should suppuration or gangrene appear imminent, the proper course would be to lay open the part freely, and apply ligatures above and below, as in the case of the so-called diffused traumatic aneurism already described. Arterio-venous Wounds.—Occasionally an artery and its contiguous vein are simultaneously Avounded, the external Avound healing, but a communica- tion remaining between the two vessels. This accident most frequently fol- lows upon punctures, as of the brachial artery in bleeding, though it may also result from a gunshot wound, as in a case to Avhich I have already referred. The preternatural communication between an artery and vein may assume two distinct forms, knoAvn respectively as aneurismal varix and vari- cose aneurism. Aneurismal Varix consists in a direct communication betAveen an artery and a vein, part of the arterial blood finding its Avay into the vein, which is dilated and somewhat tortuous; the symptoms are the presence of a small, somewhat oblong, compressible tumor, with a jarring sensation communicated to the hand, and a buzzing or rasping sound, rather than the ordinary aneu- rismal whirr. The sound is more distinct above than below the tumor, and the limb is usually somewhat weaker and colder than natural. The condition is not progressive, and requires, as a rule, no treatment beyond the support of an elastic bandage: should anything further be needed, the artery must be tied above and below its aperture. LIGATION OF INNOMINATE ARTERY. 199 Varicose Aneurism.—In this form of arterio-venous aneurism, there is a distinct sac, Avhich communicates also Avith a vein, Avhich is itself always varicose.1*^ It differs from an aneurismal varix, in that the arterio-venous communication is indirect, through an interposed aneurismal sac. Its symp- toms are a combination of those of aneurismal varix and of ordinary trau- matic aneurism : the tumor gradually enlarges, and becomes more solid from the deposition of fibrin, there is a distinct impulse added to the jarring sensa- tion of the aneurismal varix, and there is an aneurismal whirr superadded to the rasping sound heard in the former affection. The sac in this form of dis- ease has two openings, one into the artery and one into the vein, and thereby is much in the condition of the sac of a traumatic aneurism which has become diffuse by rupture; hence the proper treatment consists in laying Fig. 91. ABC D A, aneurismal varix; B, C, and D, varicose aneurisms ; a, artery ; v, vein; s, sac. (Bryant.) open the tumor and tying the artery above and below; in doing this, it must be borne in mind that the first incision (which opens the dilated vein) merely exposes the external orifice of the sac, and that this must be laid open by a second incision, Avhen the aperture of the artery will be found more deeply seated. Annandale advises that both artery and vein should be secured Avith double ligatures, and reports a case of traumatic popliteal arterio-venous aneurism successfully treated in this Avay. A similar case in the hands of Dr. Keyes, of New York, terminated fatally from pysemia. For the varicose aneurisms met with at the bend of the elbow, Vanzetti recommends simulta- neous compression of the brachial artery and the basilic vein. Medini records a case of arterio-venous aneurism of the carotid artery and internal jugular vein, in which a cure was effected by means of direct compression. Lines of Incision for Deligation of Special Arteries. I have gone so fully into the discussion of the principles which should guide the surgeon in the management of arterial hemorrhage, and of the various accidents Avhich follow arterial wounds, that I do not think it necessary or even desirable to recur to the subject in connection with each special artery. I purpose merely, therefore, in this place, to indicate as concisely as possible the lines of incision to be adopted in applying ligatures to the several arteries, whether the operation be required on account of injury or of disease. The statistics of the various ligations will be fully considered under the head of Aneurism. Innominate or Brachio-cephalic Artery.—This vessel may be reached by an incision at least tAvo inches long, corresponding to the anterior edge 200 INJURIES OF BLOODVESSELS. of the left sterno-cleido-mastoid muscle, and extending in the form of an J across the top of the sternum, and in the line of the right clavicle (Fig. 92). Care must be taken to avoid the thyroid plexus of veins, the middle Fig. 92. Ligation of the innominate artery. A. Innominate. B. Carotid. C. Subclavian. D. Inferior thyroid vein. E. Sterno-mastoid muscle. F. Sterno-hyoid and sterno-thyroid muscle. (Skey.) thyroid artery, and the pneumogastric and phrenic nerves. The needle should be passed behind the artery, from Avithout inwards, so as to avoid the innominate vein Avhich lies on its outer side. Common Carotid.—This vessel may be tied either above or beloAV the point at which it is crossed by the omo-hyoid muscle (Fig. 93). In either case, the guide to the artery is the inner edge of the sterno-mastoid muscle, the patient's head being thrown backwards, and inclined to the opposite side. The incision for the upper operation (Avhich is the best, when practicable) extends from near the angle of the jaAV to a little below the cricoid cartilage; for the lower operation, from a little above the cricoid cartilage, about three inches dowmvards, along the edge of the sterno-mastoid muscle. The ligature should be passed from without inwards, avoiding the jugular vein and pneumogastric nerve. In opening the sheath, care should be taken to avoid the "descendens noni" nerve, Avhich, however, it is said, has been occasionally divided in this operation, without unpleasant consequences resulting. External Carotid.—This vessel may be reached by an incision parallel to but half an inch in front of, the inner edge of the sterno-mastoid muscle, and extending from near the angle of the jaw to a point corresponding to the middle of the thyroid cartilage. Internal Carotid.—Should it be thought proper in case of a wound of this vessel to attempt its ligation rather than that of the common trunk, an in- cision may be made as for ligation of the latter in its upper part, the vessel being traced to its bifurcation, and ligatures then applied above and below the bleeding orifice. Dr. W. H. Bramlette, of Virginia, and Dr. W. 0. Byrd, of Illinois, have reported cases in which they tied the common carotid and both its branches for gunshot injury. LIGATION OF SUBCLAVIAN ARTERY. 201 Vertebral Artery.—This vessel may be reached by an incision correspond- ing to either the anterior (Maisonneuve) or the posterior border (Smyth) of the sterno-mastoid muscle. The guide to the artery is the transverse process of the sixth cervical vertebra. Fig. 93. Ligation of carotid and facial arteries. (Bryant.) Superior Thyroid.—This vessel may be reached either by an incision across the upper part of the neck, from the side of the hyoid bone obliquely outAvards and downwards to the edge of the sterno-mastoid muscle, or by an incision of about two inches along the inner border of the latter muscle. Lingual Artery.—This may be tied through an incision an inch long, made in a direction dowmvards and forwards, immediately behind the cor- ner of the hyoid bone (Fig. 96). The superior laryngeal nerve should be carefully avoided in passing the needle. Podraski and Hueter recommend an incision along the upper border of the hyoid bone. The platysma my- oides being divided, and the submaxillary gland turned upwards, the artery is found immediately beneath the fibres of the hypoglossus, in the so-called triangle of Lesser. The Facial Artery is most easily secured where it crosses the loAver jaw (Fig. 93); the Occipital, as it emerges from beneath the splenius muscle, behind the mastoid process of the temporal bone (Fig. 94); and the Tem- poral, immediately above the zygoma (Fig. 95). Subclavian Artery.—The Right Subclavian may be tied in the first part of its course, that is, between the trachea and the scaleni muscles, by the incision recommended for ligature of the innominate; on the left side the vessel is so deeply seated as to render the operation almost impracticable, 202 INJURIES OF BLOODVESSELS. though if it be attempted, the same incision (reversed) should be employed. Ibis operation has, I believe, been performed but twice on the living subject —by J. K. Rodgers, of New York, and by McGill, of Leeds, the latter sur- Fig. 94. Fig. 95. and ulnar arteries. inner side, Avhile the median nerve, aiso of the paimar vessels. (Miller.) Avhich above is to the outside of the vessel, crosses in front of it at about its middle. In operating upon the brachial artery, its occasional high division must be borne in mind. 204 INJURIES OF BLOODVESSELS. Fig. 98. Radial Artery.—This vessel, in its upper part, lies between the supinator longus and pronator teres muscles; and, below, between the former and the flexor carpi radialis. It may be reached in any portion of its course by an oblique incision crossing a line from the middle of the arm, at the bend of the elbow, to the ordinary place of feeling the pulse. The radial artery behind the thumb may be exposed by an incision about an inch long, across the proximal ends of the metacarpal bones of the thumb and forefinger. Ulnar Artery.—The general course of this vessel may be described by a line drawn from the middle of the bend of the elbow, obliquely inwards, to a point half-way down the forearm, and thence parallel to the ulnar edge of the latter, but an inch to its outside. The radial border of the flexor carpi ulnaris may be considered a guide to the vessel in the middle part of its course. Interosseus Artery.—This vessel may be reached by an incision similar to that required for ligation of the ulnar in its upper third. The operation has been successfully performed by Michel, of Nancy, but is very seldom required. Abdominal Aorta.—The aorta may be reached by a curved incision on the left side of the body, convex towards the vertebra?, and extending from the cartilage of the tenth rib to near the anterior superior spinous process of the ilium, the length of the wound being about six inches. The various structures being divided down to the peritoneum, this membrane is cau- tiously pushed backwards, the surgeon tracing up the common iliac to its bi- furcation, about an inch above Avhich the ligature should be applied; the needle is passed around the aorta from left to right, and from behind for- wards, special care being taken not to injure the vena cava, which lies to the right, nor the filaments of the sym- pathetic nerve, Avhich lies in front of the vessel. Common and Internal Iliacs. — Either of these arteries may be reached by a curved incision, five to seven inches long, passing from above the anterior superior spinous process of the ilium, about half an inch above Poupart's ligament, to the external abdominal ring; the peritoneum is carefully stripped upwards, and the needle passed from within outwards, around Avhichever vessel is to be secured. In tying the internal iliac, the surgeon must be specially cautious not to Avound the external iliac vein, which lies in the angle formed by the bifurcation of the common artery. Gluteal and Sciatic Arteries.—The former vessel may be reached by an incision in a line from the posterior superior spinous process of the ilium, to a point midway between the tuber ischii and the great trochanter; the latter, by a similar incision, about an inch and a quarter below the position of that already described. Ligation of the common iliac. (Liston.) LIGATION OF THE EXTERNAL ILIAC. 205 / External Iliac.—This vessel may be tied by Liston's modification of Aber- nethy's method, or by that recommended by Sir Astley Cooper. In the first operation an incision is made from about two inches within the anterior superior spinous process of the ilium, in a curved line, inwards and .down- wards, to an inch and a half above the middle of Poupart's ligament; the wound, which is convex downwards, should be three or four inches, long. All the tissues being carefully divided down to the peritoneum, the latter is cautiously pushed and held out of the way, while the artery is secured by passing the needle from within outwards. Cooper's incision (Fig. 99), is Fig. 99. /" Pcritcncum S/iermat/c Card Deeft,fasc£a SarCcriiAS iwusrle0: Ligation of the external iliac and superficial femoral arteries. (Bryant.) about three inches long, parallel to and a little above Poupart's ligament, and reaching from near the anterior superior iliac spine, to a point above the inner border of the abdominal ring. The external oblique tendon being divided, the spermatic cord appears, and beneath it the artery may readily be found. The disadvantages of this operation are the risks of wounding the epigastric artery and circumflex artery and vein; hence, in most cases, Abernethy's is the best incision, especially as it can very easily be extended upwards, so as to alloAV the common trunk to be reached, if that should be found necessary. 206 INJURIES OF BLOODVESSELS. Fig. 100. Femoral Artery.—The Common Femoral artery can be readily reached by an incision made directly doAvnwards from Poupart's ligament, in the line of pulsation of the vessel; the operation of ligation is, however, not very safe in this situation, and the external iliac is usually tied in preference to the common femoral. The Superficial Femoral artery may be tied in any portion of its course, though the operation is best done at the apex of "Scarpa's triangle," where the artery is crossed by the sartorius muscle (Fig. 99); the incision for this operation should be three or four inches long, beginning about two inches below Poupart's liga- ment, midway between the anterior superior iliac spine and the symphysis, and carried dowmvards in the axis of the limb, somewhat obliquely to the edge of the sartorius muscle. The femoral vein in this part of its course lies to the inside of the artery, and the needle should, therefore, be passed from Avithin outwards. The femoral artery may also be tied at a lower point, where the sartorius muscle Avill still be the guide for the surgeon's in- cision, the vessel, which at first lies inside of this muscle, afterwards crossing beneath it, and finally being external to it. The Profunda, or Deep Femoral Artery, may be reached by an incision similar to that employed for the common femoral, the latter vessel being traced down to its bifurcation, and the deep femoral tied about half an inch below the origin of its cir- cumflex branches. Ligation of the popliteal at its upper and lower parts, a. The popliteal vein. b. The popliteal artery, c. The posterior saphe- nous vein. The popliteal nerve, on the outside of the artery, has been omitted in the diagram. (Miller.) Popliteal Artery.—This vessel may be reached in its upper third by an incision along the outer border of the semi-membranosus muscle, and in its lower third by an incision between the heads of the gastrocnemius (Fig. 100). The vein in the former situation lies to the outer, and in the latter to the inner side of the artery; in either case the needle should be introduced between the two vessels. Anterior Tibial.—This artery may be found, in its upper third, in the space between the tibialis anticus and extensor communis muscles. The in- cision is made rather more than an inch outside of the spine of the tibia, and should be about three inches long. In its lower half the artery may be found just outside of the extensor proprius pollicis tendon, which, in this situation, is the guide for the surgeon's incision. Care must, of course, be exercised in passing the ligature, to avoid the vense comites and the anterior tibial nerve. On the dorsum of the foot, this artery may readily be found between the tendons of the extensor pollicis and extensor brevis digitorum. Its course corresponds to the line of the first metatarsal interspace. Posterior Tibial.—This artery may be tied in the calf of the leg, or just above the ankle: in the former position, the operation should only be done for hemorrhage, Avhen the wound must be made the guide for the incision, which should be in the direction of the fibres of the gastrocnemius, and about four inches long. Above the ankle, the artery may be easily reached by a semilunar incision, concave forwards, about three-fourths of an inch LIGATION OF PERONEAL ARTERY. 207 behind the inner malleolus, and from two to three inches in length; the needle should be passed from behind forwards, so as to avoid the accom- panying nerve. Fig. 101. Fig. 102. Ligation of the anterior tibial at various parts. Ligation of the posterior tibial at various parts. The wounds are supposed to be held asunder. The The wounds are supposed to be held asunder. The ligature is under the vessel. (Miller.) ligature is under the vessel. (Miller.) Peroneal Artery.—If this vessel should require ligation, which can only be in case of wound, an incision must be made similar to that recommended for ligation of the posterior tibial in its upper third, except that in this in- stance it will, of course, be on the outer or fibular side of the calf. The artery will be found lying in a groove between the fibula, flexor pollicis muscle, and interosseous ligament. 208 INJURIES OF NERVES. CHAPTER X. INJURIES OF NERVES, MUSCLES AND TENDONS, LYMPHATICS, BURS^E, BONES, AND JOINTS. Injuries of Nerves. Contusions.—Nerves are frequently subjected to contusion; the effects of this injury, which is manifested by local pain and a tingling sensation (pins and needles, as it is popularly called) along the course of distribution of the nerve fibres, are commonly evanescent, though in persons of a hysterical or nervous disposition they may be more permanent, giving rise, in some in- stances, to a distressing form of neuralgia; or the neurilemma may become thickened as a consequence of the bruise, causing by pressure a form of partial paralysis, or, more rarely, a secondary morbid condition of the nerve centres. Laceration or Rupture of nerves sometimes occurs as a subcutaneous in- jury, as in cases of dislocation, Avhen the lesion may be a direct result of the injury, or may be caused by the force used in attempts at reduction. Pa- ralysis sometimes exists in these cases from the first, or may come on several weeks subsequently, and be attended with muscular atrophy; according to Duchenne, sensation is less impaired in these cases than motion. The treat- ment should consist in the use of electricity, douches, and suitable gymnastic exercises. Punctured Wounds of nerves usually result from the pricks of needles, or of the lancet in venesection. Partial paralysis and neuralgia may result, and may affect not only the parts supplied by the injured nerve, but adjoin- ing parts as well, as in cases recorded by Graves and others. In some in- stances general convulsions have been observed, and in one case, quoted by Mitchell from Swan, relief was afforded only by making a free incision above the seat of injury. Complete Division of a nerve causes paralysis of the parts supplied, with a diminution of temperature, and certain nutritive changes which have been studied by Sir James Paget, and more recently and fully by Drs. Mitchell, Morehouse, and Keen, of this city, and by Dr. Middleton Michel, of Charles- ton, S. C. These nutritive changes may be classified as diminished tension with muscular atrophy and contraction; a peculiar alteration of the skin and its appendages, manifested by a glossy appearance, loss of hair, incurva- tion of nails, and the occurrence of eczematous eruptions; subacute, rheu- matoidal, articular inflammations (arthropathies); absence of perspiration from the affected part;. the Avhole accompanied in many cases by a peculiar and very distressing burning pain. In some rare instances the temperature of the affected part is absolutely higher than the normal standard. Repair of Nerves after Division.—The divided ends of a cut nerve are observed to become bulbous, the proximal being invariably larger than the TREATMENT OF WOUNDED NERVES. 209 Wallerian degeneration of median nerve; 180 diameters. (Bertolet.) peripheral bulb, and to pass through certain degenerative changes which have been particularly studied by Waller and by Ranvier, and in this coun- try by Dr. R. M. Bertolet, and Avhich are subsequently folloAved by a process of repair, the nuclei of the neuri- lemma undergoing proliferation, Fig. 103. and the continuity of the trunk being ultimately restored by means of delicate fibres projected from either segment, and by the coalescence of spindle cells in the intermediate cicatricial portion. In some cases neighboring nerves appear to act vicariously for those trunks Avhich are divided, thus presenting a condition somewhat analogous to the collateral circu- lation in cases of arterial oblit- eration. If a large portion of a nerve be excised, there is usually no reproduction, and the only chance of restoration of function is in the vicarious action above alluded to. In some cases the extremity of a divided nerve, or even an undivided nerve, becomes involved in the dense tissue of a cicatrix, or in the exuberant callus produced in the repair of a fracture. A very painful neuralgic and paralytic condition may result from this circum- stance, requiring surgical interference, which has been successfully applied in such cases by Warren, Oilier, Busch, and others. Treatment of Wounded Nerves.—It has been proposed to unite the cut extremities of divided nerves by means of sutures, and numerous cases have been reported in which this has been done Avith favorable results. There is, however, no reason, according to Mitchell, who has paid particular attention to this subject, to believe that immediate union of a cut nerve can ever be obtained, though the use of a suture might hasten restoration of function. If this plan should be resorted to, the ends of the nerve may be brought together Avith a delicate wire secured by passing its extremities through a perforated shot or Galli's tube (as Avas done by Nelaton), or a fine pin or acupressure needle and Avire loop may be used as in the hare-lip suture. BakoAviecki recommends sutures of catgut, passed through the neurilemma only. Braun, Langenbeck, Ogston, MacCormac, Holmes, Wheelhouse, Holden, Savory, Hulke, Page, F. L. Parker, Parks, Letievant, and Esmarch have recorded cases in which nerve-suture Avas resorted to long after the occurrence of the injury, and, usually, with good results. Gluck has reported several successful experiments in nerve-grafting in the loAver animals. The pain attending nerve wounds may be alleviated by the application of Avarmth or cold, according to the feelings of the patient, and especially by the hypo- dermic use of morphia. Repeated blistering is recommended by Dr. Mitchell and his co-laborers, for the burning pain of nerve injuries (causalgia)—and for the muscular atrophy, faradization Avith the electro-magnetic battery, shampooing, and the alternate use of hot and cold douches. In a case of painful spasmodic contraction of the forearm, following a gunshot injury, Niissbaum afforded relief by exposing and forcibly stretching the nerves 14 210 INJURIES OF MUSCLES AND TENDONS. which supplied the affected part, and similar operations have been since reported by the same surgeon, and by Billroth, Gartner, Callender, Palmer, Petersen, T. G. Morton, Jos. Bell, Byrd, Higgens, Amboni, Blum, Duplay, Bartleet, Andrews, and others. I have myself stretched in one case the musculo-spiral, and in another the median nerve, for traumatic neuralgia of the hand; in the latter case Avith permanent, but in the former Avith only temporary, advantage. I have also stretched the nerves of the brachial plexus, for the results of "concussion," Avith decided relief to the patient. Experimental researches in nerve-stretching made by Marcus, lead him to think that the effect is due to changes produced in the spinal cord, rather than in the sensory fibres of the nerves themselves. Quinquaud finds that there is a reflex influence exerted upon the corresponding nerves of the opposite side. According to the same Avriter, the production of complete anaesthesia is necessary to ensure success. Reflex Paralysis, resulting from injuries of nerves, is a very interesting subject, but belongs more to the domain of physiology than to that of prac- tical surgery; it has been specially studied by Prof. BroAvn-Sequard, by Dr. Mitchell, of this city, and by Dr. Echeverria, of New York. Injuries of Muscles and Tendons. Strains and Sprains of muscular tissue are of very frequent occurrence, and vary in severity from the slightest stretching to absolute rupture of some of the muscular fibres; the treatment consists in keeping the parts at rest, in the use of slightly stimulating embrocations, and in the internal adminis- tration (in cases occurring to patients of a rheumatic tendency) of Dover's powder with colchicum or iodide of potassium. Corrigan's button cautery may be applied if the pain be very persistent, while the atrophy and paral- ysis, which sometimes result, require faradization, shampooing, etc. Subcutaneous Rupture of muscles and tendons may occur either from external violence, or from the forcible contraction of the muscle itself. Thus, the abdominal muscles are sometimes ruptured during the process of par- turition, while muscular rupture is a frequent attendant upon the spasms of tetanus. Rupture of the sterno-cleido-mastoid muscle during birth, is, according to T. Smith, the cause of the so-called congenital tumor or indu- ration of that muscle. Rupture of tendons is apt to occur from sudden and unusual exertions, especially on the part of persons past the middle time of life; thus, the tendo Achillis has been knoAvn to give aAvay in elderly gen- tlemen who indulge in the juvenile amusement of dancing. The line of rupture may be through the muscle or through the tendon, though more commonly at their line of junction; more rarely the tendon may be separated from its point of insertion. The symptoms of this accident are sufficiently evident. The patient experiences a sudden shock, attended Avith a sharp pain (coup defouet), and sometimes an audible snap; the power of using the part is lost; and usually a distinct depression or holloAv can be felt at the line of rupture. If the part be the seat of variocose veins, thrombosis and milk-leg may follow, as pointed out by Verneuil. Effusion into the neigh- boring joints may ensue, as observed by De Santi, from irritation of the outer surface of the synovial capsule, due to infiltration of blood, as in cases of fracture. The treatment consists in placing the part in such a position as Avill relax the affected muscle or tendon, and allow its divided extremities to be approximated as closely as possible. Repair in these cases is effected, as shown by Paget, Adams, and Demarquay, by the development of a neAV INJURIES OF THE LYMPHATICS, BURSJ, AND BONES. 211 tissue between the divided extremities, Avhich in the case of a tendon grad- ually assumes the character of the original structure, but in the case of a muscle remains permanently as a fibrous band.1 Rupture of the tendo Achillis may be conveniently treated by an apparatus consisting of a collar placed above the knee, Avith a cord which pulls up the heel of a slipper applied to the foot, so as to keep the gastrocnemius muscle thoroughly and constantly relaxed. Rupture of the extensor muscles of the thigh, or of the ligamentum patelhe, should be treated by keeping the limb in an extended position and someAvhat elevated; after recovery, a posterior splint should be Avorn for some time, to prevent sudden flexion of the knee. In a case of rupture of the biceps recorded by Dr. Samuel Ashhurst, it was found sufficient to apply compresses and a figure of 8 bandage, and to support the arm in a sling. Paralysis or atrophy resulting from these injuries requires the use of friction, faradization, etc., as already described. Open Wounds of tendons should be treated on general principles, care being taking to avoid gaping of the part by placing the limb in a suitable posi- tion, and by the use of sutures to approximate the cut extremities, if this seem necessary. If the proximal extremity of the cut tendon should be retracted out of reach, its distal end may be attached to a neighboring tendon, as advised by Denonvilliers, Tillaux, and Duplay. Annandale has successfully pared and reunited the tendo Achillis more than two months after its division. Luxation of a Tendon from its sheath is occasionally met Avith, particu- larly in the case of the biceps, peroneus, and tibialis posticus muscles; the treatment consists in restoring the displaced tendon to its normal position by manipulation, and in endeavoring to prevent redisplacement by the use of a compress and bandage. Injuries of the Lymphatics. These present, ordinarily, no features requiring special comment; in some cases, hoAvever, in Avhich there is a varicose state of the lymphatic trunks (a condition usually associated Avith one of the varieties of Elephantiasis Arabum), Avounds of the affected part are followed by a copious and some- times troublesome Aoav of a milky fluid, constituting a traumatic form of what is known as lymphorrhcea. Such wounds are difficult to heal, and sometimes degenerate into obstinate fistulas Carefully applied pressure, and the use of caustic, or even of the hot iron, would seem, in such a case, more promising than any other remedy. Injuries of Burs^e. These are chiefly of interest from the possibility of their being mistaken for injuries of adjoining articulations. Wounds of bursa? heal with ob- literation of the sac. Should suppuration occur in a bursa, Avithout external wound, the part should be freely opened, and treated as an ordinary abscess. Injuries of bursa? sometimes result in chronic structural changes which Avill be described in another part of the volume. Injuries of Bones. Beside fractures, which will be considered in a separate chapter, bones may be subjected to contusion and to alteration of shape (bending), Avithout solution of continuity. 1 According to Demarquay, however, under favorable circumstances actual regene- ration of muscular tissue may occur. 212 INJURIES of joints. Contusion of bone has already been referred to in the chapter on gun- shot wounds, as a consequence of which injuries it is not unfrequently met with. It may also occur, however, as the result of accidents met with in civil life, and is frequently productive of very serious effects as regards the limb, or even the life of the patient. The various inflammatory conditions of bone, which will be hereafter discussed, such as periostitis, necrosis, and osteo-myelitis, may all result from contusion, while in special localities, as in the skull, serious visceral complications may secondarily ensue. In the aged, shortening and atrophy may result from bone contusion, as is often seen in the neck of the femur;1 this condition may be mistaken for fracture. The primary treatment of contusion of bone is to be conducted in accordance with the principles which guide the surgeon in the management of contusion of other parts. The operative measures Avhich may be required by the after consequences of this form of injury will be referred to in another place. Bending of Bone, apart from fracture, can only be met with in very early life, or under the influence of some morbid condition which diminishes the proportion of the earthy constituents of bone, as in cases of rickets or of osteo-malacia. The treatment consists in attempting to remove the deformity by the use of suitable splints and bandages. The splint may be applied to either the concave or the convex side of the limb, but in either case care must be taken to prevent sloughing at the points of greatest pressure. Injuries of Joints. Injuries of joints, apart from dislocations, which will be considered here- after, may be classed as contusions, sprains, and wounds. Contusions of joints are of frequent occurrence as consequences of falls, blows, etc., and if not very severe, and in healthy persons, are usually readily recovered from ; in other circumstances, however, the results of these injuries may be very serious. Hip disease is not unfrequently traced to a fall or blow upon the hip, as its exciting cause, and I have known a simple fall upon the ice, in a boy of strumous constitution, to be folloAved by osteo-myelitis of the humerus, with suppurative disorganization of both elbow- and shoulder-joints, requiring eventually amputation at the latter articulation. The treatment of contused joints should consist in keeping the part at complete rest, and in applying cold, Avith leeches, if necessary ; and, in the later stages, in affording support by means of an elastic bandage, and in the use of methodical friction and of the cold douche. Sprains.—A joint is said to be sprained, Avhen, as the result of a twist or other external violence, its ligaments are forcibly stretched or torn, Avithout the occurrence of either fracture2 or dislocation. This accident may occur in any joint, though it is most frequent in the wrist, ankle, and smaller joints of the foot. The condition may commonly be easily recognized. The posi- tion assumed spontaneously by the part is that in which there is least ten- sion, the hand being slightly flexed and inclined to the ulnar side in the 1 Prof. Humphry, of Cambridge, denies the correctness of the theory that shorten- ing of the cervix femoris occurs as a senile change. 2 Under the name of sprain-fracture, Callender describes an injury consisting in the separation of a tendon from its point of insertion, with detachment of a thin shell of bone; such a case should, of course, be treated as an ordinary fracture in the same locality. WOUNDS OF JOINTS. 213 case of the wrist, and the foot being extended ("pointed toe") in the case of the ankle. The joint presents the usual evidences of inflammation, the swelling and heat being particularly marked, while the part, if not painful, is exquisitely sensitive to the touch. These symptoms may be developed in the course of from a few minutes to half an hour, though a patient with a sprained ankle may sometimes continue to go about for several hours, not being indeed conscious of the severity of his injury till he comes to remove his boot at night. The prognosis in the large majority of cases is favorable, though, in old persons, the joint may remain stiff and painful for many weeks or even months after the subsidence of acute symptoms. The articulation sometimes becomes the seat of chronic rheumatism, Avhile more rarely, if the patient be strumous, suppurative disorganization of the part may ensue. The treatment in the acute stage consists in keeping the joint at entire rest, and in making cold or Avarm applications, as most agreeable to the patient. I have often, by the use of warm spirituous fomentations, such as the tincture of opium or tincture of arnica, succeeded in dispersing the SAvelling, and relieving the other symptoms of inflammation—stimulating them down, as it were—more quickly than by the use of evaporating lotions, as usually recom- mended. In the later stages the part must be well supported Avith a soap plaster and bandage, or an elastic stocking, and subjected to methodical kneading and friction (massage), and the use of the cold douche. Massage has been recommended in the acute stage, and is said by Dr. Graham, of Boston, to shorten the period of treatment very materially, but I confess that I should hesitate to employ it in a case of recent sprain. When a patient Avith sprained ankle is unable, from the nature of his avocations, to stay at home and keep the part at rest, it may advantageously be supported with a plaster-of-Paris bandage, which will alloAv of a certain amount of exercise without injury to the joint. Should the surgeon have the opportunity of seeing the case at an early period, before the occurrence of inflammatory symptoms, it might be proper to completely surround the joint with long and broad adhesive strips, superadding a gypsum bandage—a mode of treatment which has occasionally succeeded in preventing the occurrence of inflamma- tion and its troublesome sequelse; if this plan be adopted, however, the case should be very carefully watched, lest injurious constriction or even sloughing should result from the pressure employed. Wounds of Joints.—These injuries can usually be recognized without difficulty, either by the exposure of the articular cavity, or, if the wound be smaller, by the escape of synovia; if, however, these evidences be not present, it is an imperative rule of surgery that no exploration Avith the probe or otherwise should be instituted, lest the very complication that is dreaded should be induced by these manoeuvres. The prognosis of a joint wound depends on the size and situation of the particular articulation which is affected, the nature of the Avound itself, and the constitutional condition of the patient. AVounds of the smaller joints, such as of the fingers and toes, are commonly recovered from Avithout difficulty, although anchylosis of the articulation usually results. Small incised wounds of even large joints may terminate favorably under expectant treatment, while lacerated wounds of the same joints, especially if complicated Avith dislocation or fracture, almost inevitably require excision or amputation. Again, in a strumous patient, a comparatively slight Avound may give rise to such disorganization of a joint as would not ensue in the case of a perfectly healthy person. Treatment.—In the case of a simple, uncomplicated wound of even so large a joint as the knee, the surgeon should make an attempt to save the limb. If a portion of the instrument which has caused the injury remain in 214 INJURIES OF JOINTS. the wound (as often happens in cases of needle puncture), it should be care- fully extracted, and the wound then hermetically sealed with gauze and col- lodion, or with lint dipped in the compound tincture of benzoin. Millet recommends a dressing of finely powdered aloes, a substance much employed in joint wounds by veterinary surgeons. The patient should be kept in bed, with the limb at complete rest, the joint being surrounded with ice-bags. The diet should be unirritating, and opium may be freely administered. Under this treatment the wound may heal, and a useful articulation be pre- served. If, however, the course of events takes a less favorable turn, as is apt to happen Avith patients in adult life, the whole joint may become acutely inflamed, that condition being then developed which is known as traumatic arthritis. This differs from the ordinary forms of arthritis, Avhich constitute the " Avhite swellings " so often met with in practice, in that, in them, the disease often originates in the ligaments or the bone itself, Avhile in the traumatic form the synovial membrane is invariably first inflamed, and the other tissues become involved secondarily. When traumatic arthritis occurs in a case of joint Avound, the treatment above directed should be someAvhat changed; the use of cold may be abandoned, and Avarm fomen- tations or cataplasms substituted, Avhile a few leeches may be applied to the neighborhood of the joint, and calomel and opium exhibited internally. At the same time the strength of the patient must be sustained, by the admin- istration of concentrated food, and even stimulants if necessary. Any ab- scesses Avhich form around the joint should be opened as soon as they are detected, while, if suppuration occur within the joint itself, the question of excision or of amputation may again arise. Free incisions into suppurating joints, as recommended by Mr. Gay, are often of the greatest service. To be effective, they should be free—mere punctures are Avorse than useless—and should be so situated as to allow of perfect drainage; it is not, hoAvever, necessary to slit up a joint from side to side, and it should not be forgotten that, as Mr. Holmes puts it, these incisions, "if they do no good, will certainly do harm." The object and the sole object of opening a suppurating joint is to secure free drainage, and this object can be better accomplished by an incision of moderate size judiciously placed, than by a larger one in another part of the joint. Drainage may be assisted, as suggested by Mr. Holmes, by the introduction of a Chassaignac's tube, a bent probe, or, which would be still better, a coil of fine wire, as recommended by Mr. Robert Ellis. Should this treatment prove successful, the inflamma- tory symptoms will gradually subside, and the suppuration lessen in amount, the patient eventually recovering with a probably stiff, but otherwise useful, limb; during convalescence the joint should be kept in such a position as will allow the limb to be of most use, should anchylosis occur. If, however, the patient's condition does not improve after opening the joint, the surgeon should not hesitate to resort at once to amputation, or, in some cases, excision ; for, although the prognosis of operative interference, under such circumstances, is less favorable than in cases of chronic disease, still, as it offers the patient his only chance for life, it should be unhesitatingly resorted to. Amputation or Excision in Cases of Joint Wound.—If operative treat- ment be required, either as a primary procedure or in a subsequent stage on account of the occurrence of suppuration within the articulation, the choice betAveen amputation and excision will depend in a great degree upon the particular joint concerned. In the upper extremity, amputation can be rarely required, except for special circumstances connected with the consti- tutional condition of the patient, and excision, either primary or secondary, should be preferred, in cases which require any operation at all. In the EXCISION IN CASES OF JOINT WOUND. 215 lower extremity the case is somewhat different; the hip-joint is so deeply seated that it is scarcely ever wounded except by gunshot injury, in Avhich case, for reasons already given, primary excision is the mode of treatment to be adopted. Wounds of the knee-joint are among the most serious injuries met with in civil practice; if complicated Avith fracture or dislocation, they should, I think, be considered as cases for amputation, although exceptional instances do undoubtedly occur in which recovery without operation folloAvs, even under these unfavorable circumstances. Excision of the knee-joint, for traumatic causes, is not a very promising operation; still, in a young and healthy person, if the destruction of parts were comparatively slight, it might be at least a justifiable procedure. M. Spillman, Avho rejects knee-joint ex- cision in military surgery, yet considers it a suitable operation as applied to cases of injury met Avith in civil life. Eleven such cases Avhich he has col- lected, excluding gunshot Avounds, gave six recoveries, three deaths, and tAvo consecutive amputations (Archives Gen. de Medecine, Juin, 1868, pp. 681- 701). Five cases of total excision for compound fracture, collected by Pe- nieres, gave four deaths and but one recovery, Avhile six operations for joint Avound, Avithout fracture, gave but one death and five recoveries; as justly observed, hoAvever, by this writer, these cases might, perhaps, equally well have recovered Avithout operation. Culbertson's tables include 28 cases, with 17 recoveries and 11 deaths. When an attempt has been made to save the knee-joint, but Avithout success, amputation should be unhesitatingly per- formed, as offering the only remaining chance of preserving life. One point worthy of notice in connection Avith Avounds of the knee, is the frequent oc- currence of suppuration above the joint, abscesses being formed Avhich dissect up the muscles of the thigh to a considerable extent, before giving evidence of their existence. It is this deep-seated destruction of the tissues of the thigh Avhich constitutes one of the chief dangers of Avounds of the knee-joint, and which renders any operation performed under these circumstances very apt to terminate unfavorably. Wounds of the ankle are attended with less risk than those of either hip or knee, and recovery may often be obtained without operation, though in other cases excision or amputation may be re- quired either primarily or secondarily. Spillman has collected sixty-eight cases of complete or partial excision of the ankle for compound fracture or dislocation, the results having been ascertained in sixty-six. Fifty-one patients recovered Avith more or less useful limbs, two recovered after ampu- tation, and thirteen died (two of these having been likeAvise previously ampu- tated) ; the mortality of the operation is, according to these figures, about twenty per cent. Culbertson's statistics are more favorable, 154 cases giving but 19 deaths, a mortality of only 12.3 per cent. In the conservative treat- ment of these injuries it is of great importance to support the foot, so that the patient after recovery may be able to walk properly, and may not be left with an extremity anchylosed in the position of a pes equinus. I have already referred (p. 59) to the proposal to tie the main artery of a limb, as a means of preventing or curing traumatic arthritis; recovery has indeed folloAved ligation under these circumstances, but no sufficient evidence has been adduced to shoAV that the good result Avas in any degree due to the operation, Avhich, beside being unphilosophical in conception, evidently adds an additional risk, Avithout any compensating prospect of benefit. I have, moreover, been assured by distinguished army surgeons, who saw the plan fairly tried during our late war, that it proved then as unsuccessful in prac- tice as it is unscientific in theory. 216 FRACTURES. CHAPTER XL FRACTURES. Fracture is the most common form of injury to Avhich the bones are exposed, and, as such, becomes a subject of the deepest interest to every practising surgeon. Moreover, no injuries require more care and judgment in their treatment than fractures, and no cases contribute, more than these, to establishing the fame or the discredit of the surgeon. A man Avho gets well Avith a crooked or shortened limb, is very apt, Avhether rightly or Avrongly, to lay the blame of it upon his doctor, and though cases do undoubtedly occur in which the most skilful and attentive surgeon may fail in obtaining a satis- factory result, there can be no question that a great many bad cures of frac- ture are directly traceable to ignorance or neglect upon the part of the practitioner. Causes of Fracture. These may be divided into the exciting and the predisposing causes. Exciting Causes.—The exciting causes of fracture are external violence and muscular action. 1. External Violence may act directly or indirectly. Gunshot fractures are perhaps the best examples of fracture as the result of direct violence, Avhile fracture of the clavicle from a fall on the shoulder, or of the radius from a fall on the hand, may be taken as illustrations of the injury as produced by indirect violence. Fracture by counter-stroke (the contre-coup of French writers) is a form of the fracture by indirect violence, in which the force is applied to one side or extremity of'the bone, or system of bones, Avhich are so united and fixed that, by the natural elasticity of the parts, the force is transmitted, and produces its effect, not at the point to which it was applied, but at a point opposite. Familiar examples of fracture by counter-stroke are those of fracture of the base of the skull, from force applied to the top of the head, of the frontal bone, from a fall upon the occiput, or of the sternum, from violence applied to the back. The subject of contre-coup or counter-stroke, has been involved in some confusion by the various meanings which different authors have given to the term; as used here, it is to be un- derstood as denoting merely a variety of injury from indirect violence, the mechanism of which is explicable by simple and well-understood physical laws, depending entirely upon the structure and connections of the bones and other parts involved. 2. Fracture by Muscular Action is not of very unfrequent occurrence, though the cases in Avhich fracture is produced by pure divulsion, or tearing asunder the fragments, are rarer than is commonly supposed. Indeed, the only instances of the kind with Avhich I am acquainted, are those rare cases in Avhich fracture of the sternum has occurred during the acts of parturition, vomiting, etc. In the more commonly quoted instances of fractured olecranon and fractured patella, the mechanism is somewhat different, the bones (as justly remarked by Dr. Packard) giving way like over-bent levers, across the condyles respectively of the humerus and femur, though the fracturing force in these cases, as in those of fractured sternum, is muscular contraction. CAUSES OF FRACTURE. 217 Predisposing Causes.—The predisposing causes of fracture may pertain to the bone itself, or to the general condition of the patient. Thus, the situation of a bone influences its liability to fracture; the clavicle is much oftener broken than the scapula, and the loAver than the upper jaw. Again, the function of a bone may predispose it to fracture; the bones of the lower extremity, which support the trunk, or those of the upper extremity, which are constantly engaged in the active employments of life, are more liable to fracture than the vertebras or sternum, the functions of Avhich are different. The following table, condensed from the statistics of Lonsdale, Norris, and Malgaigne, will exhibit the relative frequency of fracture in different parts of the body, in the Middlesex Hospital, Pennsylvania Hospital, and Hotel Dieu: Seat of Fracture. Lons-dale. Norris. Mal-gaigne. Seat of Fracture. Lons-dale. Norris. Mal-gaigne. Skull,...... Nasal bones, .... Upper jaw and malar, . Lower jaw, .... Ribs and costal cartilages Vertebrae,..... Pelvis, sacrum, etc., Clavicle,..... 6 years 48 13 1 32 2 357 8 7 .273 in 10 years 46 3 19 5 46 8 6 84 10 11 years 53 12 3 27 1 263 11 9 225 12 Humerus, . . Radius, . . . Ulna, . . . Radius and ulna Hand, etc.,. . Thigh, . . . Patella, . . . Tibia, . . . Fibula, . . . Tibia and fibula 6 years 118 197 96 93 116 181 38 41 51 197 10 years [252 9 133 16 1295 11 years 310 160 38 107 71 303 45 29 108 Scapula (or shoulder), . 18 515 Among the predisposing causes which pertain to the general condition of the patient, age occupies a prominent place. There can be no question that the old are more apt to be the subjects of fracture than the young, partly on account of the greater brittleness of their bones, and partly from the general rigidity of ligaments and muscles Avhich attends advancing age, and which renders the entire frame less elastic and yielding, and therefore more liable to this form of injury. No age is, however, exempt from fracture, and not a few instances are on record in which this has occurred even during fcetal life.* The circumstance that old age predisposes to the occurrence of fracture, does not contravene the well-known fact that most of these injuries are met with in those in early adult life, for the simple reason that such persons are most engaged in active employments, and are, therefore, most exposed to all forms of injury resulting from external violence. Sex, as might be supposed, exercises an influence on the liability to fracture, men, from the nature of their occupations, being more apt to have broken bones than Avomen; for a similar reason, the right side of the body is more exposed to fracture than the left. Certain forms of cachexia, or certain diatheses, may be considered as predisposing causes of fracture. Rickets undoubtedly exercises a powerful influence in this Avay, as do osteomalacia, cancer, syphilis, scrofula, gout, locomotor ataxia, and general paralysis of the insane. Some very remarkable cases are on record illustrating the fragility of bones under cer- tain conditions: Gibson, Arnott, Tyrrell, Lonsdale, and H. Thomson, have described such cases, but the most remarkable of all is that published in the Journal des Savants for 1690, and Avhich appears to be the same as one quoted by Malgaigne from Saviart, in which an apparently healthy young Avoman 1 Depaul, however, believes that supposed intra-uterine fractures are really cases of defective ossification, and not of injury. 218 FRACTURES. of thirty, during three months' confinement to bed, sustained, it is said, fractures of every bone in the body. Esquirol is said to have possessed a skeleton which exhibited traces of more than two hundred fractures.1 In many of these cases union readily took place, but in one mentioned by Stanley, and in that of H. Thomson (in Avhich, indeed, the bones are de- scribed as separating rather than breaking), the fractures appear to have remained ununited. Varieties of Fracture. Fractures may be Complete or Incomplete; these names sufficiently express their OAvn meaning. The form of'incomplete fracture usually met with in civil life is the partial or " green-stick " fracture, in which some of the bony fibres have given Avay, while the rest have yielded to the force, bending but not breaking. In military practice, incomplete fractures are Fig. 104. occasionally produced by blows from sabres, but more often by gunshot Avounds, the principal varieties being the fissured fracture, the grooving fracture, in which a piece is cut out from the side of a bone, and the button-hole or perforating frac- ture, in Avhich a piece is fairly punched out from the centre of a bone. These terms (complete and incomplete) are principally used in reference to the long bones; in the case of flat bones, as of the skull, many of the fractures met Avith in civil life are incomplete. The most usual and the most important division of fractures is into simple said compound. A Simple Fracture, as the term is used in this book, is a fracture in which there are but two fragments, and which does not communicate with an open wound. This definition, Avhich seems to me to correspond with the meaning usually attached by surgeons to the term simple fracture, is essentially the same as that given by Mr. Erichsen, but differs from the definitions given by Prof. Hamilton and Prof. Gross, the former author using the term as equivalent to Malgaigne's single fracture, without regard to its subcutaneous character, Avhile the latter regards merely the absence of external wound, Avithout reference to the number of fragments. The classifi- cation adopted by Mr. Hornidge, in Holmes's System of Surgery (which would make this form the "simple, single fracture"), is perhaps the most strictly correct, but is almost too compli- Partiai fracture, cated for common use. Compound Fractures are fractures which communicate with the external air through a wound: this wound is usually, though not necessarily, an external or cutaneous wound ; a fracture of the jaw may be compound from a wound through the buccal mucous membrane. Comminuted Fractures are those in which there are more than two fragments, the lines of fracture, however, intercommunicating Avith each other and occupying the same general position as regards the bone affected. A multiple fracture, on the other hand, is one in which the bone is the seat of two or more distinct fractures not necessarily connected with each other; 1 I have myself met with a case in which, without apparent reason, seventeen frac- tures had been sustained by the bones of the right lower extremity; when [ saw the patient, multiple enchondromata had been developed in the foot and ankle. VARIETIES OF FRACTURE. 219 thus the radius may be broken just below its head and again above the Avrist, or the tibia through the malleolus and again just beloAV its tuberosity. A double fracture is a multiple fracture in Avhich the solutions of continuity are but two in number. Comminuted and multiple frac- tures may or may not be compound, and a multiple fracture may be compound at one seat of lesion and not at the other. When the term comminuted fracture alone is used, it is understood that there is no communication AA'ith an external wound; if there be such communication, the injury becomes a compound comminuted fracture.' Fig. 105. Comminuted fracture of the patella. Fig. 1C6. Complicated Fractures are fractures which are accom- panied by some other serious injury of the same part. Thus a fracture may be complicated by dislocation of a neigh- boring joint, by rupture of an important artery, or by a severe flesh wound Avhich does not communicate with the seat of fracture. Some authors speak of fractures being complicated (in this technical sense) by any of the various lesions to Avhich the human frame is subject, but this, it seems to me, is incorrect; thus it Avould be wrong to de- scribe a fracture of the right thigh as complicated by a dislocation of the left shoulder, or a fracture of any of the extremities as]^. complicated by a wound of the pleura or lung, though the latter lesion, if produced by the sharp fragments of a broken rib, would be a technical complication of that injury, Avhich Avould then be properly called a complicated fracture of the rib. Impacted Fractures are those in Avhich one frag- ment is driven into and fixed in the other. Intra-periosteal Fracture is the term applied to a fracture unaccompanied by laceration of the peri- osteum ; it is a form of injury rarely met Avith except in certain flat bones, as those of the skull, and, in- deed, the creation of this subdivision seems to me to be of very little practical utility. Impacted fracture, through the trochanters of the femur. The upper fragment is wedged into the lower. Direction of Fracture.—Fractures are also classi- fied in accordance with the direction in Avhich the separation of the bony fibres occurs; thus fractures are said to be transverse, oblique, or longitudinal. A Transverse Fracture is one in Avhich the general line of separation is transverse, or in a plane at right angles Avith the long, axis of the bone. A perfectly transverse fracture in a long bone is very rarely met AATith, the line of separation being almost alAvays more or less oblique; a variety of the transverse is the serrated fracture, in Avhich the fragments present corres- ponding indentations Avhich render it comparatively easy to maintain them in apposition. Transverse fractures usually result from direct violence or from muscular action. The Oblique Fracture is the form most commonly met AA'ith in the long bones. The plane of fracture may, of course, vary greatly in different cases ; thus a fracture is said to be oblique from before backwards and from without inwards, etc. Oblique fractures are commonly caused by indirect violence. Longitudinal Fractures are those in Avhich the line of separation runs in the general direction of the long axis of the bone. This form of fracture is 220 FRACTURES. comparatively rare in civil life, but is frequently met Avith as a result of gun- shot injury, especially since the general introduction into Avarfare of the im- proved conoidal ball. Longitudinal fractures commonly occur in the shafts of long bones, and usually do not extend beyond the epiphyseal lines, though occasionally they pass through the epiphyses into the neighboring joints. Several other divisions are made by French Avriters, according to the peculiar form of the fracture, but the above are sufficient for practical purposes. Separation of Epiphyses.—This is a form of injury Avhich may fairly be classed among fractures, the symptoms and treatment of the two sets of cases being pretty much the same. Separation of an epiphysis may take place at either end of the humerus, the femur, or the tibia, and at the lower extremity of the radius ; it is also frequently seen in the case of certain bony processes, as the acromion and olecranon; while in certain flat bones, as the sternum and os innominatum, similar injuries are met with, consisting in a Fig. 107. Deformity resulting from injury of radial epiphysis in childhood. (From a patient in the Episcopal Hospital.) separation of the osseous structure into its original constituent parts, in the lines of cartilaginous junction. Epiphyseal separation can of course only occur before complete ossification has taken place; hence, in the long bones it is not met with beyond the age of twenty or tAventy-one, though in other situations, as in the acromion, it may occur at a much later period. The direction of an epiphyseal separation is transverse, and from the proximity of the epiphyseal lines to the articulations, these injuries are liable to be con- founded with dislocations. The diagnosis in such cases can usually be made, by taking care, in the examination, to grasp the epiphysis itself firmly with one hand, Avhile the other exercises the movements of flexion, rotation, etc., when, if the case be one of separated epiphysis, the lesion can readily be recognized as being above or below the line of the joint, as the case may be. Epiphyseal injuries are apt to be followed by arrested growth of the affected bone, and thus sometimes cause great deformity, as shoAvn in Fig. 107. SYMPTOMS OF FRACTURE. 221 Symptoms of Fracture. Deformity. — The most prominent, and one of the most characteristic symptoms of fracture is deformity or displacement. The Causes of Displace- ment, in cases of fracture, have been the subject of much dispute among systematic Avriters. Without entering into a minute discussion of this matter, I may say, in general terms, that the causes of displacement are fourfold, viz., 1, the force that produces the fracture; 2, the action of surrounding muscles; 3, the Aveight of the limb below the seat of fracture; and 4, the natural elasticity and resiliency of the ligaments and other soft tissues above the seat of fracture. 1. Deformity from the influence of the fracturing force is seen in cases of depressed fracture of the skull, in cases of partial fracture of the clavicle Avith iiiAvard angular deformity, and in cases of impacted fracture generally. 2. Muscular action is the most common cause of displacement in cases of fracture. It is seen in the shortening Avhich accompanies almost all fractures of the extremities, and in the rotatory displacement common in fractures of the femur, radius, etc. It is probably the sole cause of displacement in cases in which the fracture itself has been caused by muscular action, as in frac- tures of the patella or olecranon. Beside the ordinary contraction of the muscles around the seat of fracture, there is often a spasmodic condition in- duced by the irritation caused by the sharp fragments of the broken bone. 3. Displacement by the weight of the limb below the seat of fracture, is seen in the dropping of the arm and shoulder, in cases of fractured acromion or fractured clavicle. It assists the action of the rotator muscles, in producing eversion of the foot, in fractures of the lower extremity. 4. Finally, the natural elasticity of the soft tissues above the seat of frac- ture, is seen as a cause of deformity in the projection of the inner fragment of a fractured clavicle, when, as pointed out by Anger, the weight of the arm being taken off by the fracture, the inner end of the clavicle is jerked up- wards by the normal resiliency of its ligamentous and other attachments. Direction of Displacement. — The displacement in cases of fracture may take place in various directions; thus, there may be angular, transverse, longitudinal, or rotatory displacement. 1. Angular displacement is usually due in the first place to the action of the fracturing force, but is kept up or may be originally produced by mus- cular action. Thus, in fracture of the thigh there is often an angular dis- placement outwards and forwards, due to the fact that the most poAverful of the femoral muscles are those on the back and inner side of the limb. This is the form of displacement met Avith in partial or "green-stick" fractures, and it may also accompany oblique or comminuted fractures, or those in which there is impaction. 2. Transverse displacement is comparatively rare; it occurs principally in eases of serrated fracture of the long bones, in which the separation has not been sufficient to allow overlapping from muscular contraction. It is also met with in fractures connected Avith joints, as in splitting fractures of the condyles of the humerus or femur. 3. Longitudinal displacement is displacement in the direction of the long axis of the bone at the point of fracture. It may consist in shortening, or in lengthening. Shortening occurs principally in oblique fractures of the long bones, and is due to muscular action, often assisted by the nature of the frac- ture, Avhich alloAvs one fragment to slide upon the other as upon an inclined plane. When the shortening is so great that the upper end of the distal fragment is draAvn above the lower end of the proximal fragment, there is said to be overlapping, and the more prominent fragment is said to ride the 222 FRACTURES. other. The overlapping often amounts, in fracture of the thigh, to several inches. Another form of shortening is due to impaction; this is often seen in fracture of the cervix femoris, the shortening being principally in the direction of the axis of the neck of the bone, not of its shaft; hence the deformity in such a case is comparatively slight. The form of longitudinal displacement Avhich consists in lengthening, is chiefly seen in cases of fractured patella, fractured olecranon, fractured calcaneum, etc., in Avhich the frag- ments are often Avidely separated by muscular action; it is, hoAvever, as pointed out by Malgaigne, occasionally met Avith in fractures of the articular extremities of the long bones, as of the fibula, Avhen it is a secondary con- dition dependent on antecedent rotatory displacement. 4. Rotatory displacement consists in one of the fragments being tAvisted upon its own axis; this form of displacement may be due to muscular action, or to the Aveight of the limb below the seat of fracture. This displacement is constantly seen in fracture of the upper part of the femur, when the lower fragment is rotated outwards by the poAverful external rotator muscles of the thigh ; in fracture of the bones of the leg, by the action of the same mus- cles, the upper fragments, moving with the femur, are subjected to rotatory displacement. So in fracture of the radius, particularly if above the in- sertion of the pronator radii teres, the upper fragment is usually rotated outwards by the biceps and supinator brevis. Displacement in cases of fracture may be confused with deformity from other causes; thus a periosteal node or an exostosis may closely simulate angular displacement; shortening may result from old joint disease, or from contracted tendons; the position which a joint assumes Avhen the seat of sprain, may be mistaken for rotatory displacement; while the transverse, or, indeed, any of the varieties of displacement may be due to dislocation and not to fracture. Hence, the surgeon, in making his diagnosis, must not rely upon the appearances presented to the eye, or even upon mere tactual examina- tion. The limb involved should be carefully and repeatedly measured betAveen knoAvn fixed points, and compared with the corresponding unaffected limb; and in cases of doubt, not only the injured limb, but the bone itself should be accurately measured and compared with its fellow of the opposite side. Mobility is often a striking and easily recognized symptom of fracture; the part which gives support to the limb is broken, and the limb can be bent in any direction. In fractures, however, of the leg or forearm, when but one of the two bones is broken, the other acts as a splint, and hinders the devel- opment of this symptom; again, in serrated, and especially in impacted fractures, there will often be no undue mobility; or the SAvelling of the soft parts may be so great as to render the mobility of a fracture, especially if near a joint, difficult of recognition. On the other hand, dislocation, Avhich is usually characterized by immobility of the affected joint, may, if there be much destruction of the articular ligaments, be accompanied by positive increase of mobility, and thus simulate fracture. But in the continuity of a bone, at a distance from its articular extremities, mobility, when present, is a sign of the greatest value, and may, indeed, be considered as almost pathognomonic. Crepitus is another symptom of great importance, and when existing in connection with undue mobility, may be looked upon as establishing the pres- ence of fracture. Crepitus or crepitation is the grating sensation produced by rubbing together the rough ends of the fragments. It is felt as well as heard, and is usually recognized without difficulty; it must not be mistaken for the grating produced by moving diseased joints, nor for the crackling due DIAGNOSIS OF FRACTURE. 223 to effusion in the tendinous sheaths, nor yet for the crepitation of traumatic emphysema, each of Avhich conditions may, under certain circumstances, chisely simulate the true crepitus of fracture. The diagnosis might, perhaps, be aided in such cases, as suggested by Lisfranc, and more recently by Laughlin, of Indiana, by the use of the stethoscope. The non-existence of crepitus is no evidence that a bone is not broken, and its absence may be due to several causes: thus, the fragments may overlap to such a degree that their rough ends are not in contact—a condition often met Avith in fracture of the thigh, when it is necessary for an assistant to make extension be- fore the fragments can be brought together and crepitus produced; or the fragments may be widely separated—as in cases of fractured patella; or a portion of a muscular tissue may be caught between the fragments, and pre\rent crepitus. In partial fracture, there is no crepitus; nor in impacted fracture, as long as the impaction continues. Pain and Tenderness are symptoms of fracture, but may be equally due to so many other causes, that they cannot be considered as diagnostic. In some cases, hoAvever, persistent, localized tenderness is a sign of some value, especially in cases of partial or impacted fracture, in Avhich the more char- acteristic symptoms are absent. Loss of Function used to be considered an important symptom of fracture. Velpeau, however, shoAved that a fractured clavicle interfered Avith raising the arm to the head, merely by the pain caused by the act; and Gouget, a French army surgeon, has shoAvn the same thing as regards the poAver of walking, after fracture of the patella (Rec. de Man. de Med. de Chir. et de Plan: Mil., Mai, 1865, p. 394). I have myself known a man Avith fracture of both bones of the leg, to walk about the ward, when under the influence of mania a potu, using his fracture-box as a boot, and apparently not feeling any inconvenience from his injury. Muscular Spasm is not an unfrequent accompaniment of fracture, though, of course, in no degree a diagnostic symptom : it is produced by a reflex condition, due to the irritation produced by the sharp extremities of the fragments. Numbness is occasionally met with in cases of fracture, and is produced by simultaneous injury, or subsequent compression, of neighboring nerves. Extravasation and Ecchymosis, to a greater or less extent, occur in al- most every case of fracture : the degree of ecchymosis is often much greater after a feAv days, than Avhen the injury is first received, and may then (es- pecially if accompanied by much vesication, as it is apt to be if the soft parts have been much bruised) be mistaken by a hasty observer for incipi- ent gangrene. When extravasation proceeds from a ruptured artery, giving rise to a traumatic aneurism, it constitutes a very serious complication of fracture. When the extravasation reaches to the neighboring joints, intra- articular effusion results, as pointed out by Gosselin, from irritation of the outer surface of the synovial capsule; this symptom is, therefore, usually met Avith some hours or even days after the occurrence of the fracture. Diagnosis of Fracture. The diagnosis of fracture can usually be made without much difficulty by attending to the symptoms above enumerated, the first three of Avhich, when 224 FRACTURES. coexisting, may indeed be considered as pathogonomic. In cases of partial and of impacted fracture, the surgeon has not the evidence furnished by crepitus and mobility, and must rely upon the other signs of fracture, espe- cially deformity and localized tenderness. Again, in cases Avhere but one of several bones is broken, as in the hand or foot, the diagnosis is more obscure, especially if there be much SAvelling of the soft parts. In such a case, the surgeon carefully explores the surface, by making firm but gentle pressure upon each part in succession, and is thus enabled to detect any abnormal prominence, and often to elicit crepitus which could not otherwise be obtained. If the metacarpus or metatarsus be involved, each bone should be successively grasped by its extremities, and so manipulated as to render evident any frac- ture Avhich may be present. As it is of great importance in any case of sus- pected fracture that the surgeon should arrive at a correct diagnosis, his examination should always be made deliberately and systematically. The deformity, mobility, impairment of function, pain, etc., should be successively noted, before proceeding to the manual examination Avhich is to determine the existence or non-existence of crepitus. In this final part of the investi- gation, preliminary extension being made by an assistant, if necessary, the surgeon grasps the limb above and below the suspected seat of fracture firmly—so that he controls the bone as well as the flesh, and gently moves his hands in various directions, so that if there be a fracture, the ends of the fragments must rub against each other. It is scarcely necessary to say that, in this examination, all rough and needless manipulation is to be positively interdicted. If true bony crepitus be once elicited, it is sufficient, in con- nection with the other symptoms, to establish the diagnosis; and nothing can be more reprehensible than for a surgeon to persist, in spite of the pain thereby caused, in endeavoring again and again to reneAV this evidence, thus appearing more anxious to make a clinical demonstration for himself or for the bystanders, than to relieve the sufferings of his patient. The detection of crepitus may, as already mentioned, sometimes be facilitated by having recourse to auscultation. The examination of a case of suspected fracture should be made as soon as possible after the time of reception of the injury, as the diagnosis is then more easy than if oedema and inflammatory swelling have already occurred. If, however, the surgeon do not see the case in an early stage, it is often judicious to defer any minute examination, treating the case as one of frac- ture until the swelling has subsided, when, if there be really no bone broken, at least no harm will have been done by the delay. Or, if for any reason it were important to ascertain the nature of the case at once, the plan recom- mended by Rizet, a French army surgeon, might be tried. This plan con- sists in endeavoring to disperse the swelling by systematic friction and kneading (massage), in the course of which proceeding, the fracture, if there be one, will become evident. Under certain circumstances, the use of an anaesthetic Avould be justifiable, in order to facilitate the diagnosis (see page 73). In any case of doubt, it is safe to presume that the worst has occurred, and treat the case as one of fracture. It is remarkable what severe injuries of bone may exist, and yet, for a time at least, escape attention; Mr. Erichsen gives a remarkable case of compound comminuted fracture of the humerus, which, though carefully examined by himself and others, Avas not detected until the eighth day, and I can myself recall a case in the Pennsyl- vania Hospital, in which the swelling of the part prevented the recognition of anything further than that the patient had a fracture of both tibia and fibula, and yet in Avhich (death taking place soon after from mania a potu) an autopsy showed that the bones were broken into at least a dozen fragments. process of union in fractured bones. 225 Process op Union in Fractured Bones. In order to understand the process of repair after fractures, it will be neces- sary to pause for a few moments to consider the natural process of groAvth and maintenance of bone in its normal condition. This subject has been most thoroughly and carefully studied by Oilier, of Lyons, to Avhose elab- orate and admirable Treatise on the Regeneration of Bones I would respect- fully refer the reader for a detailed exposition of the Avhole subject of bone pathology. Bones groAvs in length by the development of bone cells from the epiphyseal cartilages, or cartilages of conjunction, and in thickness by the development of bone cells from the inner or osteo-genetic layer of the perios- teum ; while this peripheral thickening is going on, there is a simultaneous conversion of the innermost layers of bone into medulla or marroAv, and hence the medullary cavity enlarges as the bone grows. Turning noAv to consider the effects of any traumatic irritation upon the constituents of bone, we find the various nutritive and formative changes Avhich Avere described as parts of the inflammatory process (see Chap. I.), taking place in the perios- teum, the bone tissue proper, and the medulla. Direct irritation of either periosteum or medulla is apt to result in giving rise to what Avas described as the second formative change of inflammation, the formation of pus, or suppu- ration : indirect irritation, however, whether propagated from the bone or from the external soft parts, gives rise (usually) only to the earlier changes, viz., temporary hypertrophy, and the formation of lymph. In the case of the periosteum, the effect of propagated traumatic irritation is to cause a hyperplasia of the deep or osteo-genetic layer, manifested by SAvelling, and ultimately resulting in an increased production of new bone; in the marrow, the irritation, if not excessive, results in induration and a local retrograde metamorphosis into bone. Finally the bone tissue itself responds to the stimulus, and becomes medullized (assuming the character of granulations), proliferation of its cells takes place, and hypertrophy, temporary or perma- nent, results, with (if the irritation continue) the various changes Avhich will be hereafter considered under the head of osteitis. These are not mere theo- retical vieAvs, but have been adopted by Oilier after numerous carefully con- ducted and often repeated experiments upon the lower animals, as well as after extended clinical observation.1 Taking now the simplest case of fracture—an intra-periosteal fracture, so called—the process of repair can be seen at a glance. The traumatic irrita- tion propagated from the broken bone causes swelling of the periosteum, active proliferation, and formation of a sheath of new bone around the seat of fracture; this is the " ensheathing" or "ring callus" of surgical writers. At 1 It is but right to say that a different explanation is given by Billroth ; according to this distinguished surgeon and pathologist, the periosteum possesses no peculiar osteo-genetic power, and the formation of callus is due not to proliferation of pre- viously existing cells, but to an accumulation of wandering cells, Avhich, following Cohnbeim, he looks upon as white blood corpuscles escaped from the vessels. The same difference of opinion, in fact, prevails with regard to the pathology of inflamma- tion and repair in the osseous tissues, that has already been noted with regard to those processes in the soft structures of the body. According to Feltz, bone, perios- teum, and medulla, are all restored by means of an "embryo-plastic" tissue, which differs from the connective and medullary tissues, but is of an embryonic character analogous to that met with in fcetal life, and probably results from a "direct gene- sis." (Robin, Journ. de I'Anat., etc., Juillet-Aout, 1876.) Dr. H. 0. Marcy believes that the periosteum is destroyed at the seat of fracture, and that repair takes place by exudation of " plastic or germinal material " and the formation of a new perios- teum. J. Greig Smith (Journ. of Anat. and Physiol., Jan., 1882) believes that true bone is developed, in cases of fracture, by the medullary structure, but that the change in the periosteum is rather calcification than true ossification. 15 226 FRACTURES. the same time the medulla feels the effect of the irritation, becomes hard- ened and partially ossified ; this constitutes the " interior " or "pin callus." Lastly, the osseous tissue itself undergoes cell proliferation, and union of the fragments takes place, mutatis mutandis, precisely by the same process that we have already studied in considering Avounds of the soft tissues. The new material which is thus developed between the fragments themselves, consti- tutes what Dupuytren called the intermediate, permanent, or definitive callus, in contradistinction to the ensheathing and interior forms of callus, Avhich are temporary or provisional. This explanation is applicable to the process of repair as seen in every va- riety of fracture. The new formations from the periosteum and medulla gradually disappear, the ensheathing callus is partly absorbed and partly in- corporated in the bone, in the process of its normal maintenance, while the ossified medulla, or interior callus, undergoes rarefaction and medullization, so that in time the continuity of the marrow cavity is again restored, and the whole bone resumes its pristine appearance. In the case of fracture unac- companied by displacement, the periosteal and medullary new formations may be so small in amount and so temporary in duration, as to escape obser- vation ; this is seen in certain serrated, impacted, and partial fractures, and is often spoken of as union by intermediate callus alone. On the other hand, the fragments themselves sometimes fail to unite, the sole bond of union being the provisional (though in these cases not temporary) callus, resulting from the action of the periosteum or medulla. In cases in which there is great dis- placement, especially in neglected fractures of the thigh, very large and thick bands of callus are often seen, stretching across and uniting the fragments which are themselves Avidely separated. The time occupied by the process of repair varies, of course, according to the size of the fractured bone and other extraneous circumstances. For the first few days, no apparent change occurs in the neighborhood of the fracture, nature being apparently engaged in repairing the injury of the soft parts, causing the absorption of effused blood, etc. The formation of the provisional callus usually begins during the second week, and by the end of the third or fourth Aveek this new structure has commonly attained sufficient bulk and strength to prevent displacement by any moderate degree of force. The definitive union of the fragments is not completed until a later period—sometimes many months subsequently. In certain situations, or under certain circumstances which will be considered hereafter, bony union does not take place, and the fragments are connected by fibrous tissue only. In cases of compound fracture, the process of union, though the same, is much slower in its progress, being delayed by the occur- rence of granulation, of suppuration, and often of necrosis, and presenting similar differences to those which are observed in the healing of open, as compared with that of subcutaneous wounds. Cartilage is occasionally met with in callus; it is, however, but a temporary constituent, due to excess of irritation. Separated epiphyses unite as fractured bones: the part usually remains permanently thickened, while, from the injury to the cartilage of conjunction, the growth of the bone in length is permanently interfered with. (See Fig. 107.) For further information on the interesting subject of the repair of bones after fracture, I would respectfully refer the reader to the writings of Dupuytren, Malgaigne, Stanley, and Paget, but especially to the work of Oilier, already referred to. Treatment of Fractures. The general indications to be met, in the treatment of all fractures, may be said to be—1, to reduce or set the fracture as soon as possible; 2, to pre- vent a recurrence of displacement; and 3, to see to the well doing of the treatment of simple fractures. 227 part affected, and to look after the constitutional condition of the patient. I shall first consider the general principles AA'hich should guide the surgeon in the treatment of simple fractures, then the modifications of treatment re- quired by the principal complications of simple fracture, and finally the treatment of compound fractures. Treatment of Simple Fractures.—Fractures are often met with at a dis- tance from home, and in localities where no surgical appliances are at hand, and Avhere no treatment can be satisfactorily carried out. Under such cir- cumstances, it becomes necessary for the surgeon to attend, in the first place, to the transportation of his patient. If the fracture be in the upper ex- tremity, it may be sufficient to support the injured limb in a broad sling made from handkerchiefs, when the patient can ride or even walk a short distance without much inconvenience; if the fracture be in the loAver ex- tremity, it will be necessary for the patient to be carried upon a sofa, or litter extemporized from boards, a Avindow-shutter, etc. If a mattress can- not be obtained, the patient's head and the broken limb may be supported on any old cloths that can be procured, or upon straAV. Temporary splints may sometimes be formed from the bark of trees, or made by laying together three or four thicknesses of folded straAV or rushes. The limb should be laid in as easy a position as possible, and the litter borne deliberately, but Avith a firm step ; it is usually recommended that the bearers should be instructed to step off Avith alternate feet, as it is said that thus less vibration is communicated to the litter. Before the patient is removed from the litter, the surgeon should see that a suitable bed has been prepared. Various fracture-beds have been invented by surgeons, amongst the most ingenious being those of Daniels, Burges, Coates, and HeAvson, but, for practical purposes, I knoAV of nothing better than a simple perforated hard mattress, Avith a pad accurately fitting the perforation, and a pan which slides in a frame-work beneath a corresponding opening in the bedstead; the latter should be provided Avith strong wooden or metallic slats, so as to furnish an even surface and secure firmness and rigidity to the whole arrangement. The lower sheet must, of course, be also perforated, and should be secured to the mattress so as not to form ridges under the patient's body. If a fracture-bed cannot be procured, an ordinary bedstead Avith.a hard mattress may be used, in Avhich case a bed- pan must be employed to receive the fecal evacuations. These preliminary matters having been attended to, and the patient being in bed (if the fracture be in the lower extremity), the surgeon removes the clothing as gently as possible, and exposes the injured part and the corres- ponding part of the opposite side. He then, by a careful and methodical examination, proceeds to satisfy himself as to the nature and extent of the injury, and then, replacing the limb in an easy position, prepares his splints and bandages before attempting to reduce the fracture. 1. Reduction, or Setting the Fracture, consists in replacing the fragments by manipulation as nearly as possible in their normal position, as regards each other. I say advisedly, " as nearly as possible," for I believe Avith Prof. Hamilton, that it is only in exceptional cases that the displacement of frac- ture can be entirely overcome. Reduction should be effected as soon aspos- xlble, for the reason that it is much easier to the surgeon, and much less painful to the patient, if done before the development of inflammation; if, however, the patient is not seen until a later period, or if displacement should, from any cause, have recurred, the surgeon need not hesitate at any stage of the case to effect as perfect reduction as he can, for the slight addi- tional irritation thus produced will be of much less consequence than the evils Avhich would result from continued displacement. Reduction should 228 FRACTURES. be effected by the hands alone; no mechanical contrivance should be used to give increased force, lest serious mischief to the already lacerated tissues should be produced. In the immense majority of cases, little or no force will be required, it being sufficient to place the limb in such a position as to relax the displacing muscles, Avhen the bones will fall into position of them- selves. Even in fracture of the femur, in Avhich extension is commonly necessary to effect reduction, it is a good rule that no more force should be used than can be applied Avith the hands alone. In cases in which one or both fragments are embedded in the muscular tissue, or in Avhich, from any other cause, there is great muscular resistance, it may be justifiable to employ anaesthesia as an aid to reduction. 2. To Prevent the Recurrence of Displacement, the surgeon makes use of various forms of apparatus, splints, bandages, etc. It is often very difficult to maintain reduction during the first few days, on account of the spasmodic action of the muscles constantly reproducing the deformity; but the ten- dency to spasm gradually passes off, so that by constant attention and care- ful dressing during the early stage of the treatment, it is almost always possible to obtain such accurate apposition of the fragments, as Avill secure a well-shaped and useful limb, though probably not one absolutely free from deformity. The different forms of bandage used by surgeons, and their modes of application, Avere considered in the chapter on Minor Surgery; the splints and special apparatus employed, will be described in discussing frac- tures of the several bones. Suffice it to say here, that the surgeon should aim to use as simple apparatus as possible; plain and light splints of wrood, pasteboard, Avires,x or thin metal, such as can be made by any carpenter or blacksmith, are, I think, in every Avay preferable to the elaborate and com- plicated appliances which have been, from time to time, recommended for the treatment of fractures. Straight and angular splints, made of smooth half-inch boards, for the upper extremity, straight splints and plain fracture- boxes with soft pilloAvs for the lower extremity, a roll of cotton wadding or of tow for padding splints, or bags filled with bran or sand for the same purpose, a feAv pieces of binders' board, a half dozen or a dozen roller band- ages, a few yards of adhesive plaster, and two or three bricks for use in making "weight extension," constitute an armamentarium sufficient for the treatment of almost all cases of fracture. The general principles to be ob- served in the use of splints and other apparatus may be stated as follows: (1.) They are to be used as means of retention only, not of reduction or extension; these are effected by the surgeon's hands, and splints and bandages are merely to prevent the recurrence of displacement. (2.) All splints, etc., should he firmly and evenly padded, so as not to exert injurious pressure on the bony prominences Avith Avhich they come in con- tact, while at the same time the padding must not be so bulky as to render the splints clumsy or unmanageable. (3.) Circular compression is to be carefully avoided, as SAvelling is inevi- table after a fracture, and the risk of gangrene from this cause is by no means only theoretical. Hence, as a rule, in the early stages of fracture, no bandage should be applied beneath the splitds. (4.) In treating fractures of the shaft of a bone, the nearest joints above and below should, if practicable, be fixed by the splints used; if the fracture involve an articulation, the shafts of the bones Avhich form the joint should themselves be so fixed. (5.) When a fracture is properly " put up," unless the patient suffer so 1 Surgeon-Major Porter, of the Medical School at Netley, suggests that, in mili- tary practice, splints might be readily made from abandoned telegraph wire. TREATMENT OF SIMPLE FRACTURES. 229 much pain as to render it probable that displacement has recurred, or that the splints are pressing uneArenly, the dressing should not be disturbed more than absolutely necessary. It is a good rule to leave the fingers or toes ex- posed, so that the surgeon can by them judge of the condition of the circu- lation in the injured limb; and if they appear unduly congested or swollen, the dressings should be at once removed, and reapplied Avith additional pre- cautions against gangrene. If a case do Avell, every other day is quite often enough to renew the bandages during the first fortnight, the interval between the dressings being gradually lengthened after that time to half a Aveek, and finally to a week. At the same time, while in no class of cases is meddle- some surgery to be more reprobated than in this, fractures should be inva- riably looked upon as cases requiring careful and continual Avatching, and a patient Avith a broken bone should receive from his surgeon at least daily visits, until after the subsidence of all inflammatory symptoms. 3. The third indication for treatment (see p. 226) brings up the consid- eration of the various accidents Avhich may arise during the management of a case of fracture. Muscular spasm and extravasation are such constant ac- companiments of fracture, as to entitle them to be considered as symptoms, under which head they have been referred to. Spasm is best controlled by the free use of opium; moderate compression with a firm bandage is often recommended, but is a somewhat hazardous remedy, and should be used with great caution. Tenotomy has been also proposed for this purpose; but I can scarcely conceive of a case in Avhich its use Avould be justifiable. Ex- travasation, if moderate, may be disregarded; if there be much contusion and vesication, the limb should be simply laid on a pillow, protected by oil-cloth, while evaporating lotions are applied until the subsidence of inflammation; if large vesicles or bulhe form, they should be opened Avith the point of a lancet. If the extravasation proceed from the rupture of a large artery, the case Avill require special treatment, Avhich Avill be considered under the head of complications. Embolism by particles of fat is an occasional complication of simple fracture, which bas been already referred to at page 138. Gangrene is the most serious accident which can be met Avith in the treat- ment of a simple fracture, and may be due either to arterial obstruction at a point abovre the seat of fracture, to venous obstruction due to SAvelling of the part or to tight bandaging, or to a combination of these causes. With regard to tight bandaging, it is to be remembered that a bandage may seem suffi- ciently loose Avhen applied, and yet in a few7 hours may become the cause of great constriction from subsequent swelling of the limb; hence the importance of not applying a bandage beneath the splints; it is, as remarked by Mr. Erich- sen, almost invariably to a neglect of this rule that the occurrence of gan- grene from the pressure of a bandage is due. Especially is this true in the case of the forearm, in fracture of Avhich part this accident most often occurs. It should not be forgotten, however, that this accident may be partly or entirely due to arterial obstruction, Avhich is, of course, an unavoidable oc- currence; hence avc should not be too hasty in accusing a felloAV-practitioner of malpractice on account of such an accident, for it may be really due, at least in some measure, to causes entirely beyond control. The treatment of gangrene occurring under such circumstances must vary according to its nature and extent; if it be due to constriction, and the surgeon fortunately discover it in time, he must instantly remove the bandages, Avhen possibly the patient may escape with superficial sloughing. If complete gangrene have occurred, amputation, of course, becomes necessary; if the disease shoAV a disposition to self-limitation, the surgeon may aAvait the formation of the lines of demarcation and separation; but if the gangrene be of the rapidly spreading traumatic variety (p. 149), immediate removal of the limb must be 230 FRACTURES. practised at a point above the furthest limits of the disease. In the former case a favorable result may be anticipated, but under the latter circumstances the patient is apt to sink after the operation, as happened in a case in Avhich Fig. 108. Gangrene from tight bandaging (Bell.) some years since I amputated at the shoulder-joint, for spreading gangrene following a badly treated fracture of the forearm. The other accidents Avhich occur during the treatment of fractures, cannot be considered as peculiar to these injuries. Thus there may be excessive inflammation, followed by abscess or sloughing, surgical fever, traumatic delirium, tetanus, erysipelas, or pyaemia. In old persons the confinement to bed required in the ordinary treatment of fractures may produce pulmonary or cerebral congestion; hence the advantage in such cases of using the plaster-of-Paris bandage or other immovable apparatus, which may enable the patient to get about as soon as possible. In renewing the dressings of a fracture, the limb should be firmly and care- fully held by an assistant, so as to prevent any recurrence of displacement while the splints are off; it is well at each dressing to gently rub the affected limb with soap liniment or dilute alcohol (carefully drying the part after- wards), so as to keep the skin in a healthy state. The patient's general condition should be attended to, and any disorder of the bowels or chest remedied by appropriate measures. The use of the catheter is very often required for a few days, when the patient is confined to bed, especially if the fracture be situated in the pelvis or femur. Passive Motion is effected by the surgeon flexing and extending the joints of the injured limb, while firmly holding the parts above and below. There is a difference of opinion as to the time at which passive motion (which is designed to prevent anchylosis) should be begun ; my own conviction is very clear that it should not be practised until firm union has occurred between the fragments—usually, therefore, not before the third or fourth week after the accident, and that it should even then be used with moderation and with gentleness. The patient may, indeed, often be safely left to regain mobility of the joints by the ordinary physiological exercise of the limb, assisted by methodical friction, and the use of the cold douche. In the case of the upper extremity, the patient may, after recovery, be advantageously directed to swing a flat-iron or put up a dumb-bell with the affected member, several times a day, continuing the exercise on each occasion until slight fatigue is experienced. Treatment of Complicated Fractures.—Fractures may be complicated by various conditions which will require special modifications of the general TREATMENT OF COMPLICATED FRACTURES. 231 course of treatment above described. Thus the extraA'asation, although pro- ceeding from vessels of moderate size, may produce so much swelling as to give rise to great congestion or even strangulation of the tissues, and con- sequent gangrene, demanding amputation; or the contusion and subsequent inflammation may be so great as to cause suppuration and sloughing, result- ing in the conversion of the case from one of simple, into one of compound fracture. Rupture of the Main Artery of a limb is a very serious complication of fracture. This accident is principally met with in connection Avith fracture about the knee-joint, and the injured vessel may be either the posterior tibial or the popliteal. In either case, a rapidly increasing, obscurely pulsating tumor—a diffuse traumatic aneurism in fact—forms in the ham ; and, unless promptly treated, will inevitably cause gangrene. If the posterior tibial be the wounded artery, at least partial warmth will be restored to the leg and foot, and pulsation will return in the anterior tibial: under these favorable circumstances, an effort should be made to save the limb by resorting to com- pression or ligation of the superficial femoral, in Scarpa's space. The reason for not treating the case as one of ordinary wounded artery is, that by so doing, even if the opening in the vessel could be found, Avhich would be doubt- ful, the injury would be converted into a compound fracture of the worst kind, Avhich would almost inevitably require amputation ; Avhile there Avould be a chance, though not a very brilliant one, that by the use of the proximal ligature, the arterial Avound might heal, and allow the preservation of the limb. If, hoAvever, the temperature of the leg and foot continue to sink, and no pulsation can be detected in the anterior tibial, gangrene appearing im- minent, it becomes almost certain that the popliteal artery is ruptured ; and, under such circumstances, amputation should be at once performed. So, also, if after an attempt to save the limb gangrene should occur, amputation Avould be necessary. In any case of doubt, I think the safety of the patient would be consulted rather by removing the limb, while he Avas yet in good general condition, and when the operation could be done immediately above the knee, than by running the risk of being compelled to amputate at a higher point, with the patient under the depressing influence of gangrene. Dr. Laurent, a French surgeon, has collected 27 cases of this form of injury, occurring in various parts of the body, nine, or one-third of the cases, having terminated fatally. More favorable results were obtained by compression and ligation according to the Hunterian method than by other modes of treatment. Rupture or other Serious Injury of an Important Nerve, as the musculo- spiral or median, is a very troublesome and annoying complication of fracture, causing loss of power or permanent impairment of the nutrition of the limb, as in a number of cases collected by Callender. This accident may not be apparent at the time of reception of the injury, and I have even known a surgeon to treat a broken arm until complete union of the fracture had oc- curred, not discovering the existence of paralysis until the splints were finally removed, Avhen the limb dropped helplessly by the patient's side. The treatment of such a case is not very satisfactory ; it should be conducted on the principles laid doAvn in the last chapter, in discussing injuries of the nerves in general. A very Severe Flesh Wound, even if not communicating with the seat of fracture and thus rendering it compound, may seriously complicate the pro- gress of the case, and may occasionally necessitate amputation, Unless, however, the injury to the soft tissues were, in such a case, in itself sufficient to condemn the limb, a fair trial should ahvays be given to conservative treatment before resorting to amputation. The Implication of a Joint in the line of fracture, will very often give rise 232 FRACTURES. to a certain amount of stiffness, if not to absolute anchylosis, after recovery ; or, in a strumous constitution, may cause disorganization of the articulation, and thus eventually render amputation imperative. In every case of fracture involving a joint, the treatment should be conducted Avith great caution, and the prognosis should be extremely guarded. Dislocation of an Adjoining Articulation is a not unfrequent complication of fracture. In such a contingency the fracture should be temporarily put up Avith wooden splints and firm bandages, so that the limb may be used as a lever in effecting reduction of the dislocation, the patient being, of course, etherized. The fracture is then to be treated in the ordinary manner. If the dislocation be not recognized until a later period of the case, the sur- geon must Avait until firm union of the fracture has occurred, and then, ap- plying splints, make an effort to reduce the dislocation, a feat which, under these circumstances, may be very difficult to accomplish. A fracture in a limb Avhich is the seat of an old Unreduced Dislocation, or of a Previously Anchylosed Joint, presents no peculiar difficulties of treat- ment, though it may require a modification in the form of the splints used, to adapt them to the existing deformity of the part. Fracture of the bone in a Stump, or into the site of a Previously Excised Joint, is occasionally met with, but requires no special treatment beyond the necessary modification of apparatus. Chorea, affecting a limb which is the seat of fracture, is a very serious complication : in a case of simple fracture of the humerus complicated with chorea, reported by Dr. Wm. Hunt, of this city, it Avas found impossible to keep the parts at rest, and the patient died exhausted on the tenth day. A fracture occurring in a Previously Paralyzed Limb, commonly unites Avithout particular difficulty. There is, of course, no risk of recurring dis- placement from muscular action, but special care must be taken to avoid undue pressure, Avhich might readily induce sloughing. Treatment of Compound Fractures.—The first question to be determined with regard to any case of compound fracture, is whether or not amputation is to be performed ; if the operation is to be done at all, it should be done as soon as possible, for the reasons already given in Chapter V. If ampu- tation have not been done before the setting in of the intermediate or in- flammatory stage, it must be, if possible, further postponed until suppuration is freely established. Amputation for Compound Fracture.—No universal rules can be laid down, as to Avhat cases of compound fracture should be submitted to primary ampu- tation, but each individual case must be treated on its own merits, according to the judgment of the surgeon. It may, however, be said that the circum- stances Avhich usually call for amputation in these cases are the following: 1. Extensive and severe laceration of the muscular and other soft tissues.— A compound fracture, in Avhich the Avound is made by the fracturing force, is a more serious injury than one in which the wound is made by the frag- ments perforating the skin, for the reason that in the latter case the soft tis- sues are comparatively little injured, Avhile in the former they are apt to be greatly torn and bruised, or perhaps completely pulpefied. Hence compound fractures from railway and machinery accidents, especially in the lower ex- tremity, are almost invariably cases for amputation ; in the upper extremity it is often possible to save the limb, even in these unfavorable circumstances, and if the age and general condition of the patient should justify the attempt, it should certainly be made. It is in such cases that irrigation is found to be of special service in moderating the consecutive inflammation. 2. A compound fracture accompanied with a wound of a large artery will TREATMENT OF COMPOUND FRACTURES. 233 often require amputation. If the bleeding vessel can be readily found and tied in the wound, or can be controlled by position, pressure, etc., this should be done, when, if other circumstances are favorable, an attempt may be made to save the limb. If, however, the wounded vessel cannot easily be secured, and if the part injured be the loAver extremity, immediate amputa- tion should be unhesitatingly resorted to. In the upper extremity such ex- treme measures may not be required, and if the bleeding vessel can neither be controlled by pressure, etc., nor secured in the wound, a ligature may be applied to the brachial artery, Avhich has been several times successfully tied under such circumstances. 3. (heat comminution of the bones themselves may be a cause for amputa- tion in cases of compound fracture. In the upper extremity much may be done in the Avay of conservatism, by removing splinters, and then placing the bones in such a position as to favor union. In the lower extremity, if the comminution be so extensive that removal of the primary and secondary sequestra Avill leave a gap in the continuity of the bone, the resulting limb, even if it could be preserved, Avould scarcely have sufficient firmness to be useful, and hence in such cases primary amputation is to be recommended. An exception should, perhaps, be made in cases of compound fracture in the upper third of the thigh, in Avhich position primary amputation is so fatal an operation that the surgeon is loath to resort to it under any circumstances; but, indeed, these injuries are very apt to terminate in death under any mode of treatment. 4. Compound fractures into large joints often require amputation. In the case of the shoulder or elbow, provided that the extent of bone lesion, or of laceration of the soft tissues, be not too great, excision should be practised in preference to removal of the limb. The hip-joint is so deeply seated that it is seldom involved in a compound fracture, unless from gunshot Avound, or from some crushing injury which necessarily proves fatal from visceral com- plication ; Avhen the accident does occur, however, primary excision is, I think, the correct mode of treatment, and it has been successfully employed, under these circumstances, by P. A. Harris, of NeAv Jersey. Compound fractures of the wrist, ankle, and knee-joints are usually cases for amputa- tion. Especially should this rule be considered imperative as regards the knee-joint; much as I admire the operation of excision, and strenuously as I would advocate the practice of conservative surgery, I cannot but believe that in the immense majority of instances the best interests of the patient will be promoted by primary amputation in cases of compound fracture of the knee-joint. 5. A compound fracture, Avhich Avould of itself require amputation, may be complicated by the existence of a simple fracture in the same limb, but at a higher point. In such a case, should the amputation be done at the seat of the upper fracture, or beloAV ? In my own experience, such cases, when an attempt has been made to save the limb, have invariably terminated fatally; hence, I should be disposed (unless the upper fracture were situated high up in the thigh) to recommend primary amputation, at or above the seat of highest lesion. Still, if it Avere certain that the soft parts between the two fractures were healthy, and quite free from injury, it might be right to re- move only the part that Avas irretrievably hurt, and to make an attempt to save the rest of the limb; as it happens, hoAvever, these cases are usually such as result from accident by raihvay or other vehicles, or by machinery, and are apt to be attended Avith much greater destruction of soft parts than is at first apparent; so that, in most instances, amputation at the highest point of injury Avill be found the safest mode of treatment. The complication of compound fracture with dislocation at a higher point 234 FRACTURES. of the same limb, is of less consequence. In such a case the broken bones should be temporarily put up, and the dislocation reduced, the compound fracture being afterwards treated on its own merits. Compound epiphyseal separation is sometimes met with in young persons, and may be mistaken for compound fracture involving an articulation, from Avhich lesion it can, however, ahvays be distinguished by careful examination. If, as sometimes happens, the diaphysis project through the Avound, reduction is very difficult, and can usually be accomplished only by resecting the pro- jecting portion, an operation which may be best performed Avith Butcher's or a chain saw. The after-treatment does not differ from that of ordinary com- pound fracture; the resulting limb, though shortened, is not materially im- paired in utility, even in the case of the lower extremity. Treatment of Compound Fractures which do not require Amputation.— Many ingenious forms of special apparatus have been invented for the treat- ment of compound fractures, but I am not aware that they present any advan- tages over the ordinary splints and boxes habitually used in the management of simple fractures. The only special precaution to be observed is, to so arrange the splints and bandages that free drainage may be secured from the wound, and that the latter may be readily accessible Avithout removing the entire apparatus. The points to be particularly attended to in the treatment of these injuries are: 1. Reduction of the fracture. 2. Extraction of splinters. 3. Closure of the Avound; and 4. Management of the consecutive inflammation. 1. Reduction is to be effected, as in the case of simple fracture, by relaxing the neighboring muscles, and by gentle manipulation. If a fragment project through the skin, the difficulty of reduction is much increased, and in such cases it may be necessary to enlarge the external wound, or even to resect the projecting end of bone. This measure should, hoAvever, be resorted to with extreme hesitation, especially in the lower extremity, for the loss of any considerable portion of the continuity of a long bone will be apt to result in the formation of a false joint, requiring subsequent amputation. This, indeed, has been the ordinary result in cases in Avhich I have seen this operation performed. 2. In the management of splinters or sequestra, the rules which were given in the chapter on Gunshot Wounds, founded on Dupuytren's division of splinters into primary, secondary, and tertiary, are to be observed. Those fragments which are loose or but slightly connected are to be removed, while those which are more firmly attached are to be pushed into place, that they may give solidity to the callus, and assist in the repair of the injury. In case of doubt, it is better to err on the side of allowing fragments to remain, as, if they afterwards become necrosed, they will be spontaneously loosened, when they can usually be removed Avithout much difficulty, though in some cases a dead splinter may become surrounded by callus, requiring division of the latter before the sequestrum can be extracted. 3. If the external wound be small, and unaccompanied Avith much contu- sion, an attempt should be make to close it, and thus convert the case into one of simple fracture. I have frequently succeeded in doing this ; and the effort should always be made when the nature of the case will permit it. For this purpose the wound is to be washed and freed from blood, and then her- metically sealed with gauze and collodion, styptic colloid, Paresi's antiseptic preparation (page 147), or the compound tincture of benzoin; or, in the absence of these agents, simply Avith a piece of lint dipped in blood, as recommended by Sir Astley Cooper. If, however, the wound be a large one, or if it be accompanied Avith much contusion and laceration, it will be useless to attempt its closure, and it should then be dressed lightly, and in such a TREATMENT WITH IMMOVABLE APPARATUS. 235 way as to alloAv of free drainage. Even if an attempt have been made to close the Avound, the parts should be frequently examined, and if it appear that pus is accumulating underneath the dressing, the latter should be im- mediately removed, and free vent given to the accumulated discharges. 4. The management of the inevitable consecutive inflammation which attends compound fractures, is to be conducted in accordance Avith the principles enun- ciated and the rules laid doAvn in the chapters on the Treatment of Inflamma- tion, and on Wounds in General. Ice, Avater-dressing, irrigation, laudanum fomentations, poultices, astringent Avashes, antiseptic applications, etc., may each and all be appropriately used in different cases and under different cir- cumstances. The splints employed should be protected by oiled silk from being soiled by the discharges ; and Avhile the fracture should not be unneces- sarily disturbed, the utmost care must be taken to keep the parts clean, and to preserve the neighboring integument in a healthy condition. In compound fractures of the lower extremity, the bran dressing, introduced by Dr. J. Rhea Barton, of this city, will be found most serviceable. It affords equal pressure and support to the injured member, restrains hemorrhage, absorbs discharges, and can be daily reneAAred, as far as necessary, Avithout material disturbance of the limb. Its mode of application will be described in the next chapter. The patient's general condition must also receive attention. The action of the boAvels must be regulated, and traumatic fever moderated by the admin- istration of suitable remedies. When suppuration is fairly established, tonics, especially iron, quinia, and cod-liver oil, may be freely exhibited. The diet should be nutritious, but unirritating; and in the later stages, or perhaps from the first, free stimulation may be required. The connection Avhich has now been so often traced as to make it appear causal, betAveen prolonged sup- puration and the peculiar form of visceral degeneration knoAvn as albuminous or amyloid, clearly indicates the paramount importance, in these cases, of maintaining the patient's strength and supporting his system in every pos- sible manner. The time required for the cure of a compound fracture may be estimated at from tAvo to three times as long as would be needed in the case of a simple fracture of the same part. Secondary amputation may be required in the treatment of compound fractures, on account of traumatic gangrene, sloughing folloAving erysipelas, osteo-myelitis, extensive necrosis, general exhaustion of the patient, hectic, etc. The proper period for amputation in cases of traumatic gangrene has already been pointed out in preceding chapters. In the case of the other complications Avhich have been mentioned, the surgeon must choose his time as best he can, operating at some period Avhen there is a momentary sub- sidence of constitutional disturbance, and Avhile not hastily condemning a limb Avithout fair trial of conservative measures, yet not delaying interference until the patient has sunk so low that interference will be of no avail. The only general rule that can be given Avith regard to these cases, is, to avoid, if possible, operating during the intermediate stage, Avhich usually ranges from the second to the "tenth or tAvelfth day. After suppuration has been fairly established, the case becomes someAvhat assimilated to one of chronic disease, and amputation can then be performed Avith comparatively fair prospects of success. Treatment of Fractures with "Immovable Apparatus."—In the later stages of the treatment of fractures, advantage may often be derived from the use of a plaster-of-Paris bandage, or one of the other forms of immovable dressing described in Chapter IV. It is right to add that several excellent surgeons, both at home and abroad, recommend the use of these dressings even in the early stages of fractures, and believe that by their employment 236 FRACTURES. as good, if not better, results may be obtained than by the ordinary methods. For my own part, I cannot but regard any form of immoArable dressing as unsafe, when employed before the swelling Avhich ahvays folloAvs a fracture has entirely subsided, and I am not in the habit of applying the plaster bandage until the union of the broken bones has become tolerably firm—usually in the course of the third or fourth Aveek. I Avould invite those Avho are inter- ested in the further consideration of this subject to refer to Prof. Hamilton's excellent treatise, Avhere the comparative advantages of these different modes of treatment are fully, and—as far as I am able to judge—very fairly, set forth. There are tAvo principal Avays in Avhich the plaster-of-Paris bandage may be applied ; one, and that Avhich I think upon the whole the best, consists in the application of the Avetted gypsum roller over a dry roller, in the way described on page 83, care being taken to keep the limb Avell extended Avhile the plaster is setting; and the Fig. 109. other, or "Bavarian plan," in Avhich two pieces of flannel, stitched together at their middle by a straight seam, are laid beneath the limb, the inner layer being then folded evenly around the part and secured with pins or stitches, when the liquid plaster is spread over it, and the outer layer Bavarian immovable splint. (Bryant.) finally brought up and secured in the same manner as the first; after the plaster has become hard, the pins or stitches are removed, Avhen the splint may be opened and taken off, the seam at the back serving as a hinge. Treatment of Badly United Fractures.—From various causes, over some of Avhich the surgeon may have no control, a fracture may unite Avith so much deformity as to disfigure the limb, if not to render it useless. If the deformity be in a longitudinal direction, depending on overlapping of the fragments, the case is, I believe, hopeless, for the surrounding muscles will have probably become permanently contracted and shortened, and attempts at extension after union has once occurred Avill prove fruitless. Transverse deformity will be gradually lessened by the processes of nature, superfluous callus being absorbed, and projecting bony prominences rounded off. Angular deformity, if very slight, may be left to nature, in the hope that it will be gradually removed by the physiological action of the muscles. If at all marked, however, it will require treatment, and this, if the bony union be comparatively soft, can usually be satisfactorily carried out by careful band- aging and the judicious use of pads and compresses—or the surgeon may by gentle but firm pressure bend the newly-formed callus, so as to restore the limb to its proper shape. If the union of the fracture be further advanced, more force may be required, and the surgeon may break the bone over again, with a vieAv to resetting it in a better position. This may be done Avith the hands, or at a later period Avith a screAV clamp, such as those devised for the purpose by Rizzoli, Von Bruns, Butcher, and C. F. Taylor, of New York. A remarkable case has been reported by Mr. Switzer, an English army sur- geon, in Avhich a large amount of deformed callus disappeared under inunc- tion with compound iodine ointment, and it would certainly be proper to try the sorbefacient effects of this remedy before resorting to the severer measures which will next be described. When the callus is so firm as to resist the application of such an amount of force as the surgeon deems justifiable, he may adopt measures to weaken the bond of union, by operative interference. UNUNITED FRACTURE AND FALSE JOINT. 237 Perhaps the best plan in such a case is that suggested by Brainard, of Chicago, which consists in subcutaneously drilling through the uniting medium in various directions, and then rupturing the remainder; or the bone may be partially divided with a saw (Langenbeck) or chisel (Niissbaum, O'Grady), or, as done by Warren and Heath, a wedge-shaped piece may be removed from the apex of the bony angle, the rest of the bond of union being, in either case, broken through, as in Brainard's method; or the deformed callus might be exsected, and the fragments firmly wired together—an operation Avhich I have successfully resorted to in one instance, and which has also succeeded in the hands of Dr. Forbes, of this city, but which, in addition to its inherent risks, of course, exposes the patient to the chance of recovering with a false joint; or, finally, in an aggravated case, it might be necessary to resort to amputation. For further information on this subject, the reader is respectfully referred to Dr. G. W. Norris's excellent paper, in his well- knoAvn Contributions to Practical Surgery. Reduction of Deformity in Partial, and in Impacted Fractures.—In connec- tion with the subject of Badly United Fractures, I may refer to the question which often arises as to whether or no reduction should be attempted in cases of partial and of partially impacted fractures. The ansAver to this question may be said to depend upon the position of the fractured bone; thus, while it would be manifestly improper to attempt reduction of an impacted fracture of the neck of the femur, it is, I think, right to reduce a partial fracture of the clavicle or of the forearm, even at the risk of converting the case into one of complete fracture. In the forearm (and in the clavicle, if the angular projection be outwards), the deformity would be so great as to be very objectionable, while inward angular displacement of the clavicle might endanger the integrity of the important underlying structures by irritation from bony spiculse. Tardy or Delayed Union of Bones is occasionally met with, and is, prob- ably, more often dependent on constitutional than on local causes. Some- times it appears to result from mere debility and depression, Avithout the existence of any positive cachexia; under such circumstances it may be sufficient to get the patient out of bed, with his limb supported in a plaster-of- Paris bandage, letting him recover his health by means of out-door exercise. In some cases the process of union may be assisted by the use of tonics, especially cod-liver oil and the phosphates (Avhich, however, have not been found as practically useful as Avas anticipated), and by giving an extra alloAvance of ale or porter. If a syphilitic taint be suspected, iodide of potassium or mercury may be cautiously administered. Ununited Fracture and False Joint. Occasionally a broken bone does not unite at all, or unites only through the medium of fibrous or ligamentous bands, or, having been united, becomes again separated by the absorption and softening of the callus. In some bones, indeed, as in the patella, bony union almost never occurs, but in such cases the Avant of union cannot be considered abnormal. The terms ununited frac- ture and false joint are applied only to fractures in those situations in Avhich bony union is habitually met Avith, as in the ATarious long bones, or the lower jaAv. The proportion of cases in which non-union occurs is estimated by Hamilton at 1 in 500; it is, therefore, a rare accident. Dr. Norris, of this city, whose monograph on this subject is the best that has yet been published, has described four distinct forms under which non- union of fracture may occur. The first is that which has already been re- 238 FRACTURES. ferred to under the name of delayed union; here callus is formed, but does not undergo complete ossification, and, hence, the union is imperfect. "In the second class of cases, there is entire want of union of any sort between the fragments, the ends of Avhich seem to be diminished in size, and are ex- tremely movable betAveen the integuments. The limb in these cases is found greatly shrunken, and hangs perfectly useless."1 In the third and most usual form, the ends of bone are rounded off and tapering, and "are con- nected together by strong ligamentous or fibro-ligamentous bands," passing betAveen the fractured extremities; there may be but one band, or several; " in either case the newly-formed substance is firmly adherent to the bones, and, if of any length, is in a high degree pliable." In the fourth variety, to Avhich the name ofpseudarthrosis or false joint is properly given, "a dense capsule without opening of any sort, containing a fluid similar to synovia, and resembling closely the complete capsular ligaments, is found. In these cases the points of the bony fragments corresponding to each other are rounded, smooth, and polished, in some instances are eburnated, and in others are covered with points or even thin plates of cartilage, and a membrane closely resembling the synovial of the natural articulations. It is in this kind of cases that the member affected may still be of some utility to the patient, the fragments being so firmly held together as to be displaced only upon the application of considerable force. The diagnosis of ununited fracture is usually sufficiently easy: I have, however, knoAvn great relaxation of the ligaments of the Avrist-joint to be mistaken for ununited fracture of the extremity of the ulna. Causes of Non-union after Fracture.—These may be either constitutional or local. Among the former may be enumerated general impairment of health, and various cachectic conditions and diatheses, such as scurvy, phthisis, rickets, syphilis, or cancer. With regard to the influence of cancer in preventing union after fractures, Dr. Norris says that when the accident depends upon the presence of a cancerous tumor at the seat of fracture, union Avill not occur, but when it depends on mere brittleness, resulting from what Mr. Curling has called eccentric atrophy, the bones unite readily enough. So with regard to syphilis and rickets; though cases are recorded in which these appear to have acted as causes of non-union, other cases are frequently met Avith in Avhich the disease is well marked, and yet union readily occurs. Pregnancy is often regarded as a cause of non-union in fractures, but it is probably thus effective in those cases only in wdiich the pregnant state is accompanied by great debility, as from sympathetic vomit- ing. The same remark applies to the supposed efficiency of lactation as a cause of ununited fracture. Age does not appear to exert any particular in- fluence, fractures in the very young and the very old often uniting quite as well as in those of middle life, and more than one-third of the whole number of cases of ununited fracture occurring in those between twenty and thirty. Among the more prominent local causes, may be mentioned deficient vascu- lar or nervous supply, mobility or Avant of proper apposition of the frag- ments, the intervention between the fragments of a shred of muscle or other soft tissue, or of a foreign body, necrosis or other disease of the ends of the fragments themselves, injudicious treatment (especially tight bandaging and prolonged use of cooling applications), and too early use of the fractured limb. The frequency Avith Avhich ununited fracture occurs in different parts, is shown in the following table taken from Dr. Norris's paper. 1 Dr. C. B. Porter, of Boston, reports a case in which after ununited fracture the humerus was absorbed, and entirely disappeared without exfoliation. TREATMENT OF UNUNITED FRACTURES, ETC. 239 Locality. Number of cases. Cured. No benefit. Died. Result unknown. »i...... 4S 33 48 19 2 31 32 31 17 2 9 .1 1 6 3 1 2 Total, .... 150 113 25 10 2 Ununited fracture is also occasionally met Avith in the clavicle, scapula, ribs, and spine. Treatment.—The treatment of ununited fracture, and of false joint, con- sists in removing, as far as possible, by constitutional, hygienic, and local measures, any cause which may seem to hinder the process of union betAveen the broken bones, and in endeavoring to excite in the periosteum, in the medulla, and in the fragments themselves, such activity as Avill induce those changes which we have seen to be necessary in the natural process of repair after fracture. For this purpose, those remedies should be employed which were spoken of in treating of delayed union, the fragments being accurately adjusted, and rendered perfectly immovable by the use of suitable splints and bandages. Firm and accurately-fitting splints of metal, leather, or paste- board may be employed, or the plaster-of-Paris bandage,1 or (in the case of the lower extremity) the ingenious and elegant contrivances of Prof. Smith, of this city, or of Dr. Hudson, of New York. In order to excite renewed activity in the periosteum and other bone-producing tissues, various plans, such as blistering, cauterizing, or galvanizing the skin, have been employed, and when the beneficial effect of transmitted periosteal and medullary irrita- tion is remembered, it can readily be understood that these methods should occasionally have proved successful. Other plans Avhich have sometimes succeeded, consist in rubbing together the ends of the fragments them- selves, and in "percussing" the injured limb with a rubber-protected mallet (Thomas). In the event of these simple remedies failing, severer measures may be employed: of these the most important are the establishment of a seton betAveen the fragments, as recommended by Dr. Physick, or on either side of the ununited fracture, as suggested by Oppenheim ; the introduction of stimulating injections, as practised by Hulse, Bourguet, and Fitzgerald; acupuncture, as suggested by Malgaigne; the introduction of ivory pegs (Dief- fenbach and Hill) ; electro-puncture (Lente) ; subcutaneous scarification (Mil- ler) ; drilling the fragments themselves (Detmold and Brainard) ; scraping or cauterizing the fragments; holding the fragments together by means of sutures or pins (Severinus, Rodgers, Gaillard, and F. Mason); resection (White, Roux, Jordan, and BigeloAv) ; covering in the false-joint Avith peri- osteal flaps inverted from the bone above and beloAV (Rydygier); transplanta- tion of fragments split off from a neighboring bone (Niissbaum), or from 'Guenther, a Danish surgeon, and Nillien, of Illinois, have observed that the growth of the nails is arrested during the early stages of a fracture, to be resumed as the process of repair goes on, and they snggest"this as a means of testing the progress of cure, without disturbing the dressings, in cases of delayed union, or of false joint. It would appear, however, that the growth of the nails may be checked by any cause which interferes with the nutrition of the part, and hence this test might not be uni- versally applicable; Mitchell has noticed an arrest of nail growth in cases of cerebral paralysis, and Gay has observed the same phenomenon as a result of compression of the subclavian artery. 240 FRACTURES. bones of other patients (MacEwen), or of dogs (Patterson); and finally amputation. Of all these, the most promising methods are, I think, those oi Physick, Brainard, Gaillard, and BigeloAv. Before resorting to any of them, the suggestion of Oilier may be adopted, to rejuvenate, as it were, the peri- osteum by the milder forms of irritation, that it may afterwards more readily respond to the severer operation. Physick introduced a piece of silk or tape, by means of a long seton needle, directly betAveen the frag- ments, and allowed the foreign body to remain four or five months. Norris has, however, shown that the seton is equally efficient and more safe Avhen removed at an earlier period, and surgeons now seldom alloAV it to remain longer than a fortnight; it is rarely used in the case of the thigh, Avhere other means are- more successful. Brainard's plan consists in drilling the fragments subcutaneously Avith a metallic perforator or bone drill. His manner of using the instrument, as quoted by Hamilton, is as follows: " In case of an oblique fracture, or one with overlapping, the skin is perforated Fig. 110. Improved bone-drill. Avith the instrument at such a point as to enable it to be carried through the ends of the fragments, to wound their surfaces, and to transfix whatever tissue may be placed between them. After having transfixed them in one direction, it is Avithdrawn from the bone, but not from the skin, its direction changed, and another perforation made, and this operation is repeated as Fig. 111. Gaillard's instrument for ununited fracture. often as may be desired." Prof. Gaillard's method consists in pinning to- gether the fragments by means of a gimlet-like instrument, provided with a movable silver sheath, a handle, and a brass nut (Fig. Ill): the sheath is introduced through an incision, and held against the bone, while the shaft is passed through and made to transfix both fragments; the nut is then screwed down firmly on the sheath, the whole instrument being allowed to remain in situ till union is obtained. This plan affords more secure apposi- tion than merely Aviring together the fragments, as practised by Rodgers, Flaubert, N. R. Smith, and others. The operation employed by Prof. Bige- FRACTURES OF THE FACE. 241 low, of Boston, is almost identical with that independently suggested by Oilier, of Lyons, and is probably the surest method of treating ununited fracture; it consists in making a subperiosteal resection of the ends of the fragments, the freshened extremities being then held together by a Avire suture. Dr. Bigelow has thus treated eleven cases, with but one failure, and that from disease of the bone, which subsequently required amputation. This plan has also been successfully adopted by other surgeons, including Byrd, of Illinois, Annandale, Packard, and myself. Whatever method be employed, the after-treatment must be carefully con- ducted by the use of proper splints, and by the administration of tonics and good food. The phosphate of lime is recommended by Bigelow and Dolbeau, the latter of whom finds that the action of the drug is manifested by the occurrence of formication in the injured limb. In some cases, when the inconvenience resulting from the ununited fracture is not very great, it might be advisable to decline any operation, and employ the apparatus of Prof. Smith, already referred to, or some similar contrivance. CHAPTER XII. SPECIAL FRACTURES. I have gone so fully, in the last chapter, into the consideration of the causes and symptoms of fractures in general, and of the principles by which the surgeon should be guided in undertaking their treatment, that it will not be necessary to repeat what has been said, with regard to each several bone ; hence, in the present chapter, I purpose merely to point out the peculiar symptoms and diagnostic marks of the special fractures, and to indicate very briefly the most convenient and satisfactory modes of treatment, referring the reader, for more detailed information upon this subject, to the excellent treatises of Hamilton, Malgaigne, Cooper, Smith (of Dublin), Lonsdale, etc., and to the chapter on Fractures in Dr. Wales's valuable Avork on Mechanical Therapeutics, Avhich contains a very good account of the different forms of apparatus devised for the treatment of broken bones. Fractures of the skull, and of the vertebrae, are principally interesting on account of their involving respectively the brain and spinal cord; hence their consideration Avill be post- poned till Ave come to speak of injuries of those parts of the body. Fractures of the Face. Any of the facial bones may be broken by direct violence, and especially by gunshot wound; the nature of the injury is usually recognized Avith facil- ity, and the treatment should be particularly directed to the lesion of the soft tissues. Nasal Bones.—These are not unfrequently broken, and the injury may escape detection from the rapid swelling of the soft parts. The treatment consists in removing the displacement (if there be any), by inserting a broad director or a pair of polypus forceps into the nostrils, and moulding the bones into their proper places; the parts may then be supported by means of a com- 16 242 SPECIAL fractures. press on either side, and a feAv strips of adhesive plaster, or, as suggested by L. D. Mason, of Brooklyn, by passing a pin beneath the bones so as to keep them in position. If the septum be broken, it should be restored to its proper place in the same Avay, the shape of the nose being preserved by plugging the nostrils, if necessary. Occasionally the Avhole nose is split off, as it Avere, from the face, hanging by the alas in front of the mouth. In such a case, in which the injury Avas produced by a bloAV from an iron pan, I kept the nose in place by numerous sutures, the patient making a good recovery. Sometimes the whole nose is driven inwards, fracturing the ethmoid bone, and involving the brain. Under such circumstances, the nose should be gently drawn forwards Avith forceps, and the case treated as one of fracture at the base of the skull. Profuse hemorrhage may require plugging of the nares. W. Adams and R. F. Weir have devised special apparatus for for- cibly straightening the nose when deformity has ensued, and for subsequently keeping the parts in position. An ingenious nasal splint has also been de- vised by Gamgee, of Birmingham. Fracture of the Lachrymal Bone may cause obstruction of the nasal duct, and consequent epiphora; or emphysema of the subcutaneous tissue may follow whenever the patient blows his nose. Fracture of the Malar Bone is to be treated by keeping the parts in place by compresses, adhesive strips, and bandages. Fracture of the Zygoma, if comminuted, may interfere with mastication, by the impaction of splinters in the temporal muscle; in such a case, the surgeon should cut down and remove the offending fragments. Upper Maxilla.—Fractures of the upper jaw are sometimes attended Avith such profuse hemorrhage as to require plugging the antrum, or even ligation of the external carotid. If the malar bone be thrust in upon the antrum, it should be drawn out with a tirefond, or screAV elevator (Fig. 78), aided by pressure from within the mouth. If the upper jaw be broken through the alveolus, the teeth may be held together by means of Avire. The vascular supply is so free in this part, that necrosis rarely folloAvs, even in cases of gunshot injury; the fetid discharge is, however, a source not only of annoy- ance, but of constitutional depression, and hence free use should be made in such cases of detergent and disinfectant washes. Sometimes all the bones of the face are crushed and separated from their attachments by explosions, violent blows, or falls. Such cases are attended Avith great shock, and usu- ally prove fatal from hemorrhage or cerebral complication. Lower Maxilla.—The loAver jaw is more frequently broken than any other bone in the face. The fracture, which is usually caused by direct violence, may be in any part of the bone, the most usual seats being, hoAvever, near the symphysis, and about the position of the mental foramen. The lower jaw is often broken in two or more places at once, and its fractures are fre- quently rendered compound by laceration of the mucous membrane. Frac- tures near the symphysis are more or less transverse, AA'hile those further back are almost invariably oblique from before backwards, allowing considerable displacement, Avhich is evidenced by shortening of the alveolar border, and depression of the chin. In fractures near the angle of the bone, the dental nerve is occasionally involved, an accident which causes temporary paralysis, or more rarely convulsions. The displacement, mobility, and crepitus, which accompany fracture of the jaw, render its diagnosis usually easy: in cases of fracture of the LOWER MAXILLA. 243 Fig. 112. Barton's bandage for fractured jaw. fracture below the condyle, there is, besides, embarrassment in the motions of the jaAv, and pain, felt especially on opening or shutting the mouth. Frac- tures of the lower jaAV commonly unite without much difficulty, and with little deformity. Treatment.—For the treatment of an ordinary case of broken jaAv, nothing is required except a compress to support the chin, and a roller bandage. Velpeau, indeed, during the last years of his life, is said to have abandoned all forms of apparatus, in the treatment of these injuries, believing that suf- ficient rest Avas insured to the fragments by the inevitable occurrence of pain upon any attempt at motion made by the patient. I am in the habit of treating these fractures in the manner recommended by Dr. J. Rhea Barton, of this city, Avith the superaddition of a few occipito- frontal turns of the roller, as in Gibson's band- age. The following description of Barton's band- age is taken from Sargent's minor surgery:— " Comj>osltlon : A roller five yards long, and tAvo inches Avide ; suitable compresses. Application : Place the initial extremity of the roller upon the occiput, just below its protuberance, and conduct the cylinder obliquely over the centre of the left parietal bone, to the top of the head ; thence de- scend across the right temple and zygomatic arch, and pass beneath the chin," Avhich should be sup- ported by a compress, " to the side of the face; mount over the left zygoma and temple to the summit of the cranium, and rejoin the starting-point at the occiput, by traversing obliquely the right j:>arietal bone; next, wind around the base of the lower jaAv on the left side to the chin, and thence re- turn to the occiput along the right side of the maxilla;" to these three turns, I add a fourth, around the head just above the ears, making an occipito- frontal turn, Avhich being pinned at its intersection Avith the others, serves to prevent slipping. The same course is to be continued until the roller is ex- hausted, and additional security may be furnished by sealing the bandage (as it were) Avith a feAv strips of adhesive plaster. Gibson's bandage consists of a compress beneath the chin, with turns of a roller passing from that part to the top of the head, from the occiput to the forehead, and from the nape of the neck to above the mental protuberance, the Avhole being held in place by a short strip passing from the forehead, backAvards to the nape along the median line of the head. Many surgeons prefer to treat fractures of the jaw Avith an external splint, moulded from pasteboard or gutta-percha, and held in place by a simple sling of four tails, tAvo of Avhich are tied on the top of the head and two be- hind the neck (Fig. 1 o), or with an ingenious apparatus composed of a leathern sling, Avith strong linen Avebbing straps, devised for the treatment of these cases by Prof. Hamilton ; wiring together the teeth on either side of the frac- ture is often recommended, but I confess to have seen very little advantage from the practice: a better plan is the application of clasps of ivory, silver, steel, or other material, as practised by Lonsdale, Mutter, N. R. Smith, Nicole, Wales, Bullock, and others, or of interdental splints of gutta-percha or vulcanized India-rubber, as ingeniottsly applied by Dr. Gunning, of New York, and Dr. Beans, of Atlanta, Ga. In a case of fracture of both rami of the jaAv, Aunandale succeeded in obtaining a good result by cutting down externally, on each side and securing the fragments by means of the wire suture. A similar plan, in cases of single fracture, had been previously em- 244 SPECIAL FRACTURES. ployed by Buck and Hamilton, of NeAv York, and by Kinloch, of Charles- ton, and I have myself adopted it with good results, Avhen there has been much tendency to separation of the fragments. Whatever mode of treatment be adopted, care must be taken not to pro- duce uneven or undue pressure. Neglect of this precaution will cause great irritation, and probably the formation of abscess, a very troublesome and painful complication of fractured jaw, and one that may give rise to necrosis and to consequent non-union, which accident is, in this position, I believe, more apt to result from tight bandaging than from the bandage being too loose. Gunshot fracture of the lower jaw is sometimes attended with so much splin- tering as to require partial resection of the bone. The period required for the cure of a simple fracture of the jaw is usually from three to six Aveeks. Fracture of the Hyoid Bone is a very rare accident. Hamilton has col- lected ten cases, of Avhich three Avere caused by hanging, three by grasping the throat between the thumb and fingers, three by direct bloAvs or falls, and one by muscular action. The accident is attended with great pain, sometimes with hemorrhage, and with difficulty in opening the mouth, in SAvallowing, and in speaking. The diagnosis can be made by observing the mobility of the fragments, and the imvard angular displacement, with or Avithout crepitus. The treatment consists in reducing the deformity, by press- ure from within the mouth, and in keeping the parts at rest by use of a pasteboard or leather collar, Avith the enforcement of quiet, and the hypo- dermic administation of opium. Of thirteen cases- collected by Dr. Gibb, two proved fatal. Fractures of the Trunk. Ribs.—The ribs are more frequently broken than any of the other bones of the trunk: these injuries may be produced by direct violence, as from the kick of a horse, or by indirect violence, the front and back of the chest being pressed together, and the ribs giving way like an over-bent bow, at the weak- est part.1 The ribs are occasionally broken by muscular action (as in partu- rition), or, according to Malgaigne, even by the impulse of the heart. The middle ribs, from the fourth to the tenth, are those most exposed to fracture, and the usual seats of injury are near the junction of the costal cartilages, and in the neighborhood of the angles. The direction of the fracture is com- monly transverse or slightly oblique; occasionally a rib is comminuted, or broken in more than one place. These fractures are rarely compound, except as the result of gunshot wounds. The displacement in cases of fractured rib is usually slight; if the result of a direct bloAV, there will probably be some inward angular deformity, Avhile if from indirect violence, the projection Avill be outAvards ; if a number of ribs on the same side be broken, there may be a slight tendency to overlapping. The diagnostic signs are deformity, mobility, and crepitus, Avhich is sometimes readily perceived, but at other times can only be elicited by careful and prolonged manipulation, by compressing the chest from before backAvards, or by auscultation. There are, besides, pain and localized tenderness, Avith a sharp stitch, if the pleura be Avounded, and, possibly, haemoptysis, pneumothorax, or emphysema, if the lung be involved. The pain is much increased by movements of the chest Avail, and the breath- ing is therefore shallow, and to a great extent diaphragmatic. The prognosis is favorable; except in cases complicated with thoracic or other severe in- 1 This is denied by E. H. Bennett, of Dublin, who has shown that impaction with splintering, and inward displacement, may result from indirect violence. FRACTURE OF THE STERNUM. 245 jury, it is very rare for death to folloAV fracture of the ribs. Union com- monly takes place in from three to five Aveeks, Avith very little deformity, and by means of a Avell-marked ensheathing callus. False-joint is occasionally met Avith in this situation, Avhile, on the other hand, the production of new bone is sometimes excessive, causing coalescence betAveen adjacent ribs. Treatment.—In the treatment of fractured ribs, the surgeon may disregard any existing deformity, Avhich will usually spontaneously disappear by the expansion of the chest in the respiratory movements; even if it should not, it would be preferable to allow the displacement to remain, rather than to attempt its removal, as has been proposed, by the use of sharp hooks or screAV elevators. The chief indication in any case of fractured rib, is to put the affected part in a state of complete rest, and this may best be done by sur- rounding the side of the chest Avhich is involved, Avith numerous overlapping broad strips of adhesive plaster, each reaching a little beyond the median line, both behind and before. This mode of treatment, Avhich appears to have originated Avith Dr. Hannay, of England, is, according to my experi- ence, much superior to any other Avhich has been proposed. The strips, Avhich should be about tAvo inches wide, are laid on in circular layers, beginning from beloAV, each strip overlapping its predecessor by about one-third of its width. As the dressing becomes loosened, other layers of strips are to be tightly applied immediately over the first, so that the chest is kept constantly fixed by a stiff and firm splint of adhesive plaster. The patient will usually be most at ease in a sitting posture for the first day or tAvo. Thoracic com- plications must be met by appropriate treatment, and in any case opium may be freely administered. The dressing may be removed at the end of three weeks, Avhen union is commonly sufficiently firm to enable the surgeon to discontinue his attendance. If, in any case of injury of the chest, it is uncertain whether a rib be broken or not, the dressing above described should be ap- plied, as it Avill aff! >rd great comfort, even in cases of contusion Avithout fracture. The emphysema Avhich sometimes accompanies fracture of the ribs requires no special treatment, usually disappearing spontaneously in the course of a feAv days or Aveeks. Rupture or laceration of an intercostal artery, Avhich proved fatal in a case recorded by Amesbury, could scarcely be recognized unless the fracture Avere compound. Under such circumstances an effort should be made to secure the bleeding vessel, for which purpose, if necessary, a portion of the adjacent rib might be excised. In cases of gunshot fracture, all spiculse should be carefully removed, and the after-treatment conducted Avith reference to the condition of the thoracic Ariscera, on the principles which Avill be laid doAvn in the chapter on Injuries of the Chest. The (ostal Cartilages are occasionally broken, either at their junction Avith the ribs or through their middle. The causes are the same as in the case of fractured ribs; but, as the violence required is greater, there is more apt to be serious visceral complication. The symptoms are the same as those of fractured ribs, except that crepitus is rarely perceptible. The direction of the fracture is commonly transverse, the anterior fragment usually project- ing in front of the posterior. Union takes place by the production of bone, not of cartilage, the callus being chiefly developed on the pleural side of the fracture; non-union has been observed in one case by Hamilton. The treat- ment consists in the application of adhesive strips, as for fractured ribs.1 Sternum.—True fracture of the sternum is a very rare accident. Dias- tasis of the first from the second bone is more often met Avith, and is a less 1 See interesting papers by Dr. E. H. Bennett, in the Dublin Journal of Medical Science for March, 1876, and October, 1877. 246 SPECIAL FRACTURES. serious affair. These injuries may result from direct violence, from counter- stroke (the force being applied to the back), or from muscular action, as in parturition, or in the act of vomiting. The line of separation is usually transverse, though it may be bevelled as regards the thickness of the bone. Malgaigne, Kramer, and Meyer have each observed longitudinal fractures of the sternum. The most usual seat of injury is at the junction of the manubrium and gladiolus, and in this situation the lesion is, as already ob- served, commonly a diastasis, or, according to Maisonneuve, Brinton, and Rivington (aa4io have repeatedly observed a true joint in this position), a dislocation. It is a matter of some importance, as regards the prognosis, to be able to say in any individual case whether the lesion be a true fracture or a diastasis, for in the latter case, the posterior ligament being intact, the patient usually escapes visceral complication. In true fracture, the lung or even the heart may be torn, and, even if these dangers be avoided, there is considerable risk of the subsequent formation of abscess in the mediastinal space. The following may be looked upon as evidences of true fracture, viz., the presence of crepitus, the injury being beloAV the junction of the first and second bones, or the fact of the upper fragment projecting in front of the lower. In diastasis the lower rises in front of the upper fragment. Direct violence exerted upon the manubrium has never been known to produce true fracture, while when exerted upon the gladiolus it almost never produces diastasis. In cases of injury from indirect violence, if the marks of fracture above given be not present, the diagnosis must be made by noting the presence or absence of haemoptysis, emphysema, etc. The ensiform cartilage is rarely the seat of fracture or dislocation, though well-marked cases have been observed by Hamilton, Martin, Billard, Mau- riceau, Gallez, and Polaillon. In making the diagnosis of fractured sternum, the possibility of a con- genital deformity being mistaken for the result of violence, must not be over- looked. The detection of crepitus and mobility may be facilitated, as sug- gested by Despres, by placing a cushion beneath the back, so as to render the front wall of the thorax prominent. The diagnosis in cases of fracture from counterstroke may, according to Hewitt, be aided by noting the occur- rence of ecchymosis some days after the reception of the injury. The prog- nosis of diastasis, or of uncomplicated fracture, is favorable; union usually takes place in from three to four weeks. The treatment consists in keeping the parts at rest, by the application of a broad compress, held in position with adhesive strips or bandages. If there be much displacement, attempts at reduction may be made, by straightening the spine and drawing the shoulders backwarks. Opium will usually be required, and any thoracic complications must be met by suitable remedies. Mediastinal abscesses should be opened at the side of the sternum, when pointing occurs; they have been evacuated by Gibson and others by the use of the trephine, but the results of the operation do not Avarrant its repetition. Pelvis.—Fractures of the pelvis are chiefly interesting on account of the liability to implication of the adjacent viscera. One of the Ossa Innominata may be broken, the injury being sometimes limited to a separation of the crista ilii, or of one of the spinous processes, and at other times passing through the rami of the pubis or ischium, or in the neighborhood of the sacro-iliac symphysis. The ilium, pubis, and ischium may separate in their lines of conjunction, the acetabulum being thus split into three portions ; or diastasis may occur at the pubic or sacro-iliac symphyses. Fractures of the pubis and ischium assume a somewhat oblique direction, Avhile those about the sacro-iliac junction correspond pretty generally to the line of the symphysis. FRACTURES OF THE SACRUM AND COCCYX. 247 The diagnosis of fractured pelvis can usually be made without much difficulty. There is great pain, aggravated by motion, and especially by any attempt to walk or stand; there is abnormal mobility; and crepitus can be elicited by grasping the ilia in either hand and moving them in opposite directions. The displacement in fractures of the pubis and ischium is often considerable, and can usually be readily detected. These injuries are commonly caused by great violence of a crushing nature, such as the fall of a bank of earth. In one case, Avhich Avas under my care, the crest of the ilium was knocked off by a sharp bloAV resulting from the fall of a stove-pipe. The pubis has some- times been fractured as the result of muscular contraction, as in a remarkable case recorded by M. Letenneur, Avhile diastasis of the pubic, and occasionally of the sacro-iliac, symphysis may occur in the process of parturition. Frac- ture of the Acetabulum is an accident that is often spoken of as complicating dislocation of the hip. I believe, however, with Prof. Bigelow, that this fracture is much rarer than is generally supposed, and that its existence should never be assumed unless crepitus can be detected at the seat of supposed lesion, Avhile even in such a case the injury (as pointed out by Birkett) may really consist in a luxation, complicated with fracture of the head of the femur. Fracture of the acetabulum may consist merely in a separation of its posterior lip, or in a destruction of its floor, attended some- times Avith impaction of the head of the femur in the pelvic cavity. The latter form of injury is commonly attended Avith such severe visceral lesions as to prove fatal. Separation of the lip of the acetabulum is marked by the signs of dislocation, the displacement being readily reduced with crepitus, but as readily reproduced Avnen extension is discontinued. The great danger in cases of fracture of the pelvis is from rupture or lace- ration of the bladder or urethra. Hence the surgeon's first step should be to pass a catheter, Avith a vieAv of ascertaining the condition of those organs ; if they are found to have been injured, prompt treatment must be employed, according to the principles which will be laid down in speaking of Injuries of the Pelvic Viscera. The treatment of fractured pelvis consists in the first place in restoring the displaced fragments to their proper position, if this can be done Avithout vio- lence ; in the case of a woman, reduction may be assisted by introducing one or more fingers into the vagina. The entire pelvis should be surrounded by a padded belt, or firm and broad roller, so as to keep the parts at perfect rest, while the hip-joint of the affected side is fixed by means of a pasteboard splint or a sand-bag, as in cases of fractured thigh. The patient should lie on his back, on a hard mattress, Avith the knees slightly flexed, and supported by pilloAvs. Compound fractures of the pelvis are usually fatal accidents, though I have seen recovery after perforating gunshot fracture of the ilium. In the treatment of such a case, all splinters should be carefully removed, and means adopted to secure free drainage through the external wound. Sacrum and Coccyx.—Fractures of these parts usually result from direct violence, the fracture being trans\rerse, and the lower fragment pressed in- Avards upon the rectum. Richerand gives one case of longitudinal fracture of the sacrum. These injuries are rarely met Avith except in connection with other severe pelvic lesions, and are then apt to prove fatal; the treatment Avould consist in endeavoring to effect reduction by pressure from Avithin the rectum, and in the application of a padded belt. Bernard, a French sur- geon, plugged the rectum Avith a lithotomy tube, in order to maintain reduc- tion, but I should prefer, Avith Hamilton, to dispense with such an instrument and rely upon keeping the parts at rest and administering opium. Fracture of the coccyx sometimes results in the development of a very painful neu- 248 SPECIAL FRACTURES. ralgic condition of the part, constituting a form of the affection described by Dr. Nott and Sir J. Y. Simpson, and known as coccygodynia; the treatment recommended by those gentlemen consists in subcutaneous division of the ligamentous attachments of the part, or, if that fail, in excision of the bone itself, an operation Avhich has been successfully resorted to by several sur- geons, including Dr. Burnham, Dr. Mursick, Dr. Morton, and myself. Fractures of the Upper Extremity. Clavicle.—The clavicle is peculiarly liable to fracture, not only from its exposed position, but from the fact of its being the sole bond of osseous con- nection between the trunk and the upper extremity. It may be broken by direct violence in any part of its length, but is much oftener fractured by indirect violence (such as a fall or blow on the shoulder), and then usually giAes way near the outer end of its middle third, where the bone is Aveakest. Partial fracture from indirect violence is usually situated tOAvards the inner Fig. 113. Attachments of outer end of clavicle; showing branches of coraco-clavicular ligament. (Gray.) end of the middle third, and is characterized by slight angular projection. Partial fracture from direct \riolence is commonly situated more externally, and is marked by angular depression. Muscular action is an occasional cause of fractured clavicle, particularly, according to Delens, of fractures of FRACTURE OF THE CLAVICLE. 249 the inner third of the bone; the immediate mechanism of the accident in some cases may be, as suggested by Dr. Packard, the bending of the clavicle over the first rib, Avhich acts as a fulcrum. Fractures from direct violence are commonly transverse, and may occasionally be comminuted; fractures from indirect violence are almost invariably oblique, the bevelling being from before backAvards, and from without imvards. Fracture of the sternal end of the clavicle, within the fibres of the costo-clavicular ligament, is usually attended with but little displacement, though, according to R. W. Smith, the outer fragment is in these cases displaced forwards, or forwards and slightly downwards; similarly, there is little displacement in fracture of the outer third, within the limits of the coraco-clavicidar ligament, but if the fracture be outside of the trapezoid branch of that ligament, the displacement, accord- ing to the same surgeon, is quite marked. According to A. Gordon, how- ever, even the- existence of the last-named variety of fracture is doubtful. Fractures of the middle of the clavicle, especially such as are produced by indirect violence, are accompanied Avith great and very constant displacement. This consists in a tilting upAvards of the inner fragment, and a dropping of the outer fragment, Avhich is also rocked inwards and someAvhat backwards by the action of the powerful muscles attached to the scapula, particularly the rhomboidei, trapezius, levator anguli scapulae, pectoralis minor, and some fibres of the serratus magnus. The diagnosis of fractured clavicle can usually be made Avithout difficulty: if the middle of the bone be invoked, the displacement is in itself sufficiently characteristic, Avhile crepitus can readily be elicited in any position of Fig. 114. the fracture, on account of the sub- cutaneous character of the bone in its Avhole length. In cases of partial or partially impacted fracture from direct violence, an accident of not unfrequent occurrence among quite young children, persistent tenderness over the point of injury will be found a valuable diagnostic sign. The at- titude of the patient, in cases of com- plete fracture, is peculiar, and often significant of the nature of the in- jury ; the head is bent tOAvards the affected side, so as to relax the mus- cles, Avhile the elboAV and forearm are supported in the opposite hand, so as to diminish the dragging sensa- tion produced by the Aveight of the limb. The prognosis, as regards the life of the patient and the utility of the limb, is very favorable; I believe, however, that a perfect cure—that is, Avithout deformity—is very rarely ob- tained, at least in oblique fractures Of Complete oblique fracture of clavicle near its mid- the middle of the bone. Comminided die. (Gray.) fracture of the clavicle is sometimes a serious injurv, from concomitant laceration of the subclavian vein or plexus of nerves, ('ompound fracture of this bone is rare, except as the result of gunshot injury, Avhen it is apt to prove fatal from thoracic complications; I had, however," under my care, some years ago, a case of multiple fracture of 250 SPECIAL FRACTURES. the clavicle from direct violence, which became secondarily compound by the occurrence of suppuration; slight necrosis followed, but the patient eventually made a good recovery. Fracture of both clavicles is an accident of rare occurrence, but presents no peculiarities, except that of course it requires some modification of the apparatus used in treatment. Treatment of Fractured Clavicle.—The treatment of fractured clavicle may be conducted by position alone, or by position aided by various forms of appa- ratus. The deformity, as we have seen, depends (1) on the tilting up of the inner fragment, by the resiliency of its ligamentous attachments and the action of the sterno-cleido-mastoid muscle; (2) on the falling of the shoulder with the outer fragment, due to the weight of the arm; but (3) chiefly on the rocking inwards and backwards of the outer fragment, by the action of the powerful muscles attached to the scapula, Hence the indications for treat- ment are, (1) to relax the sterno-cleido-mastoid muscle, (2) to prevent the weight of the arm from dragging doAvn the outer fragment, and (3) by fixing the scapula, to carry the attached external fragment outwards and forwards, and thus restore the shape of what has been not inaptly called the "shoulder girdle." These indications may all be met by position alone. For this pur- pose the patient should lie flat on his back, on a firm, hard mattress, Avith the head slightly elevated, and the arm flexed and carried across the chest, so that the hand rests on the sound shoulder—the position commonly knoAvn as the " Velpeau position," from its having been employed by that distinguished surgeon in the treatment of these and other injuries (see Fig. 116). The elevation of the head (by means of a single pilloAV, Avhich must not touch the shoulders) relaxes the sterno-cleido-mastoid muscle, and thus obviates the tendency to upAvard tilting of the inner fragment; the position of the arm across the chest makes the weight of the limb act, if at all, in an upAvard direction, and thus effectually prevents any downward displacement; while the weight of the chest, together Avith the firm and even counter-pressure of the mattress, serve to fix the scapula, and thus prevent that rocking of the bone around the chest which causes the imvard and backward displacement of the outer fragment. By this simple mode of treatment the deformity can, at least in the immense majority of cases, be completely reduced, and could the patient be trusted to remain quiet for a sufficient length of time (three to four weeks), nothing further would be required. In practice, however, very few patients can help shifting their posture in sleep, if not while awake, and hence retentive apparatus is usually necessary. If the patient can remain in bed, the scapula may be fixed by a broad and long wedge-shaped pad, applied as a compress on the lower blade of the bone, and held in place by several broad strips of adhesive plaster, Avhile the arm is fastened in the "Velpeau position" by a few strips of the same material. If the patient cannot remain in bed, the same appliances may be used, with the addition of a compress upon the projecting end of the inner fragment, and a broad roller bandage used as what is knoAvn. as the " third roller of Desault,"1 Avith additional cir- cular turns to fix the arm in the required position. The same indications may be met by using Fox's apparatus (to be presently described), or any of 1 The application of the third roller of Desault is thus described by "Wales: Place the initial extremity of the roller " under the axilla of the sound side, then conduct the cylinder over the broken clavicle, upon which a compress must be placed, down the posterior surface of the arm under the elbow., and over the forearm to the point of departure; thence across the back obliquely over the injured shoulder, down the front of the arm and under the elbow, to pass obliquely across the chest to the axilla of the sound side." These turns are repeated until the roller is exhausted, thus form- ing two triangles, one in front and the other behind the chest; the firmness of the bandage may be much increased by making additional circular turns as recommended in the text. FRACTURE OF THE CLAVICLE. 251 Fig. 115. its modifications, taking care to apply the pad—not as an axillary fulcrum, but simply as a scapular compress. The posterior figure of 8 bandage, recom- mended by some authors, is defective in that its force is exerted on the acro- mial part of the scapula only, and not on the entire bone ; the same objection applies to most of the back splints devised for these cases, though a back splint, such as that devised by Dr. Staples, of Minnesota, broad enough to fix both scapuhe, might be made a useful adjuArant to the compresses already described. Vacher, of Birkenhead, has modified the figure of 8 bandage by applying metallic caps to both shoulders, and draAving them backAvards by means of a posterior strap and buckle. The apparatus introduced by Dr. (Jeorge Fox, of this city, is thus described by Sargent: "The apparatus con- sists of a firmly stuffed pad of a Avedge shape, and about half as long as the humerus, having a band attached to each extremity of its upper or thickest margin; a sling to suspend the elbow and forearm, made of strong muslin, with a cord attached to the humeral extremity, and another to each end of the carpal portion; and a ring made of muslin stuffed Avith cotton to encircle the sound shoulder, and serve as means of acting upon and securing the sling." Fox's apparatus has undoubtedly produced a great many ex- cellent cures; it has done so, however, I believe, by fixing the scapula more or less perfectly, and not by affording leverage to the humerus, as it Avas originally intended to do. Indeed, the wedge-shaped pad, if used as a fulcrum, pro- duces so much pain that feAv patients can endure it for any length of time; so that in practice surgeons generally apply it far back—where it acts merely as a scapular compress—or else reduce its thickness to such a degree that its action as a fulcrum is entirely defeated. Fox's apparatus has been ingeniously modified by Dr. Levis, Prof. Hamilton, and others, and any of these forms of the sling and pad dressing may be used Avith good results, provided that they are accurately adjusted and carefully watched by the surgeon.1 Moore, of Rochester, and Sayre, of NeAV York, belieA-e that the point of most importance is to render tense the clavic- ular fibres of the pectoralis major muscle, and thus draw the inner fragment downwards; the former surgeon accomplishes this purpose by forcing the entire arm backwards, and fixing it Avith a shaAvl or strip of muslin folded as a cravat and made to describe figures of 8 around the sound shoulder and the elbow of the affected side; Avhile Prof. Sayre employs two broad adhesive strips, one of Avhich fixes the arm and acts as a fulcrum, Avhile the other forces the shoulder backwards by drawing the elbow fonvards, at the same time supporting the forearm, as shown in Fig. 115. Dr. Satterthwaite has modified Sayre's dressing by adding an axillary pad, and employing elastic bands instead of adhesive plaster. Union of a fractured clavicle usually occurs Avithin three weeks, but the dressing should be retained, as a matter of safety, at least a couple of Aveeks longer. 1 See a full and able discussion of the principles of treatment of fractured clavicle, and the comparative merits of different forms of apparatus, by Dr. Edward Harts- horne, of this city, in the 2d volume of the Pennsylvania Hospital Reports, pp. 108-142. Sayre's dressing for fractured clav- icle. (Hamilton.) 252 SPECIAL FRACTURES. Scapula.—The scapula may be broken through its body, through its neck, through the glenoid cavity, or through the acromion or coracoid processes. Fracture of the Body of the Scapula is a rare accident, and is usually due to direct violence, though it is said in one case (Heylen's) to have been pro- duced by muscular action. If the spine of the scapula be involved, the line of fracture can commonly be detected with facility by palpation, and in other cases crepitus can generally be elicited by pressing firmly on the scapula Avith one hand, Avhile the other moves the shoulder in various directions. The treatment consists in attempting to reduce the deformity, if there be any, by manipulation, and in then fixing the arm to the side by circular turns of a roller bandage or by adhesive strips, the forearm and elboAv being supported in a suitable sling. If the loAver angle have been separated from the rest of the bone, it may be secured, as advised by Boyer, by the additional applica- tion of a firm compress. Fracture of the Neck of the Scapula (in the anatomist's sense of the term) is an accident the possibility of Avhich has never been established by dissec- tion, and which, if it have ever occurred, except when complicated Avith comminution of the glenoid cavity, must certainly be very rare. The term "fracture of the neck of the scapula," as used by Sir Astley Cooper, hoAv- ever, means fracture through the supra-scapular notch, and in this position the lesion has unquestionably been met Avith, though very rarely. I have myself seen one example, in a child five years old. The amount of displace- ment depends on the degree of integrity of the various ligaments of the part, especially the coraco-clavicular and coraco-acromial. If these be ruptured the glenoid cavity and head of the humerus fall into the axilla (Avhere the latter may be sometimes felt), causing a depression beneath the acromion as in dislocations of the shoulder, though not so deep; crepitus is elicited by laying one hand on the shoulder, so as to touch the coracoid process, and Avith the other hand moving the arm in various directions. In a child the part may be grasped by placing the fingers on the shoulder and thrusting the thumb deeply into the axilla. The deformity can readily be reduced, but instantly recurs Avhen support is removed, and the coracoid process can be felt moving Avith the humerus, instead of Avith the acromion. The treatment consists in fixing the scapula by placing a thin pad or folded toAvel in the axilla, fastening the arm to the side by circular turns of a roller or adhesive strips, and supporting the forearm and elbow in a sling. The same dressing would be applicable in a case of comminution of the glenoid cavity. Fracture of the Acromion is probably a rarer accident than epiphyseal separation of that process. AVhen the line of fracture is through or behind the acromio-clavicular articulation, the shoulder drops fonvards, inwards, and dowmvards, as in cases of fractured clavicle; if, hoAvever, the fracture be in front of the acromio-clavicular articulation, there Avill be little or no displacement, and the diagnosis must be made by the detection of mobility and crepitus. Union occurs without much deformity, though rarely, accord- ing to Cooper, except by fibrous tissue. The treatment consists in fixing the arm and scapula by an axillary pad and bandage, and in supporting the elbow Avith a sling. This, as Avell as fracture of the body or neck of the scapula, may be also efficiently treated Avith the bandage known as Velpeau's, the application of Avhich can be seen from the accompanying illustration. Fracture of the Coracoid Process occasionally, though rarely, occurs, as the result of direct violence. There is seldom any displacement, and no treat- ment is required beyond the use of a sling, with perhaps a feAV turns of a roller around the arm and shoulder. Tavo or more of these various forms of scapular fracture may coexist in the same case, or any one of them may be complicated by fracture or dislo- FRACTURES OF UPPER EXTREMITY OF' HUMERUS. 253 €T^ cation of the humerus or clavicle; for the treatment of such injuries no gen- eral rules can be laid down, but each case must be managed Avith reference to its oAvn peculiar exigencies. The ingenuity of the surgeon will often be much taxed in endeavoring to meet the different indications presented, and he will often be disappointed by the persistence of deform- Fig. 116. ity, Avhich, however, fortu- nately seldom proves much of an impediment to the use- fulness of the arm. The time required for treatment, in cases of fractured scapula, is usually from three to four weeks. Fractures of the Humerus. —Fractures of the humerus are divided by Hamilton into eleven classes, of Avhich four are fractures of the upper ex- tremity (head, neck, and tu- bercles), one of the shaft, and six of the lower extremity. 1. Fractures of the Upper Extremity of the Humerus.— (1.) The fracture may pass through the Head and Ana- tomical Neck of the bone, being chiefly intra-capsular, and may or may not be impacted, according to circumstances. If the fracture be entirely In- tra-capsular, bony union cannot Avell occur, and the detached head of the humerus is apt to become carious or necrosed, requiring an operation for its removal. Fracture of the anatomical neck is attended Avith but little de- formity, nor does it much interfere with the motions of the part. There may be slight shortening, and crepitus can usually be elicited by pressing the head of the bone into its socket and making rotation; the shoulder is the seat of severe pain. This injury results from direct violence, and is principally met Avith in old persons. (2.) Fracture through the Tubercles of the humerus differs from the pre- ceding variety merely in being completely extra-capsular. Bony union takes place in these cases, but the motion of the joint is apt to be impaired by the irregular masses of callus which are formed. Crepitus may be detected by grasping the tubercles with one hand, and rotating the arm Avith the other; there is rarely much displacement, though, if the fracture be impacted, there may be slight shortening. The signs of this injury are very obscure, and in many cases the diagnosis cannot be positively made during life. i 3.) Longitudinal Fracture of the Head and Neck, or Splitting off of the Greater Tubercle, produces a marked increase in the antero-posterior diameter of the upper end of the humerus, and, while there is some depression under the acromion, a smooth, bony prominence can be felt under the coracoid proc- ess ; crepitus can be usually elicited by pressing together the tubercles and rotating the arm, while the mobility of the limb is unimpared. Union takes Velpeau's bandage. 254 SPECIAL FRACTURES. place by bone, or by fibrous tissue, according to the amount of separation be- tween the fragments. (4.) Fracture of the Surgical Neck of the humerus, under which head may be included separation of the upper epiphysis, is the most frequent form of injury met Avith in this region. The surgical neck is that part of the hume- rus Avhich extends from the line of epiphyseal junction to the place of inser- tion of the latissimus dorsi and pectoralis major muscles. Fracture of this part usually results from direct violence, and is often accompanied with great contusion and swelling of the soft parts. Separation of the epiphysis (Fig. 117) is an accident of early life, but true fracture, though met Avith in chil- dren, is more frequent among adults. Crepitus can be readily elicited, unless either impaction or overlapping have occurred ; in the latter case the diagnosis Fig. 117. Fig. 118. Separation of upper epiphysis of humerus. patient in the Episcopal Hospital.) (From a Fracture of the surgical neck of the humerus. (Gray.) can be easily made from the deformity, which is characteristic, and which consists m the upper end of the lower fragment being drawn upwards, inwards, and towards while the upper fragment is rotated outwards. Reduction is often difficult and sometimes impossible in these cases, in spite of Avhich, union commonly occurs without material impairment of the usefulness of the limb. Treatment of Fractures of the Upper Extremity of the Humerus.—Com- pound fractures of these parts, especially if resulting from gunshot injury, usually require either excision or amputation. The treatment of simple fractures of the upper end of the humerus may be conducted satisfactorily in the following way. A roller should be in the first place applied smoothly and evenly to the injured arm, from the tips of the fingers to, but not above, the seat of fracture. This bandage should be applied while the elbow is in a flexed position. A thin pad, compress, or folded towel is then to be placed in the axilla, so as to fill up the hollow of that part and afford a firm basis of support FRACTURES OF LOWER EXTREMITY OF HUMERUS. 255 to the humerus. This pad may be held in place by a bandage or by adhesive strips. The arm is then brought to the side, with the elbow a little forwards, so as to obviate the anterior angular projection, and sufficient extension made to reduce the fracture. The arm is to be securely fastened to the chest Avith circular turns of a roller or adhesive strips, and the forearm secured across the chest, somewhat as in the " Velpeau position," or merely sup- ported by a sling, as may be found most conve- nient. After a few days, when SAvelling has subsided, a moulded pasteboard or gutta-percha cap may be applied to the shoulder and upper half of the humerus, and will give additional security and firmness to the dressing. This simple mode of treatment, Avhich is very similar to that recommended by Fergusson (Fig. 119), will, I think, be found quite as efficient and a great deal less annoying to the patient than the angular splint, short splints, and axillary pad often used for the purpose. Erichsen uses a pad, a leather shoulder-cap, and a sling, while Hamilton employs a simple outside splint of gutta-percha without any pad. Welch's shoul- der-splint may be also used in the treatment of those injuries. Dressing for fracture of the surgical neck of the humerus. (Fergusson.) 2. Fracture of the Shaft of the Humerus is an accident of frequent oc- currence, and may result from either direct or indirect violence. The seat of the fracture is more often below than above the middle of the bone, and its line usually someAvhat oblique, from above doAvnwards and outwards. The displacement consists in the draAving upwards and inwards of the lower frag- ment, Avith some eversion of the upper fragment, and an anterior angular projection, due to the weight of the forearm. The diagnosis is easy, the in- creased mobility and crepitus rendering the nature of the injury almost unmis- takable. The treatment consists in the application of a bandage up to, but not above, the seat of fracture (until after the subsidence of SAvelling), and the use of an internal angular splint, with an outside splint moulded from paste- board or gutta-percha. If the anterior angular deformity give any trouble, the internal may be replaced by an anterior angular splint, or a short ante- rior splint may be used Avith the moulded pasteboard splint, while the forearm is laid across the chest, and fixed by a broad bandage, or merely supported by a short sling around the wrist. Various plans of making permanent ex- tension have been proposed, but are all of questionable utility, sufficient extension being afforded by the weight of the elboAv, which for this purpose should be unsupported, or, at least, not pressed upAvards. If the internal angular splint be used, care should be taken that it do not press on the axil- lary vein; the angle of the splint may be varied at different dressings so as to avoid stiffness of the elbow. 3. Fractures of the Lower Extremity of the Humerus.—(1.) Of these, the first to be considered is the Fracture at the Base of the Condyles not im- plicating the joint, under Avhich head may be properly included separation of the lower epiphysis of the humerus. This form of fracture usually results from indirect violence exerted upon the extremity of the elboAv, and its line is generally oblique, upwards and backwards. This injury is frequently confused Avkh dislocation of the elbow backwards, but the diagnosis can be 256 SPECIAL FRACTURES. made by observing that in fracture there is increased mobility, crepitus, short- ening of the humerus, but no change in the relative position of the olecranon and condyles, and that the deformity, while easily reduced, instantly recurs on the removal of extension. In dislocation, on the other hand, there is immobility, no crepitus, no shortening, but an obvious projection of the olecranon behind the line of the con- dyles, and the displacement A\Then reduced does not re- turn. (2.) Fracture at the Base of the Condyles, complicated by a Splitting Fracture be- tween them, is a somewhat rare accident; it is marked by the same symptoms as the preceding variety, with the addition of increased breadth of the lower end of the hume- rus, and of crepitus between the condyles, developed by pressing them together. Besides the above varieties, there may be separate fractures of (3) the Inner Condyle (trochlea), (4) the Inner Epicondyle (epitrochlea), (5) the Outer Condyle, and, possibly, (6) the Older Epicondyle, though I am not aware that the existence of this lesion has ever been demonstrated by dissec- tion. The diagnosis of these varieties of fracture can usually be made by the detection of mobility and crepitus, elicited by grasping the arm firmly Avith one hand, and moving either condyle succes- sively in various directions, or by pressing and rub- bing the condyles together. There is commonly not much displacement, except in case of fracture of the inner epicondyle, when the separated fragment is often displaced downwards in the direction of the hand. These injuries generally result from direct violence, and after recovery the elbow is often left stiff, if not absolutely anchylosed. Treatment of Fractures of the Lower Extremity of the Humerus.—Any of these fractures may be con- and^between1 Ihl condyles! veniently and efficiently treated by means of a sim- (Erichsen.) pie internal rectangular splint (Fig. 122), the fore- arm being in a semi-prone position with the thumb pointing upwards, or by means of an anterior angular splint, the forearm being supine. The splints should be Avell padded, and no bandage should be applied beneath the splint, until after the subsidence of inflammatory swelling. Indeed, the soft parts are often so much involved in these cases, that the use of evaporating lotions may be required for a few days, the limb being bandaged to the splint above and below, while the joint itself is left exposed. Several forms of apparatus have been devised for the treatment of these injuries, among the most ingenious of which may be specially men- tioned the splints of Sir A. Cooper, Hamilton, Bond, Welch, and Mayo. I am not aware, however, that they present any advantages over the simple form of dressing above recommended; whatever plan be adopted, great care must be taken to avoid undue or uneven pressure, which might produce ex- coriation or even gangrene. Great difficulty is sometimes experienced in Fracture at the base of the condyles. (Gray.) FRACTURE OF THE OLECRANON. 257 Fig. 122. Physick's elbow splints. maintaining reduction, from the action of the poAverful muscles at the back of the arm; by careful bandaging, however, and the judicious use of com- presses, this difficulty can usually be overcome.1 As already men- tioned, if the elboAA'-joint be in- volved in the fracture, there -will ahvays be great risk of anchylosis ; hence, it may be proper to resort to passive motion at a comparatively early period in these cases, as soon sometimes as the end of the third or fourth Aveek; or the patient may be directed to swing a flat-iron, as recommended in the last chapter. Compound fracture of the elbow-joint is a very serious injury, and usually re<|iiires excision or amputation. The time required for the treatment of a fractured humerus is commonly from five to eight Aveeks, according to the age of the patient, and other modifying circumstances. Fracture of the Olecranon is usually produced by direct violence, such as a fall on the point of the elboAv. It may also be caused by indirect vio- lence—a fall on the hand, etc.; or even by muscular action, through the poAverful contraction of the triceps extensor muscle. In the latter case, the mechanism of the injury probably consists in the olecranon process being broken as an overbent lever, across the condyles of the humerus, which act as a fulcrum. The symptoms of the accident are sufficiently obvious. If the ligamentous expansion of the triceps be extensively ruptured, the de- tached process will be drawn a considerable distance up the arm, giving rise to marked displacement. In the majority of instances, however (at least ac- cording to my OAvn experience), there is little or no separation, and the diag- nosis must then be made by noting the existence of abnormal mobility and of crepitus. Crepitus can commonly be elicited simply by seizing the ole- cranon and rubbing it laterally against the extremity of the shaft of the ulna, or, if there be any displacement, by grasping the forearm just beloAV the elbow, so that the forefinger rests upon the point of the olecranon, Avhich it draws doAvn in contact Avith the shaft, Avhen crepitus may be brought out by flexing and extending the forearm Avith the other hand. Union occa- sionally takes place by bony deposit, but is more often ligamentous merely. The utility of the arm may, hoAvever, be preserved even Avith considerable retraction of the upper fragment. The treatment consists in fixing the ole- cranon in apposition Avith the shaft (which may be conveniently effected by means of a compress and adhesive strips), and keeping the joint at rest in an extended position for four or five Aveeks, or until union has occurred. Surgeons are divided as to the comparative advantages of complete or of partial extension, many agreeing Avith Sir Astley Cooper and Prof. Hamil- ton, in recommending the former, while the majority of French surgeons, Mr. Erichsen, and others, prefer the latter. I am myself in the habit of using a simple obtuse-angled splint, well padded, and applied to the inside xDr. T. Blanch Smith reports a case in which, others means failing, reduction was maintained by extending the forearm upon the arm, and applying a long straight splint. Dr. Allis, of this city, also employs tho extended position in the treatment of these injuries. 17 258 SPECIAL FRACTURES. of the arm and to the palmar surface of the forearm, which is kept in a semi-prone position. Figure of 8 turns around the elboAv assist in fixing the olecranon. This position—one of slight flexion—is less irksome to the patient, and is at least as effective in obviating deformity as that of com- plete extension, which sometimes causes an angular depression at the seat of fracture. In cases of compound fracture of the olecranon, or of any com- pound fracture about the elboAv-joint, in which an attempt is made to pre- serve the limb, the arm should be flexed to an angle of from 100° to 120°, which will be found the most useful position should anchylosis ensue. Fracture of the Coronoid Process of the Ulna has been supposed to be a frequent complication of backward dislocation of the elbow-joint. I have, howeArer, been unable to refer to more than twenty cases in which this lesion has been diagnosticated during life (and in none of them does the diagnosis seem to have been confirmed by dissection), Avhile only three of nine speci- mens described by authors appear to give satisfactory evidence as to the ex- istence of fracture. Hence, though the possibility of the accident must be admitted, it must be considered very rare. The cause of such an injury would probably be indirect violence, and its diagnosis would have to be established principally by exclusion. The treatment would consist in fixing the elbow on a rectangular splint, and in practising passive motion after three or four Aveeks. Fractures of the Forearm.—Both bones of the forearm are frequently broken through their shafts, either by direct, or more frequently by indirect, violence, Avhile by direct violence either the radius or the ulna may be frac- tured separately. If only one bone be broken, the other acts as a splint, and prevents the occurrence of much displacement, in spite of the obliquity of the fracture; but if both bones have given way, there is marked shortening, which, with the mobility and crepitus, render the nature of the case evident. The treatment consists in reducing the deformity by extension and manipula- tion, and in fixing the limb so that the line of the bones is preserved, and the interosseous space not encroached upon, while the motions of pronation and supination are preserved. For this purpose the supine position, advised by Lonsdale, is preferable to that of semi-pronation ordinarily recommended. The reason is that in any fracture of the radius, particularly in one above the insertion of the pronator radii teres, the upper fragment is supinated by the action of the supinator brevis and biceps muscles, and therefore, unless the lower fragment be also supinated by the surgeon, union with rotatory de- formity Avill almost inevitably ensue. Tavo straight splints are required, which should be just wide enough to prevent the encircling bandage from pressing the bones together, and thus diminishing the interosseous space. The palmar splint should reach from the bend of the elboAv to beyond the fingers; the dorsal from just beloAV the olecranon to just above the styloid process of the ulna. They should be Avell and evenly padded, the object being not to thrust the bones apart as by a wedge, but to fix them in the position Avhich they have assumed under the surgeon's manipulations. No bandage should be used underneath the splints, and the dressing should be reneAved at least every other day during the first fortnight. For fracture of both bones, the splints should be retained for from five to seven Aveeks, but for fracture of the shaft of either bone alone, four weeks will usually suffice. A perfect cure of a fracture of both bones of the forearm is perhaps rarely obtained; but I believe that the surgeon will secure better results by this mode of treat- ment than by any other. FRACTURE OF LOWER EXTREMITY OF RADIUS. 259 Fracture of the Head of the Radius is a rare form of injury Avhich does not appear to have been recognized during life, though the possibility of its occurrence has been demonstrated by dissection. Fracture of the Neck of the Radius is rarely met Avith except when com- plicated with other lesions. The diagnostic signs are slight anterior dis- placement, Avith localized pain, mobility, and crepitus. The treatment consists in the application of a Avell-padded internal rectangular splint, the separated fragment being kept in place by means of a firm compress. Fracture of the Lower Extremity of the Radius is an accident of very frequent occurrence. Its nature and pathology have been made the subject of special study by Colles, R. W. Smith, Erichsen, Goyrand, Voillemier, Nelaton, Barton, (lordon, Moore, and Pilcher, of New York. There are two varieties of this form of fracture, Avhich are known generally in this country as Colles's and Barton's fractures. Colles's fracture, Avhich is by far the most common, is a transverse or slightly oblique fracture, situated at from a quarter of an inch to an inch and a half above the articular extremity of the radius. Barton's fracture is a very oblique fracture, extending from the articulation upAvards and backwards, separating and displacing the Avhole or a portion of the posterior margin of the articulating surface. It is a very rare accident, constituting probably not more than one or two per cent, of the whole number of fractures in this locality. The cause of these injuries is almost invariably a fall upon the palm of the hand, the position of over-ex- tension causing the bone to give way, as pointed out by Gordon, by Avhat mechanicians call a " cross-breaking strain;" the displacement is very con- Fig. 123. Fracture of the radius near its lower end. (Liston.) stant, the loAver fragment being draAvn somewhat upAvards and backwards, Avhile the upper fragment projects downwards and forwards; the hand at the same time inclines someAvhat to the radial side, though if, as sometimes hap- pens, there be also a fracture of the styloid process of the ulna, this symptom may not be present. In some cases, according to Moore, of Rochester, the styloid process is dislocated and caught beneath the annular ligament, from Avhich position it must be released before reduction can be accomplished. The so-called "silver fork" deformity, Avhich usually characterizes this injury, is Avell seen in the accompanying illustration (Fig. 123). The diagnosis of this fracture is generally easy. Beside the peculiar displacement, there is pain, greatly increased by motion and especially by attempts to rotate the Avrist, Avhile crepitus can be readily elicited by drawing doAA'n the hand and rubbing together the fragments. In some rare cases the fracture is completely im- pacted, Avhen crepitus will be absent, and reduction very difficult, if not impos- sible. The treatment consists in effecting reduction by means of extension and manipulation, and in fixing the limb by the use of splints and compresses. Two compresses are required, one over the dorsal projection (loAver fragment), and one OArer the palmar prominence (upper fragment). Tavo straight splints 260 SPECIAL FRACTURES. may be applied over these compresses (as recommended by Dr. Barton), or, which I prefer, the well-knoAA'n splint of Dr. Bond (Fig. 124) may be used, or one of the ingenious modifications of Drs. Hays, Hamilton, and others. To any of these a short dorsal splint may be sometimes advantageously added. Bond's splint consists of a piece of wood, of the shape indicated in the figure, with a carved block to support the hand and fingers, and side strips of leather or pasteboard. It is prepared for use by placing in it a layer of cotton Avad- ding or folded lint, and adjusting upon this the palmar compress in such a Fig. 124. Bond's splint. position that, when the splint is applied, it Avill press accurately upon the loAver end of the upper fragment. The splint is laid on the fractured limb, so that the hand folds lightly over the block (which should fit the hollow of the palm), and the dorsal compress is then adjusted to the lower fragment so as to main- tain the reduction which has hitherto been kept up by the surgeon's hands. The dressing is completed by the application of a roller bandage, firmly, but not tightly, for fear of gangrene. Another efficient, but, as it seems to me, unnecessarily complicated apparatus, is that employed by Dr. A. Gordon, of Fig. 125. Gordon's splint for fracture of the lower end 01 the radius. Belfast, which, like the splint devised by Dr. Carr, of NeAv Hampshire, em- ploys a curved instead of a plane surface for the support of the broken bone. The semi-prone position is that usually recommended for the treatment of this injury, but I myself prefer the position of supination, Avhich I have already advised for fractures of both bones of the forearm. When Colles's fracture is complicated Avith Fracture of the Styloid Process of the Ulna, the case should be treated with two straight splints, as an ordinary fracture of the forearm, with the addition of compresses to combat the "silver-fork" de- formity, if required. Five to seven Aveeks are usually necessary for the treatment of these cases. Fractures of the Hand.—Fracture of the carpus or metacarpus should FRACTURES OF UPPER EXTREMITY OF FEMUR. 261 be treated on a broad palmar splint, which is so padded as to fill up the hollow of the hand, and afford firm support to the injured member; frac- tures of the phalanges commonly require, in addition, a small pasteboard splint, applied immediately to the injured finger. The use of apparatus may be dispensed Avith after two or three weeks. In the treatment of all fractures of the upper extremity, the limb should (unless fastened to the chest) be supported in a sling, Avhich may, Avithin reasonable limits, be lengthened or shortened according to the patient's preference or fancy. Fractures of the Lower Extremity. Femur.—Fractures of the thigh-bone maybe divided into—1, those of its upper extremity; 2, those of its shaft; and 3, those of its condyles. 1. Fractures of the Upper Extremity of the Femur are usually classified as fractures (1) of the neck Avithin the capsule, (2) of the neck Avithout the capsule, (3) of the neck, partly intra- and partly extra-capsular, (4) through the trochanter major and base of the neck, and (5) of the epiphysis of the trochanter major. The terms intra- and extra-capsular have, hoAvever, as justly remarked by Prof. BigeloAv, not much practical significance, for the reason that the attachment of the capsule varies in different individuals, so that, apart from the difficulty of diagnosis during life, it is often impossible, in looking at a specimen Avhich shows bony union, to say Avhether the frac- ture Avas originally inside or outside of the capsular ligament. Hence, this distinguished surgeon divides these injuries merely into the impacted and non-Impacted varieties of fracture. The old classification, however, is at least unobjectionable, and may properly be retained, as being more familiar than any other. 1. Intra-capsular Fracture of the Neck of the Thigh-bone is an accident of frequent occurrence, being met Avith principally in those of advanced life, and in women oftener than in men. It is predisposed to, by the ordinary senile change in the structure and shape of the cervix femoris, Avhich is, in old age, often less obliquely attached to the shaft than in earlier life. This form of fracture results, usually, from indirect violence of an apparently trivial nature, such as slipping from a curbstone, tripping over a loose piece of carpet, or even turning in bed. The symptoms are alteration in the shape of the hip, pain, crepitus, inability to stand or Avalk, shortening, and eversion of the foot. Alteration in the shape of the hip is evidenced by flattening of the trochanter, which may also be observed to rotate in an are of abnormally small radius, the reason being that its centre of motion is changed from the acetabulum to the seat of fracture. Dr. Allis has observed that, in the erect posture, the fascia lata is relaxed upon the injured side ; and flaccidity of the tensor vaginae femoris and glutams medius muscles is regarded by Bezzi and Lagorio as a sign of pathognomonic Aralue. Pain is markedly increased by any motion of, or pressure on, the joint, and is sometimes so intense as to render the use of anesthesia necessary as an aid to diagnosis. Crepitus may sometimes be detected by simply rotating the limb, but is usually not elicited until, by means of extension, the separated fragments are brought into contact, Inability to stand or walk is usually present from the first, though instances are not Avanting in which patients have Avalked a short distance after the accident before falling, probably from the fracture being at first incomplete, 262 SPECIAL FRACTURES. Fig. 126. or partially impacted. The attitude of the limb, as shown in the accom- panying illustration (Fig. 126), is often characteristic, and sometimes almost diagnostic. The shortening, in these cases (as ascertained by measuring both limbs from the anterior iliac spines to the tips of the inner malleoli), is commonly not very marked at first—probably not exceeding half an inch to an inch; it subsequently, and often suddenly, increases, by the giving way of ligamentous attachments, by rupture or stretching of the capsule, or by unlocking of frag- ments, and not unfrequently amounts, under these circumstances, to two inches or even more.1 Eversion of the limb almost always accompanies these cases, and is probably due to a combination of causes, some mechanical—as the weight of the limb itself, the centre of gravity of the lower extremity in the recumbent position being (as pointed out by Owen) on the outer side of a line connecting the acetabulum and heel, and others physiological—as the action of the external rotator muscles upon the lower fragment. In a feAv cases inversion has been observed, and is attributed by Mr. Erichsen to paral- ysis of the external rotator muscles from concomitant injury. Pirrie reports a case in which inversion was accompanied by adduction and great flexion, the de- formity thus closely resembling that of dislocation dowiwards and backwards. (See Chapter XIII.) In cases of impacted fracture, these symptoms are all much less marked, and the eversion may be so slight that, as justly remarked by BigeloAv, it may be "best indicated by a comparison of the extent to which the two limbs can be inverted." The diagnosis between intra- and extra-capsular fracture will be considered when we come to speak of the latter form of injury. The prognosis of unimpacted intra-capsular fracture must always be guarded. Bony union very rarely takes place in these cases, chiefly on account of the deficient vascular supply to the pelvic fragment, and the dif- ficulty, often amounting to impossibility, of keeping the fragments in appo- sition. Many surgeons, indeed, have doubted Avhether bony union ever occurs under these circumstances, and those specimens which have been produced as instances of osseous union are all open to the objection that the line of fracture may have been at least partly extra-capsular. In cases of impacted intra-capsular fracture, hoAvever, bony union may undoubtedly occur. As these injuries are commonly met with in those of advanced age, the shock and general constitutional disturbance are often considerable; old persons, too, bear confinement badly, and, in such, these injuries not unfre- quently prove fatal, through the occurrence of congestion or inflammation of internal organs, the formation of bed-sores, etc. Under more favorable Fracture of the neck of the femur. (Fergusson.) 1 To determine whether or not the shortening is, in any particular case, in the cervix femoris, Mr. Bryant measures the distance on either side from the trochanter major to a line drawn from the anterior-superior spine of the ilium at right angles to the plane of the body. Dr. Cleemann, of this city, has pointed out that from the shortening of the limb, in these cases, a fold or wrinkle is formed over the ligamentum patellae, and can be "smoothed out" by making extension. FRACTURES OF UPPER EXTREMITY OF FEMUR. 263 circumstances the patient may recover, union taking place, if at all, by means of fibrous bands, and the limb remaining permanently shortened and lame. 2. Extra-capsular Fracture of the Cervix Femoris is a less common injury than the intra-capsular variety. It is, like the latter, usually, though less exclusively, met Avith in advanced life,1 and is generally produced by direct, though occasionally by indirect, violence, such as a fall on the feet or knees. The line of fracture commonly corresponds with the anterior and posterior inter-trochanteric lines, and the inner almost invariably penetrates the outer fragment, in such a Avay as to split and comminute it into several portions. Either trochanter may be completely detached, and the fracture may involve the summit of the shaft itself. Occasionally the fracture is completely im- pacted. The symptoms are much the same as those of the intra-capsular form of injury, the chief differences being that the trochanter moves in an arc of still shorter radius, that the pain is acuter and more superficial, and that the crepitus is more distinct, the fragments being sometimes felt loose under the skin; the shortening (unless in cases of impaction) is greater at first, but does not undergo much subsequent change, while eversion is not so invariably present. As this form of fracture usually results from direct violence, it is commonly attended with great contusion and swelling of the soft parts. The differential diagnosis between intra- and extra-capsular fracture may in many cases be made by attention to the above-mentioned peculiarities, taken in connection Avith the history of the case, the age of the patient, etc. In cases of impacted fracture, the diagnosis is much more difficult, and in such cases the surgeon must be very cautious in his examination, lest he in- advertently remove the impaction, and thus seriously complicate the condition of the patient: for in any fracture about the neck of the femur, impaction is a most desirable circumstance, limiting the amount of shortening, and favoring the occurrence of bony union. Severe contusion of the hip may cause temporary eversion and immobility, and thus simulate fracture; if the joint be also the seat of rheumatoid arthritis, there Avill be superadded shortening and false crepitus. The diagnosis, under such circumstances, must be made by careful inquiry into the history of the case and the previous condition of the patient. The prognosis of extra-capsular fracture, unless the patient die from shock or general constitutional disturbance, or from some concomitant injury, is usually favorable. Bony union readily occurs in these cases, the amount of callus, on account of the comminution of the fracture, being very large, forming stalactitic projections or osteophytes, which are most abundant along the posterior inter-trochanteric line. 3. The neck of the thigh-bone may be broken partly within and partly without the capsule; the symptoms Avould, of course, be_essentially those of the previously described varieties, and the chances of bony union proportional to the degree in Avhich the fracture Avas extra-capsular. 4. Fracture through the Trochanter Major and Base of the Neck.—The line of fracture in this injury, Avhich is sufficiently described by its name, sepa- rates the femur into two segments, the upper of which embraces the head, neck, and trochanter major. The signs of the injury are crepitus, eversion, and shortening of about three-fourths of an inch; bony union readily occurs. 5. Fracture of the Epiphysis of the Trochanter Major must be an extremely rare accident, there being, according to Hamilton, but one authentic case on record. The diagnosis, I should suppose, could only be made during life 1 According to Gordon, of Belfast, extra-capsular is more common in extreme old age than intra-capsular fracture. 264 SPECIAL FRACTURES. by observing displacement of the epiphysis, without the ordinary signs of fractured femur. Treatment of Fractures of the Upper Extremity of the Femur.—I have no hesitation in expressing my preference for the treatment of these injuries by means of the straight position with moderate extension, Avhenever that mode of treatment is applicable. In cases of impacted fracture, extension is (for rea- sons already indicated) undesirable, and such cases may be treated by posi- tion alone, the joint being fixed by means of the long splint, in any of its varieties, or simply supported by means of heavy sand-bags placed on either side of the injured member. If the fracture be unimpacted, the same treat- ment should be employed, with the addition of moderate extension. For this purpose, Liston's splint, or that of Desault (as modified by Physick and others), may be conveniently used; or the surgeon may employ Hagedorn's apparatus, as modified by Gibson, or the less cumbrous contrivances of Gross, Hartshorne, or Horner. The simplest mode of treatment, however, and that which I much prefer, is the old-fashioned weight extension, first popularized in this country by Prof. Gurdon Buck, of New York, with the addition of sand-bags to either side of the limb. Weight extension is thus applied: A strip of adhesive plaster (cut lengtliAvise and AArell stretched) is prepared, 2\ to 3 inches wide, and 3J to 4 feet long. On the middle of this is placed a block of wood, of the same width as the adhesive strip, but four inches long, and half an inch thick; over this, again, is placed another adhesive strip of Fig. 127. Adhesive plaster stirrup for making extension in cases of fracture of the lower extremity, etc. the same Avidth, and \\ to 2 feet in length; the block, Avhich is sometimes called the stirrup, is thus secured in the centre of a long band, of which the upper twelve inches at either end are adhesive. The band is then applied to the leg on which extension is to be practised, so that it adheres on either side from just below the knee to just above the malleolus, the stirrup remaining as a loop about four inches below the sole of the foot (Fig. 127). The appa- ratus is fixed by tAvo or three broad strips passed circularly around the limb, which is finally surrounded with an ordinary spiral bandage. The malleoli should be protected by a layer of cotton, to prevent excoriation. It is well to allow a short time to elapse before applying the extending force, so that the strips may become firmly adherent. To the stirrup is fixed a cord, Avhich plays over a pulley fixed at the foot of the bed, and Avhich carries the extend- ing Aveight, which, for fractures of the neck of the femur, need not usually exceed ten or twelve pounds. Counter-extension may be made by means of a perineal band, or broad adhesive strips applied to the loAver part of the trunk and fastened to the head of the bed, or, which is usually sufficient, simply by elevating the foot of the bed, thus utilizing the weight of the body itself as the counter-extending force. The sand-bags are merely long bags, like FRACTURE OF THE SHAFT OF THE FEMUR. 265 the "junks" used Avith Physick's splint, except that they are filled Avith clean sand instead of bran: the outer should reach from the axilla to the sole of the foot, and the inner from the perineum to the internal malleolus. While I have recommended this mode of treatment for every case to which it is applicable, it is but right to say that there are certain cases, especially of intra-capsular fracture in old persons, in which no apparatus can be borne, and in which even confinement to bed is fraught Avith dangerous consequences; under such circumstances, the injured limb should be simply laid across pillows, as recommended by Sir Astley Cooper, until the pain and inflamma- tion which attend the injury have subsided, the patient being then allowed to get up in a chair or on crutches; bony union, under such circumstances, cannot be hoped for, and the general rather than the local condition of the patient should be the object of attention. In some of these cases, a moulded leather or pasteboard splint, or a plaster-of-Paris bandage, may be used with advantage. Colles, of Dublin, employs a modification of Sayre's apparatus for hip-disease. 2. Fracture of the Shaft of the Femur.—This injury may be met with at any age, and in any part of the bone; it is most frequent, however, in the middle third. The accident commonly results from direct violence, and the direction of the fracture is almost invariably oblique. The fracture is marked by mobility, shortening, eversion, and crepitus, which are so manifest that the nature of the injury can scarcely be mistaken. With regard to the prognosis of fracture through the shaft of the femur, I have no hesitation in Fig. 128. Weight extension with long splints for treatment of fractured thigh; counter-extension made by raising foot of bed. saying that I have never seen a perfect cure, either in my OAvn practice or in that of others; by this, I mean that I havre never seen a cure Avithout short- ening. Without entering upon a discussion as to the possibility of such a result (for a full and candid consideration of Avhich question I would respect- fully refer the reader to Prof. Hamilton's excellent treatise), I will merely say that I have never seen less shortening than a quarter of an inch, after fracture of the thigh, even in children; and that I consider a shortening of from half an inch to an inch, a satisfactory result in adults.1 The treatment of fractures of the shaft of the thigh is most conveniently conducted Avith the weight extension apparatus already described, substituting, however, for the sand-bags, long splints (either padded or provided Avith bran junks), AA'hich have the effect of fixing both the hip- and the knee-joint, a very important 1 The question o£ shortening in fractured thigh has lost much of its significance since Drs. Cox and Roberts, of this city, and Dr. "Wight, of New York, have ascer- tained by measurement that an inequality in the length of the lower limbs is often congenital. 266 SPECIAL FRACTURES. consideration in the management of these injuries. (Fig. 128.) The chest and pelvis should both be secured to the external splint by broad and firm bands, Avhile the splints themselves should be kept in position by similar bands, passing at intervals across the affected limb. In fractures of the upper part of the shaft, there is frequently seen an anterior angular projection, Avhich is generally attributed, and is probably usually due, to the tilting forwards of Fig. 129. the lower end of the upper fragment; though that it is occasionally due to the projection of the lower fragment is shown by several specimens described by Mr. Butcher. Whatever be the cause of the projection, it may require the application of a third, anterior splint, Avhich should reach from the groin to above the knee, and should be well padded to prevent excoriation. After several Aveeks, Avhen union is pretty well advanced, short moulded pasteboard Fig. 130. Compound fracture of shaft of thigh-bone; treatment by bracketed long splint. (Erichsen.) splints may be applied immediately around the seat of fracture, the long splints and weight extension being continued as before, or, instead of the pasteboards, the plaster-of-Paris bandage may be substituted. This is the mode of treat- ment Avhich I am in the habit of employing in cases of fractured thigh, and I have found it to be as efficient as it is simple. Excellent cures may, hoAV- ever, doubtless be obtained by the use of other means, such as the various forms of apparatus already mentioned (page 264), or the " suspension splints," of Prof. N. R. Smith, of Maryland (Fig. 129), and Prof. J. T. Hodgen, of St. Louis. Compound Fractures of the Thigh may be conveniently treated Avith the Aveight extension apparatus, Avith the bracketed long splint (Fig. 130), Avith a simple long fracture-box (particularly useful Avhen the bran FRACTURE OF THE PATELLA. 267 dressing is to be employed), or, in some rare cases, with the old-fashioned double-inclined plane, Avhich Avas so popular at the end of the last and the beginning of this century.1 3. Fracture of the Condyles of the Femur.—Either condyle may be broken off separately, or there may be a splitting fracture betAveen them, complicated Avith a more or less transverse fracture through their base. The symptoms are mobility, crepitus—elicited by rubbing the condyles together —and, if the fracture extend through their base, shortening; there is also an increase in the breadth of the limb around the condyles, Avhich persists after recovery. These accidents may result from direct violence, or from falls on the knee (the patella, as remarked by Willett, acting as a w7edge in splitting the condyles asunder), and are often folloAved by secondary inflam- mation of the knee-joint, which may run on to suppurative disorganization, endangering either the limb or life of the patient. The treatment consists in placing the limb at rest in a straight or almost straight position, in a long fracture-box with a firm but soft pilloAv, and in making moderate extension if there be much shortening; recoArery will usually be attended Avith more or less anchylosis. Separation of the Lower Epiphysis of the Femur would re- quire the same treatment as fracture of the condyles. Compound Fracture of the Femur, involving the Knee-joint, should, almost invariably, be consid- ered a case for amputation. The time required for the treatment of a fractured thigh may be said to be from eight to ten Aveeks; even if union appear firm before that time, the patient should not be alloAved to bear any weight on the limb, for fear of consecutive shortening, which I have knoAvn to occur after apparently com- plete recovery. Patella.—Fractures of the patella are usually met Avith in male adults, and are commonly produced by muscular action, the patella being broken as an over-bent lever across the condyles of the femur; under such circumstances, the line of Fig. 131. fracture is transverse, and the upper fragment may be draAvn some distance upwards by the poAverful muscles of the thigh. The patella is occasionally broken by direct violence, when the fracture may be comminuted or longitudi- nal. The diagnosis is easily made : in trans- verse fracture there is almost always some dis- placement, Avhich is increased by flexing the knee ;2 Avhile in comminuted or longitudinal fractures, the nature of the case is rendered evident by the mobility and crepitus, which, Under SUCh Circumstances, are Very distinct. Fracture of patella ; fragments sepa- Inabilltl) to Walk Or Stand, which is Often rated by flexing the knee. spoken of as a sign of fractured patella, is, as remarked by Gougct, more apparent than real, the patient being able, though not Avilling, to Avalk, on account of the pain Avhich attends the effort. The 11 will merely mention, without in any degree commending, the plan proposed by Dr. Hennequin, in an essay which received the Barbier prize, that " in fractures of the thigh the limb should be placed in a horizontal plane, in moderate abduction and outward rotation, with the leg flexed at a right angle, and the trunk elevated;" a position which would require the patient to sit on the side of the bed, with his leg hanging over the edge (Archives Generates de Medicine, Dec. 1868, pp. 657-662). 2 T. Curtis Smith, of Ohio, has, however, recorded a case in which the only dis- 268 SPECIAL FRACTURES. prognosis is favorable; though bony union is rarely obtained, especially in the case of transverse fracture, the utility of the limb is not materially im- paired, and instances are on record in Avhich patients, after recovery, have engaged in duties requiring great activity and strength of limb, although Avith a separation of several inches between the fragments of the patella. The treatment consists in placing the limb in a straight position, Avith the leg someAvhat elevated, so as to relax the fibres of the quadriceps femoris muscle.1 The upper fragment of the patella, being draAvn doAvn wards, is held in place by means of a firm compress, Avhich is secured by strips of adhesive plaster fastened to a broad posterior splint, provided for the purpose Avith notches or cross-pieces. The Avhole limb and splint are then surrounded with a roller, Avhich, by figure of 8 turns around the knee, gives additional security and firmness to the part. The limb should be raised, simply by pilloAys or by an inclined plane, the relaxation of the quadriceps femoris muscle being further assisted, as recommended by Hamilton, by elevating the patient's trunk. Care must be taken, as Avith all fractures of the lower extremity, to keep the foot strictly at right angles Avith the leg, so as to avoid the " pointed toe " deformity Avhich is othenvise apt to ensue. This simple mode of treatment, Avhich is essentially the same as that recommended by Hamilton, is quite as efficient as the more complicated plans devised by Lonsdale, Amesbury, Cooper, Burge, Callender, Beach, and others. Malgaigne's hooks, and their various modifications introduced by Morton, Levis, J. M. White, and others, while doubtless efficient, and probably less dangerous than is usually sup- posed, are at least unnecessary, and, from their formidable appearance, un- desirable. A better mode of treatment, which has been revived by Gibson, of Missouri, Eve, of Tennessee, and Blackman, of Ohio, consists in holding the fragments in apposition by means of an iron ring. Dr. Blackman thus tAvice succeeded in obtaining bony union. It is certainly a safer plan than that of Volkmann, Avho by means of a curved needle carries a strong silver Avire around and beneath the patella, approximating the fragments by tight- ening the ring thus formed. Many authors advise that no dressings should be employed until the swelling which folloAvs the accident has subsided; but this delay exposes the patient to the risk of permanent shortening of the rec- tus femoris, and I, therefore, think it better to apply the apparatus at once, though, of course, not too tightly, watching it carefully, and being prepared to loosen it, should the exigencies of the case so require. After recovery, a pasteboard or leather cap should be Avorn around the joint for some time, until the ligamentous bands which unite the fragments haAre attained the necessary degree of firmness, to resist any ordinary force to Avhich they may be subjected. The duration of treatment, in cases of fractured patella, should be about six weeks, the joint being still longer protected Avith a suitable cap, as already placement was a slight anterior projection of the upper fragment, which could not be brought into place except by flexing the knee; in this instance, doubtless, the ex- pansion of the quadriceps femoris tendon, which covers the anterior surface of the patella, remained intact. 1 According to Hutchinson, this precaution is unnecessary; the separation of the fragments is due, in his opinion, not to the action of the quadriceps femoris, which he believes to be entirely passive, but to fluid pressure from within the joint. (See an able paper in Med.-Chir. Trans., vol. lii. pp. 327-340.) Schede recommends, in these cases, that the joint should be tapped with antiseptic precautions. Cameron, Lister, Uhde, H. Smith, and Rose, reviving a plan adopted many years ago by Rhea Barton, of this city, wire the fragments together (antiseptically), and have thus ob- tained good results; but subsequent amputation was required in a case under the care of Dr. J. A. Wyeth, of New York, and another case in the same city terminated fatally. Macnamara employs subcutaneous section of the quadriceps femoris muscle and of the ligamentum patellae. FRACTURES OF THE BONES OF THE LEG. 269 directed. In any case in Avhich confinement would be inconvenient, a plaster- of-Paris bandage might be used after the first Aveek or two, the patient being then alloAved to go about. Compound Fracture of the Patella, involving, as it usually does, the knee- joint, is commonly considered a case for amputation. The elaborate statistics of Mr. Poland show, hoAvever, that this extreme measure is in reality seldom called for; thus, of 68 cases treated without operation, 5(i recovered and only 12 died (17.65 per cent.), while of 7 in which amputation Avas performed, 5 recovered and 2 died (28.57 per cent.), and of 10 treated by excision, only 4 recovered and 6 died (60 per cent.). Of the whole 85 cases, therefore, 05 recovered and 20 died. Suppuration of the joint occurred in 43 of those cases which terminated favorably, and in all of those which proved fatal.1 Fractures of the Bones of the Leg.—Either the tibia or fibula, or both, may be broken, the cause of these injuries being usually direct, though occa- sionally indirect violence, and the line of fracture generally oblique, except in the upper part of the tibia, where it is commonly transverse. If only one bone be broken, there will not be much displacement, the other acting as a Fig. 132. Fig. 133. Separation of upper epiphysis of tibia. (From a specimen in the museum of the Episcopal Hospital.) splint, except in fractures just above the ankle, Avhen the foot inclines to the injured side. Fracture of both bones, in the middle or lower third, is often attended Avith considerable displacement, the line of fracture being oblique (from above doAvmvards, forwards, and imvards), and the loAA7er being drawn up behind the upper fragments by the poAverful muscles of the calf. The existence of this displacement, together with undue mobility and crepitus, 1 Med.-Chir. Trans., vol. liii., p. 49. 270 SPECIAL FRACTURES. renders the diagnosis easy; and even Avhen one bone only is broken, the na- ture of the case can be readily ascertained by careful examination. A " V- shaped" fracture, occurring at the junction of the middle and loAver thirds of the tibia, is described by Gosselin, Hodges, and other Avriters. Fracture of the upper end of the fibula has been complicated Avith paralysis of the external muscles of the leg, in cases recorded by Duplay and others. Separation of the Upper Epiphysis of the Tibia is a very rare accident, there being, indeed, as far as I know, but three instances of it on record; one is mentioned by Mad. Lachappelle, the case being that of a new-born infant, and the injury having been produced during delivery; the second is figured in the last edition of Holmes's System of Surgery, from a specimen in the museum of St. George's Hospital; and the third occurred in my own practice, in a boy eleven years old, who Avas caught betAAreen the bumpers of raihvay cars; the laceration of the soft parts Avas so great as to require amputation, and the nature of the accident Avas thus ascertained by dissection; the speci- men from which the illustrations (Figs. 132, 133) are taken, is now in the museum of the Episcopal Hospital. Dr. Voss, of XeAV York, has recorded a case of separation of the lower epiphysis, in which, in spite of the occurrence of necrosis, recovery with a useful limb was ultimately obtained. Treatment.—For the treatment of the great majority of fractures of the leg, whether one or both bones be involved, I know of no apparatus Avhich presents so many advantages as the old-fashioned fracture-box with movable sides (Fig. 134), containing a soft but firm pillow; the fracture having been reduced, the limb is gently laid in the Fig. 134. box, the sole of the foot being adjusted to the foot-board, with the heel well brought, down, and raised on a pad of cotton or tOAv placed beneath the tendo Achillis. The foot is then secured by a turn of bandage, and the sides of the box brought up so as to make firm and equa- ble pressure upon the fractured limb. Care must be taken to keep the foot at a Fracture-box, with movable sides. right angle Avith the leg, to prevent eversion of the knee by frequent adjust- ment,1 to prevent excoriation of the heel by the use of the pad under the tendo Achillis, and of the malleoli by pads above and beloAV those promi- nences, and to counteract any tendency to lateral displacement by the use of suitable compresses. By strict attention to these points, I do not hesitate to say that, in the immense majority of cases, as good a cure can be obtained Avith the simple fracture-box, as with any of the complicated contrivances Avhich the ingenuity of surgeons has suggested. In fact, the chief difficulty with the fracture-box is that it is so simple, that surgeons are apt to think that nothing is required beyond placing the limb in it, and there letting it stay for the requisite number of weeks; and it is, I believe, to the neglect of the surgeon, rather than to any fault of the apparatus, that are to be attrib- uted the bad results on Avhich many modern writers, in objecting to the use of the fracture-box, lay such stress. If in cases of very oblique fracture it be desired to make extension, this can readily be done by means of the ordinary adhesive-plaster stirrup, pulley, and weight, the extending bands (which, of course, must not be attached above the seat of fracture) being brought through slits in the foot-board of 1 A convenient practical rule is to see at each visit that the ball of the great toe, the inner malleolus, and the inner condyle of the femur are all in the same vertical plane. FRACTURES OF THE BONES OF THE LEG. 271 the fracture-box. Certain cases of oblique fracture1 may be best treated in the flexed position, and a very good apparatus for this purpose is the anterior splint of Prof. N. K. Smith, of Maryland (Fig. 129). The comfort of the patient may often be promoted by suspending the fractured limb from a yoke attached to the sides of the bedstead, for which purpose either the ordinary fracture-box, or Salter's swing cradle (Fig. 135), or the " anterior splint," may be conveniently employed. After three or four Aveeks, when union is pretty well advanced, the limb Fig. 135. Salter's cradle. may be advantageously surrounded with moulded and Avell-padded paste- board splints, being then replaced in the fracture-box; or the plaster-of-Paris bandage may be noAv safely applied. The treatment of a broken leg usually occupies from six to eight weeks. It is in cases of compound fracture of the leg, that the bran dressing, introduced by Dr. J. Rhea Barton, of this city, is particularly useful. It is thus applied : inside of an ordinary fracture-box, of suitable size, is placed a sheet of oil-cloth, or India-rubber cloth, and on this a layer of fine and clean bran about two inches deep: the fracture being reduced, the limb is laid in the box, with a pad of cotton beneath the tendo Achillis and around either malleolus, and a layer of the same material around the limb just beloAV the knee; the sides of the box are then brought up and secured, and more bran is dusted and packed around and over the leg till the box is filled, the frac- tured limb being thus firmly and evenly supported on all sides. The same precautions as to position are to be observed as in the management of a simple fracture, the daily dressing consisting in letting down one or both sides of the box, and, Avithout disturbing the limb, removing the soiled bran Avith a spatula, and replacing it Avith fresh material. The great advantages of the bran dressing are its simplicity and cleanliness, the bran readily ab- sorbing all discharges as they are formed, and affording a sure protection 1 For the treatment of these oblique fractures, Malgaigne recommends an apparatus, provided with a sharp screw to hold the fragments in place ; while Laugier, and more recently Mr. Bloxam, recommend division of the tendo Achillis. I have no personal experience with either of these modes of treatment, which, however, I cannot but think unnecessarily severe. 272 SPECIAL FRACTURES. against flies; in recent cases, the uniform pressure of the bran has been, moreover, found very efficient in checking hemorrhage. Fracture of the Head of the Tibia into the knee-joint is apt to be com- plicated Avith injury of the popliteal vessels (see page 231). For its treat- ment, a fracture-box, long enough to fit the joint, is employed, such as Avas recommended for fracture of the condyles of the femur. The injury is often folloAved by anchylosis. Fractures about the Ankle are, perhaps, more troublesome than any other fractures of the leg. The fibula alone may be broken, usually giving Avay about three inches above the joint, or the tip of the inner malleolus may be torn off as Avell (Pott's fracture), or either malleolus may be longi- tudinally splintered into the ankle-joint (an accident commonly followed by anchylosis), or, finally, the inner malleolus alone Fig. 136. may be broken, the fibula escaping. Any of these forms of injury may be safely and conveniently treated with the fracture-box, the deformity being obviated by frequent and careful adjust- ment and the judicious use of compresses. I have never had occasion to use Dupuytren's splint for fractured fibula, though I doubt not that when Wire rack for fracture of the leg. carefully applied it is an efficient apparatus. In the management of fractures of the leg, or in fact of any part of the lower extremity, the injured limb should be protected from the Aveight of the bedclothes by means of a suitable framework of bamboo, wood, or Avire, as shown in Fig. 136. In cases of fractured leg occurring in very young children, or in adults suffering from mania a potu, when no restraint can be borne, it is a good plan to surround the broken limb with a soft pillow, which is held in place by means of firm bandages; the part can then be tossed about Avithout risk of further injury. Fractures of the Bones of the Foot.—The only tarsal bones, the frac- tures of Avhich require special notice, are the calcaneum and astragalus. The Calcaneum may be broken by direct violence, or by muscular action ; the line of fracture may assume any direction, and, when the injury results from direct violence, the fracture may be comminuted or impacted. If the tuberosity of the bone only be separated, the fragment may be draAvn upAvards for a considerable distance by the action of the gastrocnemius mus- cle, Avhereas, if the fracture be through the body of the bone, there can be little or no displacement, the fragments being held in place by the lateral ligaments. The treatment, if there be no displacement, consists merely in placing the limb in a fracture-box or on a pillow, and combating inflamma- tion by evaporating lotions, etc., applying subsequently splints or a gypsum bandage. When the posterior fragment is drawn upAvards, the foot should be kept in an extended position, so as to relax the gastrocnemius, by means of a well-padded anterior splint, or the apparatus already recommended for rupture of the tendo Achillis (page 211). The Astragalus is almost invariably broken by the patient falling from a height, alighting on his feet. Simple fracture of this bone is rarely at- tended Avith displacement; in fact there are, as far as I know, but two cases DISLOCATIONS. 273 of the kind on record, one reported by Dr. Norris, and one by myself.1 In the former, the displacement was doAvnwards and forwards; in the latter, dowmvards, outAvards, and backAvards. The treatment consists in reduction (if practicable), the limb being then placed in a fracture-box, and subse- quently dressed Avith pasteboard splints or a starched bandage. If reduction Avere impracticable, in a case of simple fracture, I should be disposed to tem- porize, reserving excision (which is usually recommended under such cir- cumstances) as a secondary operation, to be employed should sloughing or necrosis ensue: in Dr. Norris's case, the displaced fragment Avas excised by Barton, but amputation Avas subsequently required, and the patient ulti- mately died, a year and a half after the occurrence of the accident. Even in fractures unattended Avith displacement, necrosis may ensue, Avhen secon- dary excision of the affected portion will be required; in a case of this kind under my care at the Episcopal Hospital, I removed the greater part of the astragalus nearly three months after it Avas broken, Avith the happiest results. In a Comj)ound Fracture of the astragalus, if reduction were impractica- ble, I should advise complete excision, which Rognetta (whose paper on this subject is classical) considers preferable to excision of the displaced frag- ment only. When, hoAvever, such an injury is attended Avith much commi- nution, or is complicated with fracture of the malleoli or other tarsal bones, amputation will often be required as a primary operation. Fractures of the Metatarsal Bones or Toes are usually produced by direct violence, and if attended with much laceration, commonly require amputation. In cases of simple fracture, it Avill be sufficient, after effect- ing reduction, to apply a plantar splint, and to place the limb in a fracture- box, the dressing being changed, after a time, for pasteboard splints or a plaster-of-Paris bandage. CHAPTER XIII. DISLOCATIONS. A dislocation or luxation is a displacement, as regards their relative position, of the bones Avhich enter into the formation of a joint. Dislocations are variously classified : thus they are said to be traumatic, pathological or spontaneous, and congenital. Traumatic dislocations are such as result from the sudden application of force ; pathological or spontaneous luxations are such as occur from an alteration in a joint as the result of disease (as in the dislocation of the femur in hip-disease), or simply from a paralyzed condition of the muscles around the joint, without any evidence of disease of the articu- lation itself; Avhile congenital dislocations are, as the name implies, such as exist at the moment of birth, being usually due to original malformation of the parts concerned. When the term dislocation or luxation is used alone, it is generally understood to mean one of the traumatic, or, as Hamilton calls it, accidental variety. When dislocation occurs in the form of joint designated by anatomists as "amphiarthrosis" or "mixed articulation," it is sometimes called diastasis, as in the separations between the first and second bones of the sternum, between the vertebras, or at the pubic or sacro-iliac symphysis. 1 Amer. Journal of Med. Sciences, April, 1862, pp. 335-340. 18 274 DISLOCATIONS. Dislocations are further classified as complete or partial; as simple, com- pound, or complicated; as recent or old; and as primitive or consecutive. In a complete dislocation, the bones which enter into the formation of the joint are entirely separated from each other; in a,partial or incomplete luxa- tion (also called a subluxation), the articulating surfaces remain in contact, through a portion of their extent. The terms simple, compound, and com- plicated, bear the same relative meanings as Avhen applied to fractures. Compound luxations may be made so directly by the luxating force, or may become so through rupture of the overstretched soft parts which surround the dislocated joint. Among the most serious complications of a luxation may be mentioned fracture of either of the articulating surfaces of the injured joint, and rupture of the main artery of the limb, as of the popliteal in back- ward dislocation of the knee. A recent dislocation is one in Avhich time has not been afforded for the production of inflammatory changes in the articu- lating surfaces and surrounding tissues, or at least not to such a degree as seriously to impede reduction; an old dislocation being, of course, one in which sufficient time has elapsed to permit such changes to occur. A primi- tive luxation is one in which the displaced bone remains in the position into which it Avas first throAvn by the luxating force. A consecutive dislocation is one in which the displaced bone has secondarily changed its position, either under a continuance of the influence of the luxating force, or as the result of subsequent muscular contraction, or of the surgeon's manipulations in an attempt to effect reduction. Causes of Dislocation.—Age and Sex are Predisposing Causes of disloca- tion, only as far as they influence the exposure of the individual to external violence; thus these accidents are rare in infancy and in old age, being usually met Avith in those in active adult life, and much more frequently in men than in women. More important predisposing causes are the anatomical relations of the joint, and the condition of the neighboring muscles and liga- ments; thus the ball-and-socket joints are more liable to luxation than the ginglymoid, Avhile persons of vigorous muscular frame are less exposed to these injuries than those whose tissues are relaxed and feeble. The folloAV- ing table, compiled from Malgaigne's statistics, shoAvs the relative frequency with Avhich various parts are dislocated: Cases. Cases. Cases. Jaw . . 7 Elbow . . . . 45 Femur . . . . 40 Vertebrae . . 4 Kadius . . . . 7 Patella . . . . 2 Pelvis . . . 1 Wrist . . . . 16 . . 9 Clavicle . . 42 Thumb . . . . 20 Ankle . . . 31 Humerus . . 370 Fingers . . . 7 Metatarsus . . . 2 Atrophy and paralysis of a limb predispose it to dislocation, as do likewise stretching and relaxation of ligaments from articular effusion, or from pre- vious dislocation, ulceration, etc. The Exciting Causes of dislocation are external violence, direct or indirect, and muscular action. The latter is the more usual agent in the production of pathological dislocations, when it acts slowly and gradually; traumatic luxations are also, howeA^er, traceable to the effect of muscular action, especially Avhen the joint has been previously Aveakened by any of the causes above mentioned ; thus cases are recorded by Cooper, Haynes, BigeloAv, and others, in Avhich patients possessed the power of producing dislocation by a voluntary effort, and I have myself seen such a case in the person of an epileptic woman, Avho was in the habit of dislocating her hip in the public streets, as a means of exciting sympathy. ARTICULAR CHANGES PRODUCED BY DISLOCATION. 275 Symptoms and Diagnosis of Dislocation.—The usual signs of dislocation are: (1) a change in the shape of the joint and in the relative position of the articulating surfaces, the extremity of the displaced bone being often felt in an abnormal position ; (2) an alteration in the length of the limb, either shortening or elongation ; and (3) unnatural immobility of the affected joint. The first is the only symptom Avhich can be considered essential, for in partial luxations (as of the elboAv) there may be neither lengthening nor shortening, and if the articular ligaments be extensively lacerated, there may be a positive increase instead of diminution of mobility. From a fracture in the neighborhood of a joint, a dislocation may usually be distin- guished by observing the immobility (Avhen that is present), the absence of crepitus, and the fact that the displacement when removed by reduction does not return. True crepitus does not exist in a case of pure dislocation ; there is, hoAvever, a rasping or crackling sound, due to effusion or inflammatory changes in the articular structures, which is commonly developed in the course of tAvo or three days, and which may readily be mistaken for the crep- itus of a fracture in which the process of repair has already begun. Again, Avhile displacement does not always recur in cases of fracture, it may recur in a case of dislocation, if there be much laceration of the ligamentous tis- sues, or if the articular surfaces themselves have undergone structural changes from inflammatory action ; thus in old luxations of the hip it is often easier to effect than to maintain reduction. Hence no one of these symptoms can be considered as in itself pathognomonic, and it is found in practice that the most experienced surgeon is occasionally liable to err in the diagnosis betAveen luxation and articular fracture. Dislocation, like fracture, is commonly accompanied by pain, swelling, and ecchymosis; Avide-spread extravasation may occur from rupture of vessels, and paralysis (temporary or permanent), or neuralgia, from compression or lacer- ation of neighboring nerves. Articular Changes Produced by Dislocation.—The immediate effects of a dislocation consist of a rupture more or less extensive of the capsular liga- ment, with or Avithout laceration of the other ligaments of the joint, and of neighboring tendons, muscles, vessels, and nerves; in cases of dislocation from muscular action, however, the capsular ligament may be merely stretched, Avithout rupture. If the luxation be promptly reduced, the lace- rated structures are gradually restored to their normal condition, though the joint is often left permanently weakened, and paralysis or neuralgia may continue for an indefinite period. If reduction be not effected, the articular surfaces themselves undergo changes. In a ball-and-socket joint, the old cavity becomes filled up, and its margins absorbed and flattened, Avhile a neAV socket is commonly formed around the head of the dislocated bone, Avhich changes its shape, and becomes gradually accommodated to its neAV position ; if, hoAvever, the head of the bone rests upon muscle, instead of a new socket being formed, the soft tissues undergo condensation, forming a cup-shaped cavity of fibrous structure, Avhich becomes attached by its margins to the displaced bone, and is lubricated by a synovia-like fluid. In the hinge-joints similar changes occur, the osseous prominences being rounded off, and the displaced bones gradually accommodating themselves more or less perfectly to their neAV positions. These changes, which occur with comparative rapid- ity in childhood, take place very slowly in adult life, often occupying several years in their completion. At the same time, the surrounding muscles and tendons become shortened and atrophied, and abnormal adhesions often form betAveen the displaced bones and neighboring nervous and vascular trunks— 276 DISLOCATIONS. a circumstance AAdiich has several times been the cause of fatal hemorrhage in attempts to reduce old dislocations. Prognosis.—In some cases, beyond a temporary stiffness and weakness of the part, a dislocation appears to entail no unpleasant consequences; but in the majority of instances, a limb Avhich has been the seat of luxation Avill not be completely restored for months or even years, or occasionally during the whole lifetime of the patient. An unreduced dislocation of course causes permanent disability, and yet it is surprising to Avhat an extent the displaced parts accommodate themselves to their new positions, the utility of a limb after dislocation being often much greater than Avould be thought probable in view of its evident deformity; so that it is sometimes a question, in cases of old dislocation, whether reduction Avould be desirable, if even it could be accomplished. Treatment.—The indications for treatment in any case of dislocation may be said to be to effect reduction, to put the joint in such a condition that the natural process of repair may take place Avithout undue inflammation, and to encourage the restoration of the functions of the part. Reduction.—This should be effected, in every case, at the earliest possible moment. While I have advised that in certain cases of suspected fracture, minute examination should be delayed until after the subsidence of SAvelling, the case meanAvhile being treated as one of fracture, in a case of suspected dislocation no such temporizing course would be justifiable, for the reason that while reduction in a recent case is usually quite easy, a very short delay will render it difficult, and in some cases almost impossible. Hence, if the nature of the case be not perfectly clear, the surgeon should not hesitate to employ anaesthesia as an aid to diagnosis, more particularly as the use of the anaesthetic will greatly facilitate reduction, should the existence of a dislo- cation be determined. The principal obstacles to reduction, in any case of luxation, are muscular resistance and the anatomical relations of the joint. There are three distinct elements to be considered in estimating the influence of the muscles in hin- dering reduction; these are, (1) the passive force which the muscles possess in common with the other soft structures of the body, and which is brought out by the stretching of their tissues across the displaced bony prominences; (2) the active force, whereby the patient voluntarily though unconsciously re- sists the surgeon's efforts at reduction; and (3) a state of reflex tonic contrac- tion into which the muscles are thrown as the result of the traumatic irrita- tion, produced by the injury itself; this, Avhich is the most important form in Avhich muscular resistance is manifested, is more and more fully devel- oped as the luxation remains longer unreduced. It often happens that if a patient is seen immediately upon the occurrence of a dislocation, the mus- cular relaxation, due to the general state of shock Avhich accompanies the accident, is so great, that the displacement can be reduced with the greatest facility, and, indeed, is often so reduced by the bystanders or by the patient himself. The knoAvledge of this fact led surgeons, before the discovery of anaesthetics, to prepare patients for the reduction of luxations by the use of the warm bath, the administration of tartar emetic, and even general bleed- ing. To obviate the unconscious though voluntary resistance of the patient, the older surgeons laid stress upon the importance of surprising the muscles, as it were, by diverting the patient's mind, by asking a sudden question, or making an unexpected remark, at the moment of attempting reduction. The tonic, reflex contraction of the muscles may be overcome, to a certain extent, by the use of opium, especially by the hypodermic method, or, as was done by TREATMENT OF DISLOCATIONS. 277 Physick, by inducing intoxication; but a more efficient and trustworthy plan than any of these, and the only one AA'hich is habitually resorted to at the present day, is the administration of ether or chloroform, so as to produce anaesthesia and complete muscular relaxation. Anaesthetics are indeed invaluable in the treatment of dislocations, occurring in vigorous adults ; but in cases met Avith in children, or in adults of feeble and relaxed muscular frame, reduction should be attempted, and may often be conveniently effected, Avithout anaesthesia. Muscular resistance having been overcome, all that the surgeon has to contend Avith, in a case of recent dislocation, is the hindrance to reduction presented by the anatomical structure of the joint, the shape and altered rela- tions of the articular surfaces themselves, and the condition of the capsular and other ligaments which in a state of health keep the bones in apposition. Hence the paramount importance of an accurate knowledge of anatomy, in undertaking the treatment of these cases; as Prof. Hamilton well observes, in a very large majority of instances force and perseverance will finally suc- ceed, by whomsoeA'er they may be employed, but they succeed at the expense of great suffering, and perhaps permanent injury to the patient. It is the mark of the skilful surgeon not to employ blind force, but to adapt his ma- nipulations to the exigencies of the case, gently eluding the resistance to his efforts, and making the ligaments, muscles, and bones themselves act as effi- cient mechanical powers under his intelligent guidance. In the immense majority of cases, at least of recent dislocation, reduction can be effected without the use of greater force than can be applied simply through the hands of the surgeon and his assistants. The processes by which reduction is effected, are three in number, viz., manipulation, extension and counter-extension, and direct pressure. 1. Manipulation.—This term is used in a technical sense to describe certain movements by Avhich the surgeon aims to effect reduction by utilizing the structural elements of the joint itself. 2. Extension and Counter-extension.—Here the proximal articular surface is fixed by the knee or heel of the operator, by the hands of an assistant, or by means of a folded sheet, padded belt, etc., while the extend- ing force is applied directly by the surgeon's hands, through Fig. 137. the medium of bandages or towels secured with the clove- hitch knot (Fig. 137), or by still more poAverful means, such as the compound pulleys (Fig. 157), Fahnestock's and Gilbert's rope windlass (Fig. 155), Bloxam's tourniquet (Fig. 156), or Jarvis's adjuster. Continuous Elastic Extension, by means of India-rubber bands, has been utilized by Dr. H. G. Davis, of New York, in the treatment of old dislocations, and by this ciove-hitch. means Dr. Davis claims to have reduced a dislocation of the hip of fourteen years' standing. Continuous extension as a preliminary to reduction has also been successfully employed by Doutrelepont. 3. Direct Pressure.—By this alone, or in combination Avith the other methods, it is often possible to simply push the displaced bone into its normal position. When extending bands are used, great care should be taken to prevent their excoriating the soft parts; for this purpose they should be smoothly and evenly applied, and should be wet—a Wet bandage being less apt to slip, and producing less friction, than one that is dry. These bands may be applied directly over the displaced bone, or to the furthest extremity of the affected limb; thus, in luxations of the humerus, they may be fixed above the elboAv, or around the wrist. I have already indicated my preference for simple and gentle means of effecting reduction in cases of dislocation, and may add that, in my OAvn 278 DISLOCATIONS. practice, I have never had occasion to resort, in recent cases, to anything beyond manipulation, with manual extension and pressure; and though I should be loth to say that more powerful means should never be employed in cases of recent luxation, I cannot help thinking that the pulleys, and even extending lacs, are less often required in the treatment of these injuries than is commonly supposed. After-treatment.—This consists in placing the joint at complete rest, by the use of suitable bandages and splints, as in cases of fracture; if there be much inflammation, it may be necessary to leave the part exposed, for the applica- tion of evaporating lotions or other topical remedies. Opium may be used to relieve pain, and the general condition of the patient should be attended to, laxatives, diaphoretics', etc., being administered, if necessary. To encourage the restoration of function, passive motion should be employed as soon as the inflammatory symptoms have subsided, usually in the course of the second or third week. Loss of tone in the muscles should be combated by the use of friction, electricity, and the cold douche, and by the cautious administration of strychnia. Compound Dislocation is ahvays a very grave accident; if the Avound be small and clean cut, Avith but little concomitant injury, it is occasionally possible to save the part, by effecting reduction and then treating the case simply as one of wounded joint; but if there be much laceration, and espe- cially if there be a fracture of either or both articular extremities, excision or amputation should be performed, according to the particular joint affected, and the extent of lesion present. As far as any general rule can be given in such cases, it may be said that the surgeon's first thought should be of exci- sion, except in the case of the knee, where amputation is preferable. Complicated Luxations.—The complication of dislocation with fracture has already been considered in Chapter XI. A graver complication is rup- ture of the main artery of the limb. This has occurred in connection with dislocations of the shoulder and of the knee; in the former situation, liga- tion of the subclavian artery (after reduction), as successfully practised in a case recorded by R. Adams, would be indicated, and in the latter (as a general rule), amputation. The consequence of non-interference Avould be the formation of a diffused traumatic aneurism, Avhich would prove fatal either by hemorrhage, or by the supervention of gangrene. Extensive ex- travasation from the rupture of the smaller vessels may, howrever, occur, and may usually be successfully treated by the enforcement of rest and the use of evaporating lotions. Paralysis from compression or rupture of nerve trunks is occasionally met with as a complication of luxation, and is to be treated by the use of friction, electricity, etc. Old Dislocations.—The reduction of old dislocations is attended with more difficulty, and likeAvise with more risk, than the reduction of recent dislocations. The increased difficulty is due to the permanent contraction and structural changes Avhich occur in the muscles, to the abnormal adhe- sions which form betAveen the displaced bone and the parts Avith Avhich it is in contact, and to the changes Avhich have already been described as taking place in the articular surfaces themselves. The increased dangers Avhich attend efforts at reduction in these cases are dependent on the same morbid changes: among the accidents which have occurred under these circum- stances may be enumerated laceration of the skin and subcutaneous tissues, rupture of muscles in the neighborhood of the dislocated joint, deep-seated inflammation and suppuration around the joint, rupture of arteries, veins, OLD DISLOCATIONS. 279 or nerves, fracture of the displaced bone or of neighboring bones, and finally avulsion of the entire limb, as happened in a remarkable case reported by (luerin. Hence, Avhile greater force is required in the treatment of these cases than in that of recent luxations, the employment of such force is ahvays attended Avith considerable risk. Even manipulation without extension is not free from danger, for the displaced bone may, in its neAV position, have acquired adhesions to the main artery or vein, rupture of Avhich, in the ac- tion of reduction, would probably cause serious, if not fatal, hemorrhage. It is impossible to fix any definite period beyond Avhich reduction should not be attempted in cases of old dislocation. Dr. Nathan Smith reduced a luxation of the shoulder nearly a year after the accident, and luxations of the hip have been reduced by Dr. Blackman, and by Dr. Smyth, of New Orleans, at periods respectively of six and nine months after the reception of the injury. Even if the attempt at reduction fail, the surgeon's manipu- lations, if practised with caution and gentleness, may be of service in in- creasing the mobility of the limb, and thus adding to its usefulness in its ab- normal position. Hence, in the case of dislocation, even of several months' standing, provided that the effort Avere warranted by the general condition of the patient, I should recommend an attempt at reduction, undertaken, of course, Avith the extremest caution and delicacy. The patient should be thoroughly relaxed by anaesthesia, and gentle manipulation and moderate extension then employed, so as to stretch or sloAvly sever any morbid adhe- sions, and alloAv the displaced bone to be gradually brought into its proper position; or the elastic extension recommended by Dr. Davis might be re- sorted to, and would certainly be Avorthy of a trial in the event of other means failing. Subcutaneous Division of Muscles, Tendons, and Ligaments, was proposed by Dieffenbach as a preparatory measure in the treatment of old dislocations, and by this plan that surgeon succeeded in effecting reduction in a case of luxation of the humerus of tAvo years' standing. In the hands of others, however, the operation has not been generally successful, Avhile it has occa- sionally given rise to extensive suppuration and sloughing. Subcutaneous osteotomy has been successfully employed by Dr. Mears, of this city, in a case of irreducible dislocation of the shoulder. Volkmann has successfully excised the head of the femur, with antiseptic precautions, in a case of hip- dislocation of tAvo months' standing. Treatment of Accidents occurring during Attempts at Reduction of Old Dis- location.—If a fracture occur in the effort to reduce an old dislocation, the attempt should be at once discontinued, and the broken bone placed in such a position as to favor union. The rupture of an important muscle, such as the pectoralis major, Avould likeAvise oblige the surgeon to desist from further efforts at reduction. Rupture of the main artery, with formation of a trau- matic aneurism, is a very grave accident when occurring under these cir- cumstances ; it has been chiefly met Avith in the case of the axillary artery, in connection Avith dislocation of the humerus. There are tAvo courses open to the surgeon in dealing Avith such a case, viz., to ligate the subclavian, or, as has been recently done (unsuccessfully, hoAvever) by Callender and Lister, to resort to the "old operation," laying open the sac, and tying the vessel above and below the point of rupture. The latter course would probably be the safest under these circumstances, the case herein differing from one of arterial rupture accompanying recent dislocation (see p. 278) ; there the effect of the " old operation " Avould be to convert the injury into a compound luxa- tion of the Avorst kind, whereas in an old dislocation the connection Avith the joint Avould be less direct (from the effects of inflammatory action), and the prospects of the operation proportionably better. Ligation of the subclavian 280 DISLOCATIONS. has been resorted to four times under these circumstances, by Warren, Gib- son, Nelaton, and R. Adams, the first and the last mentioned cases having terminated successfully. In a similar case Blackman tied the axillary artery in its upper portion, but the patient died on the eleventh day from hemor- rhage, and Maunder speaks of nine similar operations of which only one was successful. Amputation at the shoulder-joint proved fatal in a case re- corded by Mr. Bellamy. Rupture of the axillary vein terminated fatally in a case recorded by Froriep, but in a similar case in the practice of Agnew, Fig. 138. Congenital dislocation of both hips. (Holmes.) of this city, recovery ensued without the necessity of a resort to operative interference. Expectant measures likewise proved successful in a case re- corded by Sands, of New York, in which the axillary artery Avas supposed to be the vessel implicated. Avulsion of the limb, as occurred in Guerin's case, would, of course, require immediate amputation. Spontaneous, Pathological, and Congenital Dislocations.—In the treat- ment of these cases there is usually not so much difficulty in effecting, as in DISLOCATION OF THE LOWER JAW. 281 maintaining reduction. Guerin, Brodhurst, and others, have successfully employed subcutaneous tenotomy and myotomy, folloAved by continued ex- tension, in the treatment of congenital luxations, and the same treatment might be adopted in cases of the pathological variety, provided that no active joint disease Avere present at the time of operation. In cases dependent on muscular paralysis, the difficulty Avould be in maintaining reduction, and here external support (in the form of carved or moulded splints, elastic bandages, or some of the ingenious devices Avhich are used in the treatment of deformities, and Avhich will be hereafter alluded to) might be usefully employed. Congenital dislocation of both hips is well shown in Fig. 138. Special Dislocations. Fig. 139. Dislocation of the Lower Jaw is a rare accident, occurring chiefly in early adult age, and rather oftener in women than in men. It is usually double or bilateral, though occasionally one side only is displaced. The most common cause of dislocated jaAv is mus- cular action, though it may also result from a blow on the chin Avhile the mouth is open, or from other forms of violence, such as the forcible introduction of a foreign body into the mouth, or the ex- traction of teeth. When the mouth is opened, the maxillary condyles ride forwards upon the articular eminences of the temporal bones, and a very slight degree of force is then necessary to make them slip still further fonvards into the zygomatic fossae, thus producing disloca- tion. The contraction of the external pterygoid muscles, and perhaps of some fibres of the masseters, is thus quite suf- ficient to produce luxation when the mouth is Avidely opened, the tonic con- traction of the same muscles, combined Avith the position of the coronoid proc- esses (Avhich catch against the malar bones), being the principal obstacles to reduction. J. W. Hamilton, of Ohio, describes a spontaneous, backward dislocation of the loAver jaAv. Symptoms.—The symptoms of a recent dislocation of the jaAv are sufficiently obvious. There is prominence of the chin, the mouth being Avidely open, and the jaAv almost immovable; there is likewise a marked depression over the seat of the articulation, Avith a slight fulness anteriorly. In unilateral dislocation the jaw usually inclines to the opposite side—a symptom Avhich serves for the diagnosis between luxation and fracture, but Avhich, according to Hey and R. Smith, is not always present. There is generally, but not ahvays, pain; the patient speaks and SAvalloAVS with difficulty ; and there is a constant Aoav of saliva from the mouth. Prognosis.—Even if the dislocated jaw be unreduced, the patient gradu- ally acquires considerable use of the part, and is ultimately able to close the mouth, cheAv, swallow, and talk—much less inconvenience being felt from the displacement than Avould at first be supposed. Reduction in a recent / ^ Double dislocation of the inferior maxilla. 282 DISLOCATIONS. case is easily accomplished, and has even been effected (by DonoATan) more than three months after the reception of the injury. Sometimes the liga- ments are left permanently Aveakened, motion of the part being painful, and the joint being liable to a reproduction of the dislocation. Treatment.—Reduction is effected by disengaging the coronoid processes from the malar bones, and the condyles from the zygomatic fossae, by pressing the chin upwards, AA'hile a fulcrum is placed upon or behind the molar teeth. The surgeon, standing behind the patient, whose head is supported on the operator's chest, may use his thumbs (protected by a piece of leather or folded toAvel) as a fulcrum, pressing the angles of the jaAv doAvmvards, Avhile he ele- vates the chin Avith his fingers ; or pieces of cork or wood may be used as a fulcrum, in Avhich case they should be provided Avith strings to facilitate their withdrawal. Nelaton recommends simply pushing the coronoid processes backwards Avith the thumbs, applied either from within the mouth, or from Avithout. In any case of difficulty, one side might be reduced at a time, taking care Avhile manipulating the second, not to reproduce the luxation of the first. Anaesthesia is not usually required in these cases, though there Avould be no particular objection to its employment, if it were thought desira- ble. After reduction, the part should be supported for at least a Aveek or ten days, by means of a four-tailed sling or other suitable bandage. Subluxation of the Jaw.—Under this name, Sir Astley Cooper has de- scribed a peculiar condition, met Avith chiefly in those of relaxed and feeble muscular frame, Avhich is supposed to depend on the condyles slipping in front of the inter-articular cartilages, and thus rendering the jaAv temporarily immovable. Whatever be the true nature of this affection, it is undoubtedly accompanied by relaxation of the articular ligaments, which allow the con- dyles to slip about during the act of chewing, thus often producing a clacking sound, which is sometimes audible at a distance. The subluxation, if such it be, may be bilateral, or unilateral only ; it is sometimes produced by the act of opening the mouth widely, as in gaping or laughing, but, in other cases, occurs Avithout any apparent exciting cause; it may usually be reduced by the patient himself, by pressing the jaw sideAvays, or by lifting the chin slightly upwards. Sometimes this condition appears to depend on spasm of the muscles of mastication, Avhen it may be made to disappear by friction over the affected part. Tonics should be given, if the general condition of the patient appears to indicate their use, and the recurrence of the dis- placement may be prevented by wearing a sling, held in place by elastic bands. Hyoid Bone.—Cases of dislocation of this bone have been recorded by Dr. Ripley, of South Carolina, and by Dr. Gibb, of London: the treatment consists in throwing back the head, depressing the lower jaAv, and pushing the luxated bone into position. Ribs, Sternum, and Pelvis.—Dislocations of the Ribs are described as occurring either at their vertebral articulations, or at the junction of their costal cartilages. The symptoms would be much the same as those of frac- ture in the same localities, except that, of course, crepitus Avould be wanting. The treatment Avould be the same as for fracture. Dislocations, or rather diastases of the Sternum and Pelvis, were referred to in connection Avith fractures of those parts. Salleron has reported three cases of dislocation of the ilium at the sacro-iliac joint, Avithout fracture, in each of Avhich reduction was readily accomplished, and Avas folloAved by complete recovery. Gallez has met with disastasis of the pubic symphysis as the result of muscular action. DISLOCATIONS OF THE CLAVICLE. 283 Fig. 140. Dislocation of sternal end of clavicle, forwards. (Bryant.) Clavicle.—The clavicle is more frequently dislocated at the acromial than at the sternal end, the former injury occurring, according to Hamilton, about four times as often as the latter. Dislocation of the Sternal End of the Clavicle usually results from indirect violence, and is almost ahvays in a forward direction. Dislocation back- wards, hoAvever, occasionally occurs, and sometimes gives rise to troublesome dyspnoea or dysphagia, from pressure on the trachea or oesophagus, or to cerebral congestion, from pressure on the cervical veins. Dyspnoea and dysphagia may also occur in instances of upward dislocation, of Avhich rare injury R. W. Smith has been able to collect but eight cases, including one ob- served by himself, to which, however, may be added four others since recorded by Bryant and ShaAV. The diagnosis of these cases is usually easy, the subcutaneous posi- tion of the clavicle rendering the deformity very apparent. Reduction can commonly be effected Avithout much difficulty, by placing the knee against the spine, and dnnving the shoulders outwards and backwards, but the displacement is exceedingly apt to be repro- duced. The apparatus most generally ap- plicable, consists in a compress over the projecting end of the clavicle (in cases of fonvard or upAvard displacement), held in position by adhesive strips, or by an elastic band passing under the groin and perineum, the shoulder and arm being fixed as in a case of fractured clavicle. In case of backAvard dislocation, the compress should be omitted, the shoulders being simply drawn backwards by a figure of 8 bandage, or some similar contriv- ance. Though the deformity in these cases (especially when the displace- ment is forwards or upwards) is seldom entirely overcome, yet the utility of the limb does not appear to be materially diminished by the accident. In one or two cases of backward dislocation, the pressure effects have been so serious as to in- duce the surgeons in attendance to resort to excision of the displaced portions of bone. The Outer End of the Clavicle is usually dis- located in an upward direction, resting upon the margin of the acromion process; the accident results from indirect violence, and the nature of the case is usually apparent, though, if there be much swelling, it may be mistaken for a doAvmvard dislocation of the humerus. Occa- sionally the acromial end of the clavicle is dis- placed doivnwards, by direct violence, such as the kick of a horse; and dislocation under the coracoid process has been described, though the cases on record are someAvhat apocryphal. An instance of backward dislocation is recorded by Nicaise. Dislocation of the acromial end of the clavicle may be commonly reduced Avithout much trouble, though, as in the case of luxation of the sternal end, reduction can Avith difficulty be main- tained. The after-treatment is the same as for fractured clavicle, with the addition of a firm compress, held in place by broad adhesive strips passing from the point of injury to the elbow: although the deformity can be seldom entirelv removed, the motions of the limb are less interfered with than might Fig. 141. Dislocation of the clavicle on the (Bryant.) acromion. 284 DISLOCATIONS. be anticipated. Dr. Montgomery, of Rochester, has reported a case success- fully treated by Moore's method for fractured clavicle, and a somewhat similar plan has been advantageously adopted by Dr. Doughty, of Georgia. Simultaneous Dislocations of Both Ends of the Clavicle have been observed by Richerand, Gerdy, Morel-Lavalle, Col, S. Haynes, Lund, and North, of Brooklyn, N. Y. Scapula.—Under the name of dislocation of the scapula, systematic Avriters describe a projection of the inferior angle of this bone, due either to its escape from beneath the edge of the latissimus dorsi muscle, or to great relaxation of the fibres of that muscle or of the serratus magnus; the symptoms consist in the deformity, which is obvious, Avith some pain and weakness of the cor- responding upper extremity. The treatment Avould consist in the application of external support, Avith the administration of tonics, and, perhaps, the endermic use of strychnia, as recommended by Erichsen. Dislocations of the Shoulder.—The head of the humerus may be dislocated downwards, forwards or backwards. Dislocation Downwards, or into the axilla (Subglenoid Dislocation), is usually due to direct violence, such as a blow on the upper and outer part of Fig. 142. Dislocation of the humerus downwards, into the axilla; subglenoid. (Pirrie.) the humerus, though it is occasionally caused by indirect force, such as a fall on the hand or elbow, the arm being abducted at the moment of injury. In other cases the dislocation is produced by muscular action, the head of the bone being, as it were, pulled out of its socket. In this dislocation, the head of the bone rests below and slightly in front of the glenoid cavity of the scapula, being pressed forwards by the tendon of the triceps muscle; the capsular ligament is Avidely torn, the long head of the biceps often ruptured or detached, and the supra- and infra-spinatus, subscapularis, coraco-bra- chialis and deltoid muscles much stretched and sometimes lacerated, Avhile DISLOCATIONS OF THE SHOULDER. 285 the axillary vessels and nerves are compressed. The symptoms, in a recent case1, are usually obvious: there is, beneath the acromion process, a marked depression, Avhich can commonly be seen as well as felt, the arm is length- ened by nearly an inch, and the head of the humerus can be felt in the axilla, especially when the elboAv is lifted away from the body. The arm is kept somewhat abducted, and pain is developed by pressing the elbow to the side; the hand cannot be placed on the opposite shoulder when the elboAv is in contact Avith the chest. The diagnosis in a recent case is thus usually very easy, but Avhen SAvelling and inflammation have occurred, it becomes more difficult, if not occasionally impossible, to be again simplified upon the sub- sidence of the inflammatory condition. Hence, although by a careful and systematic examination, the true nature of the injury may almost always be eventually determined, the surgeon should hesitate before criticizing another practitioner for a mistake which may have been unavoidable under different circumstances. Prof. Dugas, of Georgia, has proposed as a test of the exist- ence of dislocation that the fingers of the injured limb should be placed upon the sound shoulder, and an attempt then made to bring the elbow into contact with the thorax; if this can be done, no dislocation, according to Prof. Dugas, can be present; while, if it cannot be done, he considers the Fig. 143. Subcoracoid luxation of the humerus. (Pirrie.) existence of dislocation established, no other injury of the shoulder being capable of causing this disability. The prognosis should be somewhat guarded: although reduction is usually effected Avithout difficulty, yet the arm not un- frequently remains permanently weakened, partially anchylosed, or paralyzed from injury to the axillary plexus of nerves. A certain degree of deformity may also remain in spite of reduction, the head of the humerus projecting anteriorly, probably on account of displacement or rupture of the long head of the biceps muscle. The laceration and stretching of the capsular liga- ment leave the joint predisposed to a recurrence of the dislocation. 286 DISLOCATIONS. Dislocation Forwards.—Of this form of dislocation there are tAvo varieties, the Subcoracoid (Fig. 143) and the Subclavicular: the latter may be consid- ered as an aggravated condition of the former, which Avas, indeed, described by Sir Astley Cooper as a partial luxation. As the names imply, the head of the humerus, in these injuries, rests beneath the coracoid process, or be- neath the middle of the clavicle. These luxations, Avhich more often result from indirect than from direct violence, are accompanied by a great deal of muscular and ligamentous laceration, and are attended Avith e\^en more pain than the dislocation into the axilla. The symptoms are much the same as those of the dowmvard luxation, except that the axis of the arm is even more altered, and that the head of the bone can be felt in a different posi- tion. The subcoracoid is more often met Avith than the subclavicular dislo- cation, and is said by Mr. FloAver and others to be the most common form of luxation of the shoulder-joint. Reduction appears to be more difficult in cases of fonvard than of downward dislocation; at least there are, according to Hamilton, proportionably more cases recorded of unreduced luxation of the former than of the latter injury. Dislocation Backwards (Subspinous Luxation) is a rare accident, there being probably not more than twenty or thirty cases of it on record; it is usually caused by indirect violence or by muscular action, and differs in its symp- toms from the dislocations already described, in that the elbow is brought forAvards, instead of backwards, while the head of the bone can be felt more or less distinctly beneath the spine of the scapula. The most striking de- formity is the prominence of the coracoid process of the scapula, which seems to project forward, and over Avhich the skin is tightly stretched. Re- duction has usually been effected without much difficulty in these cases, but in one instance, mentioned by Cooper, it w7as impossible to maintain the reduction, on account of rupture of the subscapularis muscle. I have seen but one example of this rare form of injury, and in that, in spite of the marked deformity, the nature of the case had not been suspected for six weeks after the occurrence of the dislocation. I succeeded in effecting re- duction without difficulty by raising the arm above the head, and then bringing it down with a broad sweep behind the level of the patient's body, so as to throw the head of the bone forwards, while the scapula Avas firmly fixed by an assistant. Partial Dislocation.—Under this name has been described an injury, which appears to consist in a rupture or displacement of the long head of the biceps muscle,1 allowing the head of the humerus to project anteriorly, rather than in any positive luxation of the bone itself. As already men- tioned, this condition occasionally remains after the reduction of an ordinary doAvnward or fonvard dislocation. Le Gros Clark has reported a case of partial backward dislocation Avhich resulted from injury, and in Avhich reduc- tion Avas readily effected. Treatment of Dislocations of the Shoulder.—The subglenoid and the subcora- coid dislocations may be reduced by the same means, while the subspinous and subclavian varieties require slight modifications in the direction in which the force is applied. Thus, in applying extension in the luxation beneath the clavicle, the head of the bone should be first drawn dowiiAvards, out- wards, and subsequently backAvards, so as to clear the coracoid process; while in the subspinous dislocation, extension should be made doAvmvards, outwards, and subsequently forAvards. A great many different plans have been de\rised for the reduction of dislocations of the shoulder, but they may 1 This inward displacement of the biceps tendon, which Soden and others have considered traumatic, is believed by Canton to be due to the existence of chronic rheumatic arthritis, which may or may not have been the result of injury. DISLOCATIONS OF THE SHOULDER. 287 all be classified in four divisions, as aiming to effect their object: 1, by ex- tension and counter-extension alone; 2, by leverage alone; 3, by a combina- tion of these methods; and, 4, by manipulation, in its technical sense (see page 277;. 1. Extension may be made (1) more or less downwards, as in Cooper's method (Fig. 144), in Avhich counter-extension is made by the heel in the Fig. 144. Sir Astley Cooper's method of applying extension with the heel in the axilla. axilla;1 as in Skey's method, in which the heel is replaced by an iron knob; or as in Hamilton's plan, in Avhich the scapula is fixed by the ball of the foot, placed against the acromion process; (2) it may be made outwards, as recom- Fig. 145. Reduction of dislocated shoulder by White's and Mothe's method. mended by Malgaigne; or (3) it may be made upwards, as directed by White, of Manchester, Mothe, and others, the scapula being then fixed by the foot or hand placed above the acromion process. The latter, though painful, is probably the most efficient of any of the methods Avhich profess- 1 T. Smith has recorded a case in which, in attempting to reduce a recent disloca- tion with the heel in the axilla, the anterior axillary fold was completely torn through ; the case terminated fatally. 288 DISLOCATIONS. edly act by extension and counter-extension alone. When extension is made with the heel in the axilla, an assistant may give aid by drawing the arm outwards, as advised by Ward, of Dublin. 2. Leverage.—The arm may be simply used as a lever, to pry the head of the bone into its place over a fulcrum placed in the armpit, as in Sir Astley Cooper's method with the knee in the axilla. 3. Extension and leverage combined are, I think, more effectual than either method separately. The plan AAdiich I am in the habit of employing, in these cases, is essentially that which was described by Dupuytren as a modification of Mothe's method, and AAThich, according to Bromfeild, was in common use in his day; it consists in placing the patient, thoroughly ether- ized, if necessary, in a supine position, and then, having drawn the arm di- rectly upwards, bringing it down fully extended in a broad SAveep over an assistant's fist, placed in the axilla to act as a fulcrum—the scapula being at the same time steadied from above by the assistant's other hand. By this plan I have succeeded in reducing dislocations of the shoulder which had defied prolonged efforts made in other ways, and, indeed, have as yet never failed in effecting reduction in a recent case. The same principle, that of extension combined with leverage, is involved in the methods recommended by Sir William Fergusson and by Prof. N. R. Smith, of Maryland, in Avhich, hoAvever, the force is applied through the medium of extending lacs or bands. The peculiarity of Prof. Smith's method is that counter-extension is made from the opposite wrist, so as to insure the fixation of the scapula, by pro- voking the contraction of the trapezii muscles. 4. Manipulation.—The reduction of dislocations of the humerus by ma- nipulation alone has been practised by various surgeons, among whom may be mentioned La Cour and Sir Philip Crampton, but the credit of reducing the plan to a system, and of prominently bringing it to the notice of the pro- fession, in this country at least, is, I believe, due to Prof. H. H. Smith, of this city, whose method consists in first converting the luxation (if it be either forwards or backAvards) into the ordinary downward or subglenoid variety, and then proceeding as follows: " Elevate the elbow and arm as high as pos- sible, and flex the forearm at right angles with the arm, thus relaxing the supra-spinatus muscle. Then using the forearm as a lever, rotate the head of the humerus upward and forward, so as to relax the infra-spinatus, carrying the rotation as far as possible, or until resisted by the action of the subscapu- laris muscle, keeping the forearm for a few seconds in its position with the palm of the hand looking upward ; then bring the elboAv promptly but stead- ily down to the side, carrying the elbow toAvards the body, and keeping the forearm so that the palm of the hand yet looks to the surgeon. Then quickly but gently rotate the head of the humerus upAvard and outward by carrying the palm of the hand downward and across the patient's body, and the bone will usually be replaced."1 In cases of old dislocation, Callender recommends, in order to avoid injuring the axillary vessels, to raise the elbow across the chest, and then force the raised arm outwards, rotating and somewhat depressing the arm while so doing. The reduction of shoulder dislocations by manipulation has also been illus- trated by Dr. A. Gordon, of Belfast. Kuhn, of Elbeuf, suggests, on account of the difficulty of fixing the scapula, that the humerus should be firmly held by an assistant, while the surgeon applies his manipulations directly to the former bone. Dr. Mears's successful osteotomy for old dislocation of the shoulder has already been referred to. After reduction, the arm should be fastened to the side and supported with 1 Packard's Minor Surgery, p. 204. DISLOCATIONS OF THE ELBOW. 289 Fig. 146. a sling, for a week or ten days, so as to allow time for repair of the lacerated ligaments. ,'J^ Dislocations of the Elbow.—Both bones of the forearm may be dislo- cated at the elbow -joint, or either separately. The Head of the Radius alone may be displaced forwards, outAvards, or backwards, the forward dislo- cation being much the most frequent, and the cause of the injury being usually a fall on the hand, though the luxation may occasionally result from muscular action. The head of the bone can or- dinarily be felt in its abnormal position, and the diagnosis can thus, unless there be much swelling, be readily made. The forearm is kept in a semi-flexed position, and either pronated, or mid- way between pronation and supination ; any motion of the part is attended with great pain. Reduction is to be effected by making extension and counter-exten- sion in the direction in which the limb is found, the displaced bone being at the same time firmly pressed into its proper position ; the arm should subsequently be fixed on an angular splint, with a compress over the head of the radius. It is always difficult to maintain reduc- tion in these cases, and reduction itself is occasionally impossible ; fortunately, the usefulness of the limb does not ap- pear to be materially impaired by the persistence of the displacement. The Ulna alone may be displaced backwards, as the result of a fall on the hand, the olecranon then projecting be- hind the condyles of the humerus, while the head of the radius can be felt in its proper position. The elbow in such a case will be flexed at a right angle, and the forearm tAvisted inwards and pronated. Reduction may be effected by Sir Astley Cooper's method of flexing the elbow over the knee; by ex- tension and counter-extension, combined with direct pressure upon the ole- cranon ; or (as recently recommended by Dr. Waterman, of Boston) by ex- tending the forearm on the arm beyond a straight line, thus using the ulna as a lever of the second order (the olecranon being the fulcrum), to bring the coronoid process over the condyles, into its proper place. Both Bones of the Forearm may be dislocated at the elbow, backwards,^to either side, or forwards. The dislocation backwards, which is the most com- mon, is usually caused by indirect violence, though occasionally by a direct bloAv, or by muscular action. Not only are the bones displaced backwards, but they are drawn upwards by the powerful action of the triceps muscle. The diagnosis, if SAvelling have not occurred, can usually be made without difficulty ; the arm is held in a slightly flexed position (rarely at a right angle), and the slightest attempt at motion causes great pain; the olecranon and head of the radius can be felt projecting backwards, while the condyles of the humerus form a hard and broad prominence on the front of the arm. 19 Dislocation of head of radius forwards ^ex- ternal appearance of limb. (Liston.) 290 DISLOCATIONS. The relative position of the olecranon and condyles is markedly altered, this being an important diagnostic mark betAveen dislocation and fracture. Re- Fig. 147. Dislocation of both bones of the forearm backwards. (Liston.) duction in a recent case is usually easy, though instances are on record in which failure has attended the efforts of the most skilful surgeons; the prog- nosis is decidedly unfavorable as regards old dislocations, though reduction has been several times effected at as late a period as six months after the reception of the injury. The usual method of treatment is that recommended by Sir Astley Cooper, which consists in forcibly but sloAvly bending the arm over the knee, which is placed on the inner side of the elbow, so as to press on the radius and ulna, separating them from the humerus, and thus freeing the coronoid process from its abnormal position (Fig. 148). An- other plan is to forcibly extend the arm so as to relax the triceps, making counter- extension against the scapula (as advised by Liston and Miller) ; or the luxation may be reduced by simple extension (Skey), or by extension combined with direct pressure on the olecranon, accord- ing to the plan of Pirrie. In a child, or in a person of feeble muscular develop- ment, reduction can usually be effected Avithout the aid of anaesthesia; prolonged efforts at reduction are, however, so pain- ful, that in any case of difficulty an anaes- thetic should be employed. Sayre, of New York, has reported two cases of old dislocation of the elbow in which reduction was greatly facilitated by Reduction with the knee in the bend of the elbow. DISLOCATIONS AT THE AVRIST. 291 subcutaneous division of the triceps tendon. Hamilton recommends, as a test for reduction, to flex the elbow to a right angle; if this can be done with- out much pain, it proves that reduction is complete. McGraw advises that in old backAvard dislocations, in children, forced and extreme flexion should be made, so as to fracture either the olecranon or the lower epiphysis of the humerus, either of Avhich occurrences, he believes, Avould improve the con- dition of the joint. Lateral dislocation of the radius and ulna at the elboAv is rarely complete, but in the majority of cases is partial, and in an outAvard direction. The cause is usually direct violence. The deformity in these cases is usually so marked and peculiar as to render the nature of the lesion unmistakable, al- though I have reduced an inward luxation of two weeks' standing which was at first attended Avith so much swelling that the gentleman in attendance did not recognize the existence of the injury; reduction may be effected by making moderate extension, with direct pressure on the displaced bones, and counter-pressure on the lower end of the humerus. Lateral dislocation is sometimes found coexisting with the ordinary backward displacement; in dealing with such an injury, the lateral luxation should be first reduced, and the case then treated as one of simple backward dislocation. Osteo- plastic resection, or temporary separation of the olecranon, is recommended by Volker as a means of exposing the joint in cases of irreducible luxation. Luxation forwards of both bones of the forearm, Avithout fracture of the olecranon, is a very rare accident, there being not more than six or seven well-authenticated cases on record. The injury appears usually to have re- sulted from direct violence, and the most striking symptom is elongation of the forearm, Avhich is in a state of supination, the elbow being fixed at a right angle. Reduction may be accomplished by making forced flexion, together with extension and counter-extension, the muscles being relaxed by the use of an anaesthetic. In a case recorded by Dr. Forbes, of this city, reduction was effected by simply flexing the forearm, and then pressing it downwards and backwards. If the luxation were incomplete, the forearm making an obtuse angle only with the arm, reduction might be accomplished by making forcible extension. , Dislocations at the Wrist.—The Lower End of the Ulna may be dislo- cated from the radius, either forwards, backwards, or inwards. These acci- dents, of which Tillmans, of Leipsic, has been able to collect but 48 cases, are usually caused by muscular action, the dislocation forwards being due to violent supination, and that in a backAvard direction to violent pronation. The inward is the rarest form of luxation, Tillmans's figures giving but 9 cases of this, as compared Avith 16 of the forward, and 18 of the backward variety, with 5 in Avhich the direction of the displacement Avas not specified. Reduction is easily effected by fixing the radius, and simply pushing the ulna back into place, the limb being then placed between anterior and posterior splints. In connection with fracture of the lower end of the radius, the backward dislocation of the ulna is not uncommon. The ligaments some- times remain permanently stretched after the accident, so as to allow a cer- tain amount of mobility of the ulna, and I have known such a condition to be mistaken for ununited fracture of this bone. The Carpus may be dislocated upon the bones of the forearm, either back- wards or forwards. These injuries are, however, rarely met with—Tillmans has collected but 24 cases—and in every case that has been submitted to the test of dissection, the luxation has, according to Hamilton, been found com- plicated Avith fracture. The usual cause of either form of dislocation is a fall on the palm, though in a case of backward displacement recorded by Hamil- 292 DISLOCATIONS. ton, the injury resulted from a fall on the back of the hand, the wrist being strongly flexed. The diagnosis is made by observing the abruptness of the angle made by the displaced bones, their relation to the styloid processes, and (if the case be not complicated with fracture) the absence of crepitus. Reduction is easily effected by extension and pressure, and there is subse- quently no tendency to reproduction of the displacement. Individual Bones of the Carpus are occasionally luxated in a backward direction, those bones which have been found thus displaced being the os magnum, semilunare, and pisiform, to Avhich some writers add the cuneiform and unciform. The treatment would consist in effecting reduction by exten- sion and pressure, supporting the part afterwards with splints and compresses. Chisholm reports a case of forward luxation of the semilunare, in which ex- cision of the displaced bone Avas required. Dr. Nancrede has met with a forward subluxation of the scaphoid. Hands.—The Metacarpal Bones, especially those of the thumb, index and middle finger, may be dislocated upon the carpus, the two latter bones back- wards, and the metacarpal of the thumb either backwards or forwards. Reduction is effected by extension and pressure, the hand being afterwards secured to a straight splint Avith compresses. The Fingers may be dislocated at the metacarpophalangeal, or, more rarely, at the inter-phalangeal joints. The proximal phalanx of the thumb Fig. 149. Levis's instrument applied to the first finger. is not unfrequently dislocated backwards, reduction being sometimes very difficult, owing, probably, to the head of the metacarpal bone being caught either between the lateral ligaments or betAveen the heads of the flexor brevis muscle, or, according to Farabeuf, to the interposition of the external sesa- moid bone. In the treatment of these luxations, extension may be made Avith the ordinary clove-hitch, or Avith Dr. Levis's ingenious apparatus, or Avith the " Indian puzzle," as recommended by Prof. Hamilton and others. A better plan, perhaps, is that practised by Prof. Crosby, Avhich consists, according to Gross, " in pushing the phalanx back until it stands perpendicularly on the metacarpal bone, Avhen, by strong pressure against its base, from behind forwards, it is readily carried by flexion into its natural position." In ex- treme cases subcutaneous division of the resisting ligaments or muscles may possibly be required. Forward luxation of the thumb is more rarely met with than the injury last described, and is to be reduced by forcibly flexing the thumb into the palm of the hand. Dislocations of the second phalanx of the thumb, or of the second or third phalanges of the fingers, may be re- duced by simple extension and pressure, made with the surgeon's hands, or, if more force be required, with the apparatus of Dr. Levis. Dislocations of the Hip.—The subject of dislocation of the hip has been most ably investigated by Prof. Bigelow, of Boston, of whose excellent monograph on the subject I shall not hesitate to make free use in the fol- lowing pages. To understand the pathology of these dislocations, and the DISLOCATIONS OF THE HIP. 293 mechanism of their reduction, it is necessary to turn for a few minutes to consider the anatomy of the joint, and especially of that portion of the cap- sule Avhich is known as the ilio-femoral ligament, or ligament of Bertin, and for Avhich BigeloAv proposes the name of " Y ligament." This ligament "is more or less adherent to the acetabular prominence and to the neck of the femur; but it will be found, upon examination, to take its origin from the anterior inferior spinous process of the ilium, passing downward to the front of the femur, to be inserted fan-shaped into nearly the whole of the oblique ' spiral' line which connects the two trochanters in front—being about half an inch wide at its upper or iliac origin, and but little less than tAvo inches and a half wide at Fig. 151. Fig. 150. The Y ligament; the inner fasciculus is known as the ilio-femoral ligament, or ligament of Bertin. (Bigelow). Backward dislocation of hip ; external ap- pearances. its fan-like femoral insertion. Here it is bifurcated, having two principal fasciculi, one being inserted into the upper extremity of the anterior inter-trochanteric line, and the other into the loAver part of the same line, about half an inch in front of the small trochanter." Both of these divergent branches remain unruptured in the ordinary dislocations of the hip, and their attachments must be borne in mind in attempting reduction of the various forms of dis- placement. The head of the femur may be dislocated in almost any direction; but there are three forms of luxation Avhich occur so much oftener than the others as to be usually classed as regular dislocations, the other varieties being called irregular or anomalous. The regular dislocations are—1, back- wards; 2, downwards; and 3, upwards. 1. The Dislocation Backwards, or Uio-sclatic Luxation, presents tAvo prin- cipal varieties, viz., upwards and backwards or on the dorsum ilii, and back- wards onlv, the dislocation into the ischiatic notch of Sir Astley Cooper, or, 294 DISLOCATIONS. which is a better name, dorsal below the tendon (of the obturator internus), according to Prof. Bigelow. These tAvo forms of luxation, taken together, probably embrace more than three-fourths of the whole number of cases, Prof. Hamilton having found that of 104 cases, 55 Avere on the dorsum ilii, and 28 into the ischiatic notch. These injuries usually result from indirect violence : thus, the dislocation on the dorsum may be caused by any force AA'hich produces great adduction, or adduction Avith inversion, the head of the bone being driven at the same time upwards and backAvards. A fall on the outside of the knee, or on the foot, while the limb is adducted,1 or a severe blow on the pelvis, Avhile the body is bent forAvards, may each in turn be a cause of this dislocation. The etiology of the ischiatic form of luxation is much the same, except that'it is more apt to occur when the thigh is flexed at a right angle upon the body, the force then driving the head of the bone more directly backwards, than backwards and upwards. The symptoms of these forms of dislocation are usually well marked. There is shortening of the affected limb, varying from about half an inch in the dislocation below the tendon, to one, two, or even three inches in that on the dorsum ilii. In the first-named variety, the shortening, is,'as pointed out by Allis, much more apparent wdien the limbs are flexed to a right angle than Avhen they are extended. Inversion is present in both varieties, though most marked in the ordinary dorsal luxation. The hip itself is altered in shape, the trochanter being unduly prominent, and thrown forwards, while the head of the femur can often be felt rotating in its abnormal position. The axis of the limb is distorted, the thigh of the affected side crossing the other at its loAver third in the dorsal dislocation, and just above the knee in the ischiatic variety ;2 in the former case the foot of the affected limb rests on the instep of the sound side; in the latter, upon the ball of the great toe. The diagnosis has to be made from sprain and from fracture. From sprain, the case can be distinguished by careful examination and measurement, the patient being etherized so as to obviate spasmodic muscular resistance. If the limb can be readily everted, the case is not one of luxation. From ordi- nary non-impacted fracture, a dislocation can be distinguished by the fact that in the former there is mobility, crepitus, and eversion ; in the latter, im- mobility, no crepitus, and inversion. From the rare cases of impacted frac- ture with inversion, the diagnosis is more difficult, but may be made by ob- serving that in such cases the trochanter is flattened, and the head of the bone still rotates in the socket, Avhile in dislocation the trochanter is unduly prominent, and the head of the bone can be felt beneath the gluteal muscles. A convenient mode of measurement, which bears the name of Nelaton, con- sists in drawing a line from the anterior iliac spine to the tuber ischii; in a normal limb, the trochanter lies immediately below this line, but in any case of dislocation will be of course displaced in one or another direction. Reduction of Backward Dislocations.—The capsular ligament is usually Avidely lacerated in these injuries, except at its anterior part, where it is rein- forced by what has already been described as the Y ligament. The liga- mentum teres, also, is usually, though not necessarily, torn in these disloca- 1Fabbri, Coote, and H. Morris teach that all dislocations of the hip occur while the limb is abducted, the downward luxation being the primary, and the others con- secutive displacements; this is, however, denied by F. S. Eve, of St. Bartholomew's Hospital. 2 According to Bigelow, in the ischiatic variety (dorsal below the tendon), the axis of the luxated limb is more changed than in the^ordinary dorsal variety, crossing the sound limb sometimes at a point as high as the middle of the thigh. The fact appears to be that the distortion varies according to the position of the head of the bone at the moment of examination, these varieties of dislocation being readily interchange- able, and the exact position of the bone differing in different cases. DISLOCATIONS OF THE HIP. 295 tions. The attachments of the Y ligament are such that extension in the line of the axis of the body can only effect reduction by violent stretching or rupture of that ligament; hence, the first step in any rational method of treatment, consists in flexing the thigh upon the pelvis, so as to relax the ilio- femoral or Y ligament. The acknoAvledged difficulty which attends reduction of the ischiatic variety of this luxation is due (as shown by BigeloAv), not to the head of the bone being lodged in the sciatic notch, but to its being fixed behind and below the tendon of the obturator internus muscle, which separates it from the acetabulum, and which renders reduction by extension in the line of the body almost impossible. By flexing the thigh on the pelvis, the head of the femur is unlocked from the grasp of the obturator tendon, and the luxation is then as easily reducible as one on the dorsum ilii; or, in case of difficulty, the limb may be flexed over a pad placed as a fulcrum in the Fig. 152. Backward dislocation ; reduction by rotation; the limb has been flexed and abducted, and it remains only to evert it, and render the outer branch of the Y ligament tense by rotation. (Bigelow.) groin, as advised by Dr. Sutton. The Y ligament being relaxed by flexing the thigh on the pelvis, the dislocation may be occasionally reduced by sim- ply lifting or pushing the head of the thigh-bone into the socket, the rent in the capsular ligament being, if necessary, enlarged by circumducting the flexed thigh across the abdomen, and thus making the head of the bone sweep across the posterior aspect of the capsule. It will usually be better, however, to employ manipulation (see page 277), which, though practised empirically in these cases for a great many years previously, was first reduced to a system by Drs. Nathan Smith, of NeAV Haven, and Reid, of Rochester. In the form of dislocation noAv under consideration, the manipulation neces- sary for reduction consists (T) in flexing the leg upon the thigh (to gain leverage), and the thigh upon the pelvis (to relax the Y ligament, and, in the case of an ischiatic luxation, to disengage the head of the femur from the obturator tendon); (2) in abducting and at the same time rotating out- wards the thigh in a broad sweep across the abdomen; and (3) in finally 296 DISLOCATIONS. bringing down the limb into its natural position. The process, in fact, em- braces the three motions of flexion, outAvard circumduction, and outward rotation. The mechanism of this mode of reduction is that, by the abduc- tion and rotation, the outer branch of the Y ligament is made to wind around the neck of the femur, thus constituting a sliding fulcrum by means of which the head of the bone is lifted into the acetabulum. In executing this manoeuvre, care must be taken not to flex the thigh too much, or the Y ligament will be unduly relaxed, and the effort at reduction will fail; and not to abduct the limb too widely, or the posterior part of the capsule will be unnecessarily torn, and the head of the bone may slip below the socket on to the thyroid foramen;1 the angle of extreme flexion should be from 50° to 60°, and that of extreme abduction from 130° to 140°. The first mistake (that of undue flexion) is readily remedied, by repeating the Fig. 153. Fig. 154. External appearances of downward Reduction of downward dislocation, by rotation and inward dislocation. circumduction. (Bigelow.) manoeuvre with the limb somewhat more extended; to remedy the second error, it is necessary, while making abduction, to lift the limb, Avhen the head of the bone will usually slip readily into its socket. 2. Dislocation of the Head of the Femur Downwards, or downwards and forwards into the Thyroid Foramen, is produced by the application of force while the thigh is in a position of abduction, or by a bloAV on the back of the pelvis while the body is bent and the legs Avidely apart. The capsular ligament is extensively torn, particularly at its inner and back parts, the round ligament being also ruptured, and the head of the bone lodging usually on the external obturator muscle, over the thyroid foramen. The symptoms 1 This accident is said by Dr. Erskine Mason, of New York, to occur only when there has been rupture of the obturator internus muscle. DISLOCATIONS OF THE HIP. 297 of this dislocation are very apparent: there is commonly an elongation of from half an inch to two inches, though, according to Rivington, there may be no lengthening, or even slight shortening; there is abduction; the leg is advanced, and the foot straight or slightly everted; the trochanter is de- pressed, and, in a thin person, the head of the bone may be felt in its abnormal situation. Reduction is effected by a process exactly the reverse of that recommended for the backward dislocations ; the leg and thigh being flexed as before, the limb is brought up in a position of abduction, then adducted and rotated in- wards1 in a broad SAveep across the abdomen (Fig. 154), the inner branch of the Y ligament being in this case the sliding fulcrum by Avhich the bone is lifted into its socket. Care must be taken, in this manoeuvre, to avoid ex- cessive flexion, and excessive adduction, Avhich would throAv the head of the bone past the acetabulum, on to the dorsum ilii. The manipulation may be sometimes assisted by drawing the upper part of the thigh outwards with a towel. Fig. 155. Application of the rope windlass, for backward dislocation. 3. Dislocation Upwards, or upwards and forAvards on the Pubis, usually re- sults from indirect violence, such as falling on the foot Avhile the leg is stretched backAvards, or stepping into a hole Avhile walking, the foot being arrested while the body goes forwards ; it may also result from a bloAV or fall on the pelvis. In this luxation, the head of the femur rests on or above the pubis, being closely embraced by the inner branch of the Y ligament. The symptoms are shortening, abduction, great eversion, slight flexion (or, more rarely, extension), Avith great depression of the trochanter, and prominence of the head of the bone, Avhich may be felt over the body of the pubis, and outside of the femoral vessels. The diagnosis from fracture is made by ob- serving the absence of crepitus, the immobility, the impossibility, or at least great difficulty, of inverting the limb, and the presence of the head of the bone in its hcav position. Reduction may be accomplished, according to Prof. BigeloAv, " by much 1 Dr. Markoe, in one case, succeeded in reducing a thyroid luxation by outward ro- tation (using, therefore, the outer branch of the Y ligament as a fulcrum), inward rotation having previously thrown the head of the bone on to the sciatic notch, from which it was immediately returned to its primitive position ; as remarked by Prof. Bigelow, inward rotation with less extreme flexion would, probably, have succeeded in the first instance. 298 DISLOCATIONS. the same method as in the thyroid dislocation, except that in the pubic luxa- tion the flexed limb should be carried across the sound thigh at a higher point. First, semi-flex the thigh, to relax the Y ligament, at the same time drawing the head of the bone down from the pubis. Then semi-abduct and rotate inward, to disengage the bone completely. Lastly, while rotating in- Avard and still drawing on the thigh, carry the knee inward and doAvnward to its place by the side of its felloAv. As in the thyroid luxation, this ma- noeuvre guides the head of the bone to its'socket by a rotation which winds up and shortens the ligament, enabling the operator, by de- pressing the knee, to pry the head of the bone into its place." As in the case of the thyroid luxation, this manipulation may be assisted by drawing the flexed groin directly outwards with a towel. Dr. M. H. Henry has reported a case of pubic dislo- cation in which reduction was successfully accomplished after twenty-six days. I can testify, from my own experience, to the facility Avith which recent dislocations may be reduced by the methods above described, and believe, with Prof. BigeloAv, that the period is not far distant "when longitudinal extension by pulleys to reduce a recent hip luxation will be un- heard of." As, therefore, I can- not recommend the use of pulleys in these cases, I forbear to de- scribe their application. Illus- trations are, however, given to show the positions in which the pulleys may be applied, and the directions in which extension is to be made, in the various forms of hip luxation, according to the teachings of Sir Astley Cooper and other standard authorities (Figs. 155, 156, 157). Beside the three regular forms of dislocation which have been above de- scribed, there are various anomalous forms, as (1) directly upwards (usually consecutive upon the pubic dislocation), (2) directly downwards, between the sciatic notch and the thyroid foramen, (3) downwards and backwards on to the body of the ischium, (4) downwards and backwards into the lesser sciatic notch, and (5) downwards, inwards, and forwards into the perineum. These various forms of downward dislocation may be either primitive or consecu- tive upon the ordinary thyroid variety. In these irregular forms of dislo- cation, there is usually great laceration of the capsular ligament, Avith, in some cases, rupture of the external branch, or even both branches of the Y ligament. Reduction may usually be effected by simply flexing the thigh, and then lifting and pushing the displaced bone in the direction of its socket; or the luxation may be converted into one of the " regular " varieties, when Bloxatti's dislocation tourniquet, applied for downward dislocation. (Erichsen.) DISLOCATIONS OF THE HIP. 299 manipulation can be applied according to the methods already described. Dislocations of both hips have been observed by Gibson, W. Cooper, Boisnot, and Crawford. Fig. 157. Mode of reducing upward dislocation with pulleys. In cases of old dislocation of the hip, greater force may be sometimes re- quired than can be applied by the surgeon's unaided hands, and under such circumstances the apparatus recommended by Prof. Bige- Fig. 158. low for effecting angular ex- tension may be usefully em- ployed, as was done in a case which I saw with Dr. H. R. Wharton, of this city. The difficulty, however, in these cases, will be often found to be not so much in effecting, as in maintaining reduction, owing to the structural changes which occur in the acetabulum and head of the femur. To meet this diffi- culty, Prof. Bigelow suggests that the limb should be fixed in the position in which re- duction Avas effected, until the socket has become again excavated by absorption; the same plan should be adopted in cases of recent luxation, in Avhich there is any ten- dency to reproduction of the deformity after reduction. MacCormac reports a case of Old dislocation Of the hip SUC- Angular extension, in reduction of old dislocations of the hip. cessfully treated by excision. (Bigelow.) The complication of dislo- cation of the hip Avith fracture of the thigh, should be met by applying firm splints, or Bigelow's "angular extension" apparatus, before attempting manipulation. Should fracture occur during the effort to reduce an old dislocation, the attempts at reduction should be at once abandoned, but ad- vantage might be taken of the accident to obtain union in such a position as would diminish the deformity of the limb. After reduction of a hip dislocation, it is usually sufficient to tie the knees 300 DISLOCATIONS. together with a few turns of a bandage, keeping the patient in bed for a week or ten days. An unreduced dislocation, especially of the ischiatic variety, alloAvs, after a time, much more use of the limb than would at first be supposed possible. Anaesthesia is almost always required for the reduction of hip dislocations in adults, though in cases of children, or of very feeble persons, it may often be dispensed with. Dislocations of the Patella.—The patella may be dislocated outAvards, inwards, or upAvards, or it may be rotated upon its own axis, constituting the vertical luxation of Malgaigne. These accidents may result from mus- cular action, or from direct violence. The Outward Dislocation is the most common, and may be either partial or complete; it may be recognized by the undue prominence of the inner condyle, and by the patella being felt in its neAV position; the limb is usually slightly flexed. Reduction is effected by extending the leg on the thigh, and flexing the latter on the pelvis, so as to relax the quadriceps femoris muscle, when the patella can be easily pushed back into its proper place; Hamilton directs that the patient should be in a sitting posture, the surgeon sitting or standing in front of him, and raising the affected leg upon his OAvn shoulder. If this manoeuvre fail, reduction may be accomplished by alternately flexing and extending the knee, Avhile lateral pressure is simultaneously made upon the patella. Dislocation In- wards is very seldom met Avith; its symptoms and treatment are (mutatis mutandis) the same as those of the outward variety. Dislocation of the Patella on its Axis is produced by the same causes as lateral dislocation, of which, indeed, it may be looked upon as an aggravated form; either edge of the patella may project anteriorly, or the bone may be entirely reversed, so that its posterior surface is in front. The leg is usually fully extended, more rarely slightly flexed ; the prominence of the patella is so marked as to render any mistake in diagnosis almost impossible. Reduc- tion may commonly be effected, as in cases of lateral dislocation, by direct pressure, aided by alternate flexion and extension. A case is recorded by W. F. Marsh Jackson, in Avhich, after the failure of other methods, reduc- tion Avas readily effected by simply pushing up the displaced bone. It has been proposed to divide the ligamentum patellae and tendon of the quadri- ceps extensor muscle, with a view of facilitating reduction in these cases, but the operation does not appear to have been productive of any marked bene- fit, while in one case it caused fatal suppuration. Dislocation Upwards can only result from rupture of the ligamentum patella?; the treatment would be the same as for fracture of the patella itself. Dislocations of the Knee.—The Head of the Tibia may be dislocated to either side, forwards, backwards, or in an intermediate direction, as back- wards and outwards, etc. These accidents may result from direct or from indirect violence, such as tAvisting the thigh upon the leg by stepping into a hole while Avalking. The lateral dislocations are ahvays incomplete, while the antero-posterior luxations may be either complete or partial. The symp- toms of these injuries are very obvious; the complete luxations are usually accompanied Avith shortening. Reduction may be effected by forced flexion of the knee, Avith direct pressure, aided by rocking movements, to which, if there be shortening, extension and counter-extension may be usefully added. The antero-posterior luxations, if complete, are apt to be attended Avith seri- ous injury to the popliteal vessels and nerves, a complication Avhich may re- quire amputation. After reduction, the limb should be placed at rest in a long fracture-box, or on a suitable splint, until the subsidence of all inflam- DISLOCATIONS OF THE ANKLE. 301 mation of the joint, the part being afterwards protected from sudden motion by the use of an elastic knee-cap or firm bandage. Compound Dislocation of the Knee is usually a case for amputation. Dislocation of the Semilunar Cartilages, or Internal Derangement of the Knee-joint (Subluxation of the Knee), consists, according to Erichsen, in the semilunar cartilages slipping either forwards or backAvards from beneath the condyles of the femur, so that the latter come in direct contact with the articular surface of the tibia, pinching the folds of synovial membrane; most authorities, hoAvever, teach that in this accident the cartilages themsel\res become Avedged betAveen the articulating surfaces, in such a way as to impede the motions of the joint, and give rise to the sickening pain which charac- terizes the injury. The accident is usually caused by tAvisting the knee, or by tripping over a stone or other obstacle in Avalking, though it has occurred from simply turning in bed. The symptoms are inability to AAralk, or even to extend the limb, intense pain, and rapid swelling of the joint. Reduction is effected by alternately flexing and extending the knee, combining these movements Avith slight twisting and rocking of the joint. As the process is painful, ether may appropriately be used in these cases. After reduction, the patient should wear an elastic knee-cap, to prevent recurrence of the displacement. Dislocation of the Head of the Fibula is a very unusual accident, except as a complication of more serious injuries of the knee. The displacement may be either forAvards or backwards, and the subcutaneous position of the bone renders the diagnosis easy. Reduction may be effected by extension and direct pressure, or by pressure Avhile the leg is flexed upon the thigh, and a compress and a bandage should be subsequently applied to keep the bone in place. Dislocations of the Ankle.—These injuries are described by Sir Astley Cooper, Malgaigne, and Hamilton, as dislocations of the lower end of the tibia: I think, however, that it is better to speak of them, with Boyer and others, as dislocations of the foot upon the bones of the leg. The displacement occurs betAveen the upper articulating surface of the astragalus and those of the tibia and fibula, and the foot may be dislocated forwards, backwards, to either side, or, as in a case mentioned by Druitt, directly upwards betAveen the bones of the leg. The lateral luxations are usually attended with fracture of one or both malleoli, the outward dislocation being sometimes additionally complicated by fracture of the outer edge of the tibia into the joint, a cir- cumstance which, as pointed out by Hamilton, may render reduction impos- sible. The backward dislocation is usually accompanied Avith fracture of the fibula, and sometimes of the tibia as well. The forward dislocation is very rare, usually attended with fracture, and, according to R. W. Smith, ahvays incomplete. These injuries may result from either direct or indirect violence, the particular form of the displacement depending upon the posi- tion of the foot at the moment at Avhich the accident occurs. The antero- posterior luxations can be easily recognized by the characteristic deformity, the foot being lengthened in the fonvard, and shortened in the backward, dislocation. True lateral luxation is a less frequent accident than is gener- ally supposed, the majority of the cases which are called dislocation, being really instances merely of rotation of the astragalus, without actual separa- tion of that bone from the articulating surfaces of the tibia and fibula. Reduction may be commonly effected in any of these varieties of luxation, by simple traction (the leg being flexed on the thigh), combined Avith direct pressure, and flexion and rotation of the ankle in various directions, accord- ing to the nature of the displacement; section of the tendo Achillis may 302 DISLOCATIONS. occasionally be required. After reduction, the limb should be placed in a fracture-box with suitable compresses, or on a Dupuytren's splint, until recovery is complete. Compound Dislocation of the Ankle is a very serious accident, and usually requires amputation, particularly when complicated Avith fracture, though in suitable cases an attempt may be made to save the limb by saAving off the projecting ends of the tibia and fibula. I have once succeeded in effecting a cure without operation, by the continuous employment of irrigation. Dislocations of the Tarsus.—The Astragalus may be dislocated at once from the bones of the leg and from the other tarsal bones, and may be thrust backwards (when it projects beneath the tendo Achillis), forwards and out- wards, or forwards and inwards. These injuries result from falls upon the foot, the particular form of the displacement depending upon the position of the foot as regards flexion, abduction, etc., at the moment at Avhich the accident occurs. In the forward dislocation, the leg is shortened, the astrag- alus projects in front of one or the other malleolus, and the foot is someAvhat extended and twisted to the opposite side. In the backward luxation, which occurs least often, the foot is in a state of extreme flexion, and the heel is elongated Avhile the instep is shortened. Reduction should be attempted by making firm traction (the leg being flexed upon the thigh), and rotating and tAvisting the foot in the opposite direction to that in which it is found, while firm pressure is made upon the projecting astragalus. Subcutaneous division of the tendo Achillis has been found a useful adjuvant in cases of forward displacement, and in a case of great difficulty Desault's plan of dividing the attachments of the astragalus itself might be tried, as has been successfully done by Fitzgerald, an Australian surgeon, in a case of five months' standing; or the surgeon might resort at once to excision. I should, however, prefer, in a case of irreducible, simple dislocation, to temporize, as advised by Cooper and Broca, reserving excision of the bone as a secondary operation, should sloughing or necrosis render it necessary. Backward dis- location of the astragalus is usually irreducible, the patient notwithstanding recovering with a very useful foot. In a case of compound dislocation, it would be proper (unless reduction Avere readily accomplished) to excise the astragalus at once, or to amputate, if the concomitant injuries were so severe as to forbid excision. Other Dislocations of Tarsal Bones are described, as of the calcaneum and scaphoid upon the astragalus, which remains in place below the arch of the malleoli (subastragaloid dislocation of Malgaigne); of the cakaneum upon the astragalus and cuboid, or upon the astragalus alone; of the scaphoid and cuboid upon the calcis and astragalus; or of the cuboid, scaphoid, or cunei- form bones, separately or together. Reduction in these cases may usually be accomplished by pressure and traction in different directions, according to the nature of the particular dis- placement. Forward extension (that is, at a right angle to the leg) is ad- vised by H. Lee and Pick in the subastragaloid variety. Even if reduc- tion cannot be effected, the limb will often be serviceable in spite of the deformity. Dislocations of the Metatarsus and Toes are of rare occurrence except as the result of great violence, when amputation will often be required. In cases of simple dislocation, reduction may usually be effected simply by traction and direct pressure, the parts being afterwards fixed with suitable splints and bandages. EFFECTS OF BURNS AND SCALDS. 303 CHAPTER XIV. EFFECTS OF HEAT AND COLD. Burns and Scalds. A Burn is usually defined as the disorganizing or destructive effect of the application of dry heat or flame, a Scald being considered as the correspond- ing effect of the application of a hot liquid, and it is often said that these tAvo forms of injury may be distinguished by the fact that a burn singes the cuta- neous hairs, which are, on the other hand, uninjured by a scald. It is evi- dent, hoAveArer, that though this distinction answers well enough for the burns and scalds met with in every-day life, it is not strictly correct; for, in many cases, the two injuries are combined (boiling oil may be at the same time burning oil), and some of the most destructive burns are produced by hot liquids—such as molten lead or iron. Again, the injuries produced by caustic acids or alkalies are essentially burns, whether the agent be applied in a liquid or in a solid form. Effects of Burns and Scalds.—The effects of these injuries are both local and constitutional. The Local Effects vary according to the temperature of the body which inflicts the injury, and the length of time during which its application is continued. Thus a momentary contact with flame will pro- duce a less degree of disorganization than prolonged contact with a substance the temperature of Avhich may be much lower. Dupuytren divided burns into six classes or degrees, according to the extent of injury inflicted; and this classification, which is in some respects convenient, is still adopted by most surgeons. The first class embraces cases of very superficial burn, marked by redness, and followed by desquamation of the cuticle. In the second class the injury extends more deeply, and is followed by the formation of numer- ous vesicles and bullae. In the third class the whole depth of the skin is involved, and is thrown off in the form of thin superficial sloughs. In the fourth class the destructive effect reaches the subcutaneous areolor tissue, the sloughs are firmer and deeper, and, on separating, leave granulating ulcers. In the fifth class the deeper-seated structures, muscles, tendons, etc., are affected; Avhile in the sixth class of burns, all the constituents of the part, including the bones, are involved in destruction. The various changes which take place in a part that is burnt, are those that have already been fully described in the chapter on Inflammation, and the processes of granulation, cicatrization, etc., by Avhich repair is accomplished in these cases, are the same as in solutions of continuity from any other cause. The Constitutional Effects of burns vary according to the degree of the burn and the extent of surface involved. In almost all cases, the constitutional symptoms may be divided into three stages, viz., that of depression, that of reaction, and that of exhaustion. The stage of depression is particularly well marked in cases of extensive burn, even though the depth of the injury be not very great. Many patients die in this stage, either from shock alone, or from this in combination Avith other causes, such as intense pain, or sup- pression of the physiological action of the skin. Thus, of ten patients re- ceived into the Pennsylvania Hospital from a fire at the Continental Theatre, in September, 1861, six died within twenty-four hours, some without any 304 EFFECTS of heat and cold. reaction, and others having reacted very imperfectly. The second stage is marked by the occurrence of inflammatory fever, accompanied often by vio- lent traumatic delirium; the duration of this stage is usually from the second to the tenth or twelfth day, and during this period death may occur from internal congestion, or from inflammation of the brain, air-passages, or ali- mentary canal; the locality of the burn influences the seat of these secondary complications, a burn of the chest being folloAved by bronchitis or pneumonia, while one of the abdomen is more apt to cause inflammation of the boAvels or peritoneum. A peculiar and very grave complication of this stage, which has been particularly insisted on by Long and Curling, is perforating ulcer of the duodenum. This, according to Curling, results from the irritation due to the vicarious action of Brunner's glands in attempting to replace the deficient action of the skin, but, according to Feltz and Wertheim, is, in common with the other visceral complications of burns, directly traceable to the occurrence of capillary embolism. The duodenal ulcer usually proves fatal either from hemorrhage, or by perforating the abdominal cavity, and thus giving rise to peritonitis. In the third stage of burn, the patient is in the condition of one suffering from profuse suppuration and wide-spread ulceration, Avithout re- • gard to the particular cause of the injury; death may occur from simple exhaustion, from secondary visceral degeneration (probably of the so-called amyloid or albuminoid variety), or from pyaemia. According to Ponfick and Lesser, one of the chief causes of death, in cases of severe burn, is disin- tegration of the red blood-curpuscles, with secondary parenchymatous in- flammation of the kidneys, and uraemic poisoning. Symptoms.—The Local Symptoms of burns are those of inflammation of the tissue affected, without regard to the cause. The intensity of the inflam- matory process varies in different cases, and in different parts of the body in the same case, so that we generally find the first four, and sometimes all, of Dupuytren's degrees of burn in the same individual. The Constitutional Symptoms vary according to the stage, as well as the extent and severity of the burn. The most prominent symptom in the first stage is a feeling of intense cold, resulting, probably, in part, from direct injury to the cutaneous nerves, and, partly, from the accumulation of blood in the central organs of the body. The patient shivers, and complains of chilliness, the temperature of the surface is depressed, the features pinched, and the whole body in a state of partial collapse. With the development of the second stage, thirst becomes the most distressing symptom; there is an insatiable craving for liquids, Avhich are rejected by vomiting as soon as they are SAvallowed. The patient is now very restless and feverish, and tosses off the bedclothes, which, during the first stage, could not be too closely applied. In the third stage, the symptoms are those of exhaustion and debility; the patient does not suffer much pain, except from the necessary exposure of dressing, unless the burns are so placed as to be subjected to pressure. Troublesome cough and profuse diarrhoea are often the most annoying complications in this stage of the injury. Prognosis.—The prognosis, in any case of burn, depends chiefly upon the extent of surface involved: as a rule, it may be said that if one-half of the cutaneous surface be affected, no matter how slightly, the case Avill probably terminate fatally. Even if one-third, or one-fourth of the surface be burnt, the prognosis should be very guarded. Another point to be considered is the locality of the injury; a burn upon the trunk is more serious than one of similar extent upon the extremities. The depth of a burn is of less prog- nostic importance than its extent, at least as regards life, which may often be saved (when the lesion is in one of the extremities) by a timely amputation. TREATMENT OF BURNS. 305 There is a popular idea that patients who are burnt often die from inhaling flame; it is, perhaps, scarcely necessary to say that such an occurrence is impossible; death, however, may occur from asphyxia (from the presence of smoke and noxious gases), or possibly from the flame entering the mouth, thus inducing rapid oedema of the glottis, and consequent suffocation. Hot steam may be inhaled (as is sometimes done by children from the spouts of tea-kettles), Avhen death ensues from inflammation of the air-passages. The older writers spoke of critical days in cases of burn, and the third and tenth days were especially so regarded. According to Mr. Holmes, hoAvever (and this corresponds Avith my OAvn experience), most deaths from burn occur during the first forty-eight hours; of 194 fatal cases which were received into St. George's Hospital in sixteen years, 98 terminated during the first tAvo days, 55 more during the first fortnight, and only 41 at a later period. Treatment.—The Constitutional Treatment of burns is of the greatest im- portance. The first thing to be done is to promote reaction. The patient should be placed in bed and covered Avith blankets, Avhile foot-warmers, or hot bricks or bottles, are employed to maintain an elevated temperature. Brandy and opium may be given pretty freely, care being taken, of course, not to intoxicate the patient; if he be already inebriated, reaction may be promoted by the use of other stimulants, such as carbonate of ammonium. As soon as reaction has begun, nutritive liquids, such as beef-tea or milk-punch, should be given, in small quantities and at frequent intervals, taking care not to excite vomiting by overloading the stomach. Thirst may be allayed by per- mitting the patient to suck small lumps of ice, or by the moderate use of car- bonic-acid Avater; but the patient should not be allowed to deluge his stomach with liquids, as the consequent vomiting and attending depression Avould of themselves often suffice to insure a fatal result. Transfusion of blood is, on theoretical grounds, recommended by Ponfick. During the first week or ten days of a burn, the patient is often consti- pated, and requires mild laxatives or enemata; diarrhoea is apt to supervene at a later stage, and must be met with chalk-mixture, astringents, and opium. Retention of urine must ahvays be Avatched for during the early stages of a burn, especially with female patients, Avho, from a feeling of modesty, fre- quently conceal their sufferings in this respect. When a patient has thor- oughly reacted, the treatment consists chiefly in the administration of food and stimulus. Tavo or three pounds of beef, in the shape of beef-tea, with ten or twelve fluidounces of brandy, and a quart or two of milk, is no unrea- sonable daily allowance for a bad case of burn. The only drug habitually required is opium: tAventy minims of laudanum, or half a grain of sulphate of morphia, every six hours, is often not too much to relieve pain and pro- mote necessary sleep. Traumatic delirium, if it occur, is to be treated on the principles already laid down, and other complications are to be met as they arise. During the third stage, tonics are usually required, the best being iron, quinia, and the mineral acids. Secondary amputation may be required, either by the depth of the burn, or by the state of general exhaus- tion of the patient; if by the latter, the operation should not be too long postponed, on account of the risk, already referred to, of the occurrence of A'isceral degeneration, probably of the so-called amyloid or albuminoid variety. With regard to Local Applications to burns, I do not believe that it makes a great deal of difference Avhat article is used, provided that the surface is thoroughly excluded from the air, and that the process of dressing is neatly and properly attended to. The application Avhich I myself prefer in cases of recent burn, is the old-fashioned carron oil, made by stirring linseed oil and lime-Avater into a thick paste, Avhich is then spread upon old linen or 20 306 EFFECTS OF HEAT AND COLD. muslin, and covered with oiled silk. It is customary to speak of this as a filthy dressing, but I cannot see that it is any less clean than other applica- tions, while it is certainly, according to my experience, extremely soothing and agreeable to the patient. Other dressings may, hoAvever, be used, if the surgeon prefer, and excellent results are doubtless obtained Avith raAV cotton, flour, white paint, lard, glycerine, iodoform, or any other of the host of sub- stances which have been recommended. More important than the particular article used is the mode of using it. Only a small portion of the surface should be uncovered at once, and the burn, if extensive, should thus be dressed, as'it Avere, in detachments. Vesi- cations, if there be any, should be punctured with the point of a sharp knife, the contained serum being alloAved to drain aAvay of itself, so as to preserve the cuticle as a covering for the parts beneath. The dressings should be covered with oiled silk or Avaxed paper, to prevent evaporation, and should be held in place Avith roller bandages, the injured parts being supported in an easy position, Avith soft pillows covered Avith oiled silk, or Avith pads of cotton wadding. The dressings should be entirely reneAved, as a rule, once in two days ; Avhile unnecessary disturbance of the patient is to be deprecated, the discharge is usually so profuse and offensive, that to delay a change of the dressings longer than this does more harm than good. When the sloughs have separated, the remaining ulcers may be dressed with lime-Avater, dilute alcohol, or zinc or resin cerate, as in the case of any other granulating sur- face. While the dressing is to be conducted w7ith all gentleness, it must be neat and thorough; especial care should be taken to Avipe clean the neAvly- formed skin around the healing ulcer, which may be advantageously stimu- lated from time to time by light touches with lunar caustic or blue stone. During the healing process, care must be taken to guard against undue con- traction of the cicatrix, by the use of appropriate splints and bandages. This contraction is particularly apt to occur at the flexures of the joints, and in the neck, where it draws the chin down to' the sternum, or ties the head to the shoulder, producing the most frightful deformity, which may be irremediable except by operative interference. Operations for Contracted Cicatrices.—In the early stages, before healing is completed, or afterwards if the cicatrix be still soft and pliable, it may be pos- sible to prevent deformity by the FlG- 159- use of splints and careful band- aging, or by means of elastic rings an d bands, so applied as to counter- act the contractile tendency. In dealing with old cicatrices, in which the contraction is firm and long established, severer measures are necessary. In the hand or foot, the deformity may be so great, and the cause of so much inconvenience, as to require am- putation. In the neighborhood of the joints, as of the elbow, it may be sufficient to divide the cicatrix by a free incision carried into healthy tissue on both sides of, and beneath, the scar; the after-treatment consists in making extension by means of screw apparatus, or, which I think better, the ordinary weight extension, applied to the limb beloAV the scar, with lateral support by means Contraction of arm following a burn. in the Episcopal Hospital.) OPERATIONS FOR CONTRACTED CICATRICES. 307 Fig. 160. Result of plastic operation for contraction of arm fol- lowing burn. (From the same patient as Fig. 159.) of side-splints or a fracture-box, the wound being allowed to heal while the limb is in the extended position. The result of such an operation is shown in Figs. 159, 160, from photographs of a patient under my care some years since in the Episcopal Hospital. These operations are not entirely free from risk, for important vessels and nerves sometimes adhere very closely to the cicatrix, and may be wounded in its division, or may themselves be shortened in the general contraction, when their in- tegrity Avill be endangered by the process of extension. Simple di- vision of the cicatrix is not suffi- cient in the case of burns about the face and neck, and here various plastic operations have been prac- tised by Mutter, Buck, and others, to remedy the deformity, which is both annoying and painful. No general rules can be given for the management of these Cases, which must be left to the ingenuity and skill of the surgeon in each particular instance. It may be said, however, that when the extent of the injury permits it, flaps of sound tissue should be brought, by tAvisting or by sliding, to cover the space left by free division and dissec- tion of the cicatrix. In cases, on the other hand, in which this cannot be done, an attempt may be made to utilize the cicatricial tissue itself, as has been ingeniously and successfully done by Butcher, of Dublin. Mr. Butcher's operation, Avhich has for its object the restoration of the elasticity of the cicatricial flap, consists in scoring subcutaneously the hardened tissue, with numerous incisions made with a long, narrowr-bladed knife. The surgeon is thus enabled to unfold, as it Avere, the matted cicatrix, and render it avail- able for autoplastic purposes. When the deformity is limited to dragging down and eversion of the lower lip, Teale's modification of Buchanan's cheiloplastic operation Avill be found very useful; this consists in dissecting up flaps from the sides of the lower lip (Fig. 161, A), and then joining these flaps together, and to the freshened edge of the central portion (b), Avhich affords a firm basis for their support; the triangular spaces (c) which are left are al- lowed to heal by granulation. James, of Exeter, has supplemented the use of the knife, in these cases, by the employment of a screw-collar, which gradually pushes the chin aAvay from the sternum. In the case of the upper lip, Teale makes a crucial incision of Avhich the point of intersection is immediately below the septum of the nose. The incision involves the whole thickness of the part, and the op- eration is completed by dovetailing together the resulting lateral triangles, so as to increase the depth of the lip at the expense of its breadth. W. Adams has introduced an ingenious mode of treating small depressed cicatrices, by simply dividing subcutaneously the deep adhesions of the part, everting the scar, and maintaining it in the everted position by the use of hare-lip pins for three days. This mode of treatment is manifestly inapplicable to large scars, and is indeed particularly recommended by its author for the cicatrices resulting from glandular suppurations or from bone disease. Fig. 161. Teale's operation; place. (Erichsen.) the flaps in 308 EFFECTS OF HEAT AND COLD. Anchylosis, or at least Immobility of the Jaw, occasionally occurs as a result of burns upon the cheek and side of the neck ; under such circumstances, operations analogous to those of Barton and Sayre in the case of the hip- joint, have been proposed by Carnochan, Von Bruns, Rizzoli, and Esmarch. Rizzoli's operation consists in simply dividing the jaw Avith a narrow saAV in front of the cicatrix, so that mastication may be accomplished by means of the natural articulation on one side, and the artificial false joint on the other. Esmarch meets the same indication by excising a wedge-shaped portion of bone, three-quarters of an inch Avide at its upper part, and an inch below ; but in a case thus operated on by Dr. Buck, of New York (for cicatricial contraction resulting from cancrum oris), though an inch and a half of bone was removed, the parts became re-approximated, and the operation seems to have been only partially successful: a better plan is, ac- cording to Durham, to separate the jaw with a screAV-lever, and then en- deavor to restore the functions of the part by practising passive motion. The statistics of Rizzoli's and Esmarch's operations have been investigated by Schulten, Avho finds that 26 cases of the former gave 13 permanent re- coveries and 3 deaths, Avhile 40 cases of the latter gave 15 permanent re- coveries and 2 deaths. The cicatrix of a burn sometimes assumes a peculiar warty appearance resembling keloid, this condition being more common in children than in adults. When the nature of the case permits, excision should be practised, but the cicatrix is sometimes too large to admit of this remedy ; the itching may be relieved, according to Erichsen, by the internal administration of liquor potassae. Occasionally a true cancerous formation appears to be de- veloped in an old cicatrix, rendering excision (if practicable) still more imperative. Effects of Cold. The effects of cold are both constitutional and local. The Constitutional Effects of prolonged exposure to cold consist in the development of a state of drowsiness and indisposition to exertion, which, if not interfered with, Avill terminate in coma and death. Hunger, great fatigue, or any circumstance which impairs the general tone of the system, may increase the susceptibility to the effects of cold, and hence the liability of soldiers in a Avinter campaign to suffer from this cause. The mechanism of death from cold has been ably investigated by Lebastard, Avho finds that it may occur from several distinct conditions, viz., (1) in cases of sudden and progressive chilling, from cere- bral anaemia; (2) in those of slow and continuous chilling, from cerebral congestion.; (3) in those of sudden reheating, as pointed out by Mathieu and Urbain, from embolism due to clots formed by the disengagement of carbonic acid from the blood ; and (4) in cases of partial congelation, usually from congestion, but sometimes from anaemia, in either case due to capillary embolism by clots originating in the injured part. Tourraine, Granjux, Pugibet, and other French military surgeons, have recorded curious cases of syncope preceded by intense redness of the whole surface of the body, as the result of cold baths. Hemiplegia was, according to Larrey, observed in many of the survivors of the retreat from Moscow. The treat- ment of a person apparently dead from cold, consists in placing him in a room of low temperature, and in practising systematic but gentle friction with snow, or Avith flannel wrung out of tincture of camphor or dilute alco- hol, together with a resort to artificial respiration. These means should be continued until reaction is well established, Avhen the body may be Avrapped in blankets, stimulating draughts administered, and the temperature of the FROST-BITE. 309 room gradually raised. Efforts at resuscitation in such cases should not be prematurely discontinued, as patients have occasionally been saved, even Avhen apparently dead for several hours. Tedenat refers to a case in Avhich a patient recovered after being buried in snow for 24 hours, and others in Avhich persons Avere taken out alive after being similarly buried for four and eight days respectively. Nicolaysen reports a case in which recovery fol- loAved, although the temperature in the rectum had sunk to 76.4° Fahr. The Local Effects of cold are divided, according to their intensity, into Pernio or Chilblain, and Frost-bite. Cold appears in some instances to cause the formation of a " perforating ulcer." (See Chap. XXVII.) Pe- ripheral paralysis is occasionally traceable to exposure to cold, the nerves most commonly affected being the facial and radial. Pernio or Chilblain is a very common affection, and is caused rather by sudden alternations of temperature, than by intensity of cold. It affects principally the extremities, especially the toes, heel, and instep, though it is also met with in the hands and face. The part affected is more or less deeply congested and swollen, and the seat of intense itching and burning. Vesica- tion sometimes occurs, and may leave ulceration of an intractable character. A patient Avho has once had chilblains is very apt to suffer from a recurrence of the affection, upon even slight changes of the weather. The treatment con- sists in plunging the part into cold water or rubbing it Avith snoAV, following this application by the use of local stimulants, such as the nitrate of silver, tincture of iodine, or soap liniment. Fergus speaks very favorably of the employment of sulphurous acid. The remedy Avhich I am in the habit of employing is the nitrate of silver in Aveak solution (gr. iv-v to f^j), fre- quently painted upon the part, which is then Avrapped in raAv cotton. The nitrate of silver seems to obtund the local sensibility, and certainly relieves the burning and itching which in these cases are so distressing. The ulcera- tions Avhich sometimes attend chilblain require stimulating applications, such as resin cerate, or dilute citrine ointment. T. Smith has called at- tention to the periodicity with Avhich the paroxysms of itching in chilblain are developed, and which he is disposed to attribute to the time at which the patient's principal meal is taken. The daily paroxysm may be antici- pated, if the patient's convenience so dictate, by immersing the part for a few minutes in a mustard bath. Frost-bite results either from exposure to an intense degree of cold, or from prolonged exposure to a less degree. The parts most often affected are the nose, lips, ears, fingers, and toes, though occasionally the effect is more extensively diffused, whole limbs becoming frost-bitten. Fremmert, of St. Petersburg, found from an analysis of 494 cases, that in 333 the lower extremities alone Avere affected; in 105, the upper extremities only; in 38, both upper and lower extremities; in 12, the extremities and other parts of the body as well; and in only 6, other parts of the body without the extremi- ties. The great toe and the little finger suffered much more frequently than any other parts, and the right side oftener than the left. Men were twelve times as often affected as women, and the most susceptible age appeared to be from 30 to 35. Of the Avhole number of cases, 42, or 8.5 per cent., terminated fatally, pyaemia and septicaemia being the most frequent causes of death. Operations to the number of 222 Avere performed upon 134 indi- viduals, 15 of Avhom submitted to major amputations upon one or more limbs. The first effect of cold is the production of a dusky redness, with some tin- gling and pain; but further exposure causes a tallowy whiteness of the affected part, which is also shrunken, insensible, and motionless, presenting much the 310 INJURIES OF THE HEAD. appearance of gangrene from arterial occlusion. Mortification may be in- duced directly by the intensity of the cold depriving the tissues of vitality, though more usually death of the part follows from the violent inflamma- tion which results from undue reaction. Thus, Larrey found numerous cases of frost-bite caused by a sudden thaw, wdien the previous severe cold had given the affected person no inconvenience. The treatment of frost-bite consists in moderating the intensity of the reaction, and thus endeavoring to prevent the occurrence of mortification. For this purpose the affected part should be rubbed with snow or ice, or covered with wet cloths, which are kept cold by means of irrigation, the patient being meamvhile kept in a cold room. Bergmann recommends that the injured part should be sus- pended in an elevated position. By assiduously persevering in this mode of treatment, gradual reaction may be obtained, and the patient may escape with moderate inflammation, manifested by slight swelling and tingling, with perhaps some vesication, and desquamation of the cuticle. In this stage advantage may be derived from the use of stimulating washes, such as the tincture of iodine, or soap liniment. Even if mortification occur, the use of cold applications should be continued, as long as the gangrene mani- fests any tendency to spread. The occurrence of mortification is manifested by the part becoming black, dry, and shrivelled, a line of demarcation and separation forming as in gangrene from any other cause. If the mortified parts be of small extent, their removal should be left to nature, the process of separation being simply hastened by the use of fermenting poultices; the reason for this is that the vitality of all the neighboring tissues is impaired, and that the use of the knife might therefore be followed by a recurrence of gangrene. When the mortification has extended further, involving the greater portion, or the whole, of a foot or hand, a formal amputation will probably be ultimately required; even in such a case, however, it may be better, at first, simply to remoAre the gangrenous mass by cutting through the dead tissue below the line of separation, waiting to improve the shape of the stump by a regular amputation at a subsequent period, Avhen the patient's general condition has been improved by appropriate constitutional treatment. CHAPTER XV. INJUKIES OF THE HEAD. Injuries of the Scalp. Contusions of the Scalp are chiefly of interest in a diagnostic point of view, the sensation which they communicate to the fingers of the surgeon being often deceptive, and leading to the supposition that the case is one of fractured skull. There is in both affections a rim of indurated tissue with a central soft depression, but in a contusion, firm pressure will usually de- tect the bone at the bottom of the cavity. The most skilful surgeons may, however, be deceived by these cases, and incisions have been made with a view of elevating depressed bone, the operation showing that no fracture existed. Large collections of blood, either coagulated or fluid, may result from contusions of the scalp, remaining apparently Avithout change for a considerable period. As a rule, no incision should be made in these cases, AVOUNDS OF THE SCALP. 311 but the surgeon should encourage absorption by the use of evaporating lo- tions, or of moderate pressure. If, however, suppuration occur, the pus must be evacuated by a free incision. Cephalhccmatoma, or Caput Succedaneum, is a bloody tumor of the scalp in neAV-born children, resulting from pressure during birth. The blood is usually effused betAveen the scalp and pericranium, though more rarely beneath the latter. The treatment is the same as for similar extravasations resulting from other causes. Wounds of the Scalp.—Scalp Wounds do not differ materially from sim- ilar injuries in other parts of the body, as regards their pathology and treat- ment. The tissues of the scalp are extremely vascular,1 hence the hemor- rhage in these cases is often profuse; on the other hand, the vascularity of the scalp is of advantage, in enabling the parts to preserve their vitality after injuries which, in other tissues, Avould be certainly followed by extensive sloughing. In all ordinary wounds of the scalp, Avhether incised or lacerated, the detached flaps should be carefully replaced (the parts being cleanly shaved), and held in position with strips of isinglass plaster, or, Avhich is better, with the gauze and collodion dressing, or one of its modifications (see page 147). A firm and broad compress should then be placed over the seat of injury, and secured by a suitable bandage; bleeding is thus readily checked, and the flaps are held in such a position as to favor union. I do not advise the use of either sutures or ligatures, in ordinary cases of scalp wound, simply because I do not believe them to be necessary. They are, indeed, thought by many surgeons to act as exciting causes of erysipelas, Avhen applied to the scalp; but there is no proof, as far as I am aAvare, that they exert any such influence. They are, hoAvever, usually unnecessary, and therefore, of course, undesirable. If a Avound of the scalp be accompanied Avith so much contusion and lace- ration that sloughing appears <• unavoidable, it will be proper simply to support the flaps with adhesive strips, and apply to the wound some Avarm and soothing application, such as olive oil or diluted alcohol. As in every case of scalp wound there is at least a possibility of some concomitant injury to the brain, a patient Avith such an injury should be carefully watched during the entire course of treatment; the diet should be regulated (all irritating or indigestible substances being avoided, AAThile at the same time easily assimilable nutriment is provided in sufficient quanti- ties), and attention should be given to the condition of the various secretions and excretions of the body. Erysipelas and Diffuse Inflammation of the Subcutaneous Areolar Tissue are usually said to be especially apt to folloAv upon Avounds of the scalp. Such has not been my OAvn experience, though 1 can readily understand that a patient should be predisposed to these affections, when treated by the plan of excessive depletion formerly in vogue in the management of these cases. The proper course to be pursued in the event of such complications arising, Avould be to remove all pressure or sources of tension, by reopening the lips of the Avound, and making counter-incisions, if necessary, for the evacuation of pus or sloughs. Necrosis of the outer table of the skull usually, though not necessarily, folloAvs in cases of scalp Avound in Avhich the bone is denuded of pericranium. Such a case should be treated upon ordinary principles, the sequestrum being removed as soon as it has become loose. 1 "NV. J. Tyson has recorded a remarkable case of traumatic aneurism of the scalp (Trans. Clin. Society, vol. xiii.). 312 INJURIES OF THE HEAD. The accompanying cuts (Figs. 162, 163) illustrate the severest case of scalp Avound which I have ever seen folloAved by recovery. The patient wTas a girl of fifteen, an operative in a cotton-mill, Avho was caught by her hair between rollers which were revolving in opposite directions, her scalp being thus, as it were, squeezed off from her head and forming a large horseshoe- shaped flap. The linear extent of the wTound was fourteen inches, the dis- tance between its two extremities being but four inches. This large flap was thrown backwards, like the lid of a box, the skull being denuded of its peri- cranium for a space of two and a half inches by one inch in extent. The Fig. 162. Fig. 163. Severe scalp wound. (From a patient in the Episcopal Hospital.) anterior temporal artery was divided, and bled profusely, and the patient, when admitted to hospital, Avas extremely depressed by shock and hemor- rhage. A ligature Avas applied to the bleeding vessel, and the flap, after it had been gently but carefully cleansed, replaced and held in position with the gauze and collodion dressing. A large compress soaked in warm olive oil was then placed over the entire scalp, covered with oiled silk, and fixed with a recurrent bandage. A considerable portion of the wound healed by adhesion, and the patient was discharged cured after fifty-four days. No exfoliation of bone occurred. Cerebral Complications of Head Injuries. The principal risk attending all injuries of the head is from simultaneous or subsequent implication of the brain, and I shall, therefore, before speak- ing of fractures and other lesions of the skull, consider the various cerebral complications which are met with in these injuries, and which may be classi- fied, as a matter of convenience, under the heads of concussion, compression, and Inflammation. Concussion of the Brain.—It is a rather mortifying confession, that the ideas of surgeons of the present day, as to this condition, are much less de- finite than those of their predecessors. We have, however, advanced so far, that we are now enabled to say pretty clearly what concussion is not, and thus to separate it from other conditions with Avhich it Avas, formerly, habit- CONCUSSION of the brain. 313 ually confused. Thus, Ave now know that cerebral concussion is not shock see page 134), and that it is not a purely functioned, apart from an organic, condition. The older Avriters had no hesitation in declaring that a man might die from concussion of the brain, without the existence of any physical lesion Avhatever, but the fallacy of this opinion has been ably exposed by modern authors, among Avhom should be specially mentioned Prescott HeAvett, the Avell-knoAvn surgeon of St. George's Hospital. In fact, while there is no evi- dence that cerebral concussion is ever a cause of Instant death, there are in- variably found after death from this cause signs of contusion, compression, extravasation, laceration, or inflammation. Concussion of the brain, as its name implies, consists in a shaking or, to use a Johnsonian Avord, a tremefaction of the cerebral mass, and it is easy to understand that such a trembling might be attended by a more or less tem- porary arrest of cell-action, by capillary stasis,1 and by functional inactivity, Avithout any persisting lesion, or permanent ill result. Such, indeed, is prob- ably the condition of affairs in the slight cases of concussion or stunning which are not unfrequently met Avith, especially among children ; though, these cases not proving fatal, our knowledge of their morbid anatomy must, of course, be purely conjectural. A more violent concussion of the brain may cause contusion or laceration of the cerebral structure itself, or rupture of the cerebral vessels, giving rise to extravasation with or Avithout compression, and more remotely folloAAred by inflammation, suppuration, or softening. Contusion and Laceration of the brain, like the same conditions in other organs, may vary from the slightest bruising or separation of fibres, to the most extensive crushing and tearing, sometimes amounting to complete pul- pefaction and disorganization of the Avhole cerebral mass. The symptoms and prognosis of these injuries depend upon their extent, and upon the par- ticular part of the brain which is affected; thus, Mr. Callender has shown that pain is especially connected Avith lesions of the outer gray matter of the brain, and eonvidslons Avith lesions in the neighborhood of the middle cere- bral arteries, and particularly in that portion of the right hemisphere which is above the corpus striatum. A laceration involving the medulla oblongata would, of course, be more apt to prove fatal than one of similar extent in a less vital part.2 The extravasation Avhich invariably accompanies cerebral contusion, pre- sents various appearances in different cases; thus there may be numerous points or specks of extravasation, each not larger than a millet-seed (miliary extravasation), or the blood may be poured out in larger masses, forming collections the size of a split pea. The latter form of extravasation is easily recognized, but the former may be mistaken for the appearance presented by the cut surface of the cerebral vessels—from which, however, it may be dis- tinguished by the fact that the points of extravasation are not easily wiped 1 According to Fischer, of Breslau, the phenomena of concussion are due to reflex paralysis of the intracranial vessels, but, from experiments on the lower animals, Duret concludes that they depend on increased tension of the cerebro-spinal fluid—a conclusion, however, which is strenuously rejected by Bochefontaine. 2 According to Brown-Sequard, lacerations of the brain are followed by pleural ec- chymosis or pulmonary apoplexy on the side opposite to that of the cerebral lesion. Fleischman and Ollivier have observed a similar condition of affairs in cases of non- traumatic disease of the brain. Extravasation has also been noted, in connection with brain lesions, in the heart, kidneys, and other organs. On the other hand, cerebral abscess appears sometimes to result from embolism following pulmonary disease, as in cases recorded by Gull and Sutton, Huguenin, and J. H. Hutchinson, of this city, or from congenital communication between the right and left cavities of the heart, as in cases recorded by Ballet, Gintrac, and others. 314 INJURIES OF THE HEAD. away, and, if picked out, leave behind them small but distinct cavities. The occurrence of these miliary extravasations is accounted for by Duret by the diffusion of the force of the injury by means of the ccrebro-spinal fluid. Contusion of the brain, with its attendant extravasation, may be circum- scribed or diffused; the former condition is frequent, and the latter rare. Certain parts of the brain are more exposed to contusion than others; thus the base of the brain is more often affected than the upper part; the middle and anterior, than the posterior lobes; the cerebellum, than the pons and medulla. The reason for this difference is, doubtless, as pointed out by Brodie, the greater or less irregularity of the surface of the various portions of the skull. When extravasation takes place on the surface of the brain, or into its ventricles, or even (in large amount) into its substance, the characteristic symptoms of compression are de\Teloped—a condition Avhich will be presently considered. Causes of Cerebral Concussion.—Concussion of the brain may be caused by various forms of external violence, such as a direct bloAV or fall, by vio- lence resulting from counter-stroke, as a fall on the loins, buttocks, or feet, or even by sudden and violent agitation of the surrounding air, as by an explosion in a patient's immediate vicinity. Symptoms of Cerebral Concussion.—Every case of concussion is, I believe, accompanied with shock, and in many instances the symptoms of the latter condition alone can be recognized. The patient, after a bloAV on the head, becomes pale and somewhat collapsed, with a cool surface, small and feeble pulse, diminished poAver of sensation and motion, and partial unconscious- ness ; after a variable period these symptoms pass off, vomiting may or may not occur, and the patient is apparently quite as well as before the accident. The symptoms here are evidently those of shock (Avith the exception of un- consciousness), and cannot be considered as in any degree characteristic of the brain lesion. So again, in cases in Avhich death folloAvs in a few minutes or hours after an injury to the head, the patient lying meanwhile senseless and collapsed, the fatal result may be due to shock, or to intra-cranial hem- orrhage, or to laceration of a vital part of the brain; but there is no symptom which AA7e can point out as pathognomonic of concussion, apart from other conditions. Even in the intermediate cases, Avhich are often spoken of as typical instances of concussion, though, as a matter of convenience, we may trace their clinical history, and divide it into stages, Ave cannot point to any symptoms which definitely characterize the lesions of concussion, apart from those of other cerebral injuries. Indeed, it Avould be better, I think, if we could dispense altogether with the term concussion as denoting a condition, and look upon it as merely indicating the cause of what have been described as concussion lesions, viz., cerebral contusion, laceration, extravasation, etc. With this explanation and reservation, the clinical history of a typical case of so-called concussion of the brain may be said to present three stages, the symptoms of Avhich are as follows: In the first stage the patient lies motionless, senseless, nearly pulseless, pale and cold, breathing feebly but naturally, the pupils dilated or contracted, fixed or acting freely (according to the particular seat and form of lesion),1 with perhaps involuntary discharge of feces and urine. From this first stage the patient may recover without any further trouble, or he may gradually sink and die without reaction; or the first stage may be very evanescent, so 1 Cerebral compression appears to be marked by fixed or slowly moving pupils; mere laceration does not affect their free action. (See 3Ir. Callender's paper in St. Bartholomew's Hosp. Reports, vol. v., p. 25.) CONCUSSION OF THE BRAIN. 315 that when the surgeon first sees the patient he has already passed into the second stage, Avhich Mr. Erichsen regards as an entirely independent condition, and graphically describes under the name of Cerebral Irritation. The dis- appearance of the first stage, Avhether by passing into the second or by direct recovery, is commonly marked by the occurrence of A-omiting. In the second stage the patient is no longer unconscious, though much indisposed to speak or pay attention to surrounding objects. If roused by a question, he will ansAver, but peeAashly or angrily, turning away as if displeased at the inter- ruption. The posture of the patient is peculiar; he habitually lies on one or other side, curled up, Avith all his joints more or less flexed, and if a limb be touched, draAvs it away a\ ith an air of annoyance. The eyelids are kept firmly closed. The pulse during this stage, at first small and weak, becomes grad- ually fuller and more frequent, Avhile the breathing is easier, and the surface regains its natural Avarmth and color. The symptoms now7 may be masked by those of the second stage of shock (see page 136), and thus, instead of being morose and taciturn, the patient, though still irritable, may be voluble and loquacious. The condition of cerebral irritation which marks the second stage of concussion, gradually subsides, after having lasted several hours or days, the patient almost invariably complaining of severe headache as he regains ability and Avillingness to communicate with those around him. The third stage varies in different cases: in some, there is positive inflammation of the brain and its membranes; in others, as irritability subsides, fatuity takes its place, and a state of weakmindedness supervenes, which may end in recovery, or in cerebral softening and death. Prognosis.—From Avhat has been said, it is evident that the prognosis in any case of cerebral concussion or contusion should be very guarded; the patient may die, as Ave have seen, in the first stage, from the shock of the injury; or, if he escape this risk, from intra-cranial congestion or inflamma- tion ; or, at a still later period, from softening of the brain or cerebral abscess. As a rule, however, if the first stage be slight, Ave may expect the others to be so likeAvise, and, numerically, the proportion of deaths to the number of cases of slight concussion, or stunning, is very small; still, it is not always possible to be sure that the amount of brain lesion is as slight as it at first appears, and every case of concussion must be, therefore, a subject of grave interest to the surgeon. Treatment of ('erebral Concussion and Contusion.—There is a popular notion that a person Avho has received a stunning bloAV on the head should not be alloAved to sleep, or even to lie quietly in bed: need I say that this is as un- reasonable as it is cruel? The first indication for treatment is certainly to place the injured organ at rest, and it would be no more unphilosophical to insist that a man should Avalk with a contused foot, or Avrite with a lacerated hand, than to expect him to exert the mental faculties Avhen suffering from concussion of the brain. A patient thus affected should be placed at rest, in bed, in a cool and moderately darkened room, and should be disturbed as little as possible. If the state of shock be so great as to threaten death from asthenia, the patient must be stimulated, preferably, however, as far as possible, by external applications, such as sinapisms or hot bottles, and by those internal remedies Avhich are most evanescent in their effect, such as the spirit of hartshorn or carbonate of ammonium. As a matter of fact, it is very seldom indeed that a case of concussion requires any stimulus at all. Reaction usually begins in the course of an hour, or two or three hours, sometimes much earlier, and as the pulse rises, the stimulants, if any have been given, must be discontinued. The risk noAv is from congestion or extravasation, Avith subsequent inflammation, and the treatment must be directed accord- ingly. It is in this stage that cold, and especially dry cold, is particularly 316 INJURIES OF THE HEAD. useful as a local application. In the first stage it Avould have added to the existing depression, but it is now eminently indicated, and is a most valuable remedy. Esmarch's ice-bag or Petitgand's apparatus may be employed, or, in the absence of these, cloths wrung out of cold Avater should be assiduously applied. The secretions and excretions should be regulated, the boAvels being opened Avith enemata, or occasional mercurial or saline purges, and the bladder relieved by catheterization if necessary. The diet should be very light, and administered in small quantities at a time; there is no article of food better, under these circumstances, than milk, to which lime-water should be added if there be vomiting. Rest, both mechanical and physiological, should still be enforced; and if the patient be restless, the surgeon need not fear to give opium. I am aware that there is a good deal of difference of opinion as to the propriety of administering opium in injuries of the head, but surely there is nothing to contraindicate it in Avhat Ave knoAV of the pathology of these cases, while its soothing and calming effect is exactly what is required. Metaphorically speaking, it puts the brain in splints, and thus places it in the most favorable position for the repair of its injuries. Of course, opium in these, as in all other cases, should be used with discretion, and if there be any threatening of coma, should not be given; but in such a case the rest- lessness Avhich calls for it would not be present. By perseverance in this plan, the patient will, in most cases, be tided over the second stage, and may then be allowed gradually, and Avith great cau- tion, to resume his usual mode of life. For a long time, however, he should live by rule, guarding against all sources of irritation, eating and drinking very moderately, and in fact remaining, if not under treatment, at least under surgical supervision. If, on the other hand, the case progresses less favorably, and the contused and lacerated brain becomes inflamed, the chances of recovery are much diminished; traumatic encephalitis is, however, of such importance as to demand separate consideration. Compression of the Brain.—It is not my purpose to enter into a theoreti- cal discussion as to whether the brain is susceptible of being actually com- pressed, or whether, in the condition known as compression, it merely changes its form, expanding at other parts to compensate for its apparent contraction at the seat of lesion. The term cerebral compression is so universally em- ployed by surgeons, and is in many respects so convenient, that I shall not hesitate to use it, although it may not exactly describe the condition which it is meant to represent. Causes.—Compression of the brain may be caused by various circum- stances: thus, it may be due to the pressure produced by a foreign body, as a bullet or piece of shell; by a portion of displaced bone; by effusion of blood, either on the surface of the encephalon or within its mass; or by what are ordinarily called the products of inflammation—lymph, serum, and pus. Symptoms.—The symptoms of compression are as follows: The patient lies unconscious and comatose; the breathing is slow, and accompanied by ster- tor, and by a peculiar blowing motion or whiff at the corners of the mouth; this sign, which is very striking, appears to be due to paralysis of the cheeks, and is compared by the French writers to the act of a man smoking a pipe. The pulse is full and rather slow, the decubitus dorsal, and the skin usually cool, though sometimes hot and moist. There is retention of urine, and the feces are passed unconsciously. The pupils are fixed and immovable, usually midway between contraction and dilatation, sometimes widely dilated, and rarely contracted; or one pupil may be contracted, while the other is dilated; the difference in different cases depending, as shown by Callender, upon the part of the brain involved. There is paralysis of motion, usually affecting COMPRESSION OF THE BRAIN. 317 the side opposite to the seat of injury. The period at which the symptoms of compression are developed, depends on the particular source of the press- ure: if this result from depressed bone or a bullet, the symptoms will be instantly manifested, and the patient will probably continue in a completely comatose condition, from the moment of injury, either till the pressure is removed, or till the case ends in death; this, it Avill be remembered, Avas the course of events in the case of President Lincoln. If, however, compression be caused by extravasation, it Avill begin gradually, and slowly increase dur- ing several hours, until the intra-cranial bleeding has spontaneously ceased, or has been artificially arrested; while compression from lymph, serum, or pus conies on at a still later period of the case. Diagnosis.—I regret that 1 cannot agree Avith those surgeons who consider the diagnostic marks between compression and concussion to be plain and easily recognizable. Unfortunately, as our knowledge of the pathology of concussion has increased, the several symptoms* which we formerly regarded as pathognomonic, are shown to be often common to both conditions; and this is not surprising Avhen we remember that extravasation is an almost con- stant lesion of concussion, and a frequent cause of compression, thus rendering the difference betAveen the two conditions, in many cases, one of degree only. It used to be said that the symptoms of concussion Avere immediate and tem- porary; those of compression, often not immediate, but permanent. We haAre, however, seen that the first stage of concussion presents no definite symptoms; none, in fact, which might not be due to shock and syncope (con- ditions Avhich might equally complicate compression)—while, if concussion be attended Avith much extravasation, compression itself may result. Again, if compression be caused by a foreign body, or by displaced bone, the symp- toms Avill be immediate—while in many cases of slight compression, the brain in a short time becomes habituated to the source of pressure, when the symptoms may pass off without surgical interference. And so with the other symptoms which used to be considered diagnostic, there is not one, I believe, which can be implicitly relied upon. A man was brought into the Episco- pal Hospital Avith a compound, comminuted, and depressed fracture of the frontal bone, with rupture of the membranes, and escape of brain substance. When I saw him he Avas comatose, and evidently suffering from compression of the brain; I removed those fragments of bone that were loose, and ele- vated the remainder; the patient breathed somewhat less stertorously, and turned on his side; the next day he Avas conscious, and rapidly recovered. Here there was manifestly compression from an obArious cause—depressed bone; and yet the only change in symptoms produced by relieving this compression (the accompanying concussion remaining), was a diminution in stertor, and the substitution of lateral for dorsal decubitus. Hence, though in certain cases Ave can say without hesitation, in view of the one-sided pa- ralysis, profound coma, and other symptoms mentioned, this is compression or that is concussion, there are other cases in Avhich it is impossible to draw such a distinction; compression may disappear spontaneously, leaving con- cussion, Avhile concussion, by a continuance of intra-cranial hemorrhage, may end in fatal compression. Prognosis.—Compression in itself is not a very fatal condition; in many 1 Bouchut has recently asserted his ability to distinguish concussion from compres- sion of the brain by the use of the ophthalmoscope, the optic nerve and retina present- ing a normal appearance in the former condition, and evidences of intra-cranial press- ure ("choked disk") in the latter; but it is evident that if the views advanced in these pages as to the pathology of "concussion " be correct, this test could only serve to distinguish those slight cases in respect to which no confusion would be likely to ■exist. 318 INJURIES OF THE HEAD. cases, in which the pressure is not very great, the brain accustoms itself to the new state of affairs, and the patient regains consciousness, and goes on to recovery. In other cases it is possible by surgical interference to relieve the compression, and then, if the brain itself be not structurally altered, there is a good prospect of recovery. The gravest forms of compression are those Avhich result from intra-cranial hemorrhage or suppuration, the latter condition being particularly dangerous, and proving almost ahvays, sooner or later, fatal. Duret has shoAvn experimentally that as soon as the com- pression becomes so excessive as to surpass the arterial tension, death super- venes. Treatment of Cerebral Compression.—When the cause of compression is recognizable, an attempt should obviously be made to remove it. Thus, if compression be due to a fragment of bone, this should be elevated or removed, provided that it can be done Avith safety; or if to hemorrhage, in a situation which can be reached, the surgeon may make an effort to evacuate the effused blood and secure the vessel; if, however, the cause of the compression be uncertain, and still more if the existence of compression itself be doubtful, it will, I think, be usually wiser to abstain from operative interference, and to treat the case on the general principles Avhich have been laid down, in speak- ing of the management of the second stage of cerebral contusion (page 315). Purgatives may be employed in these cases pretty freely ; and, if the patient cannot swallow, a drop of croton oil in mucilage may be placed on the tongue, while the bowels are solicited by turpentine enemata. The question of trephining in these cases will be considered hereafter. Traumatic Encephalitis, or inflammation of the cranial contents as the result of injury, is a very serious complication, both of fractured skull, and of the severer forms of cerebral concussion and contusion. The brain sub- stance itself may be affected, or the meninges, or both together; the arach- noid membrane is perhaps more commonly involved than any other part of the cranial contents. The meninges are injected with blood, Avhile yellowish, or greenish, and sometimes puriform, lymph occupies the cavity of the arachnoid and the meshes of the pia mater, the arachnoid itself becoming thickened, and assuming an opalescent appearance. According to Hewett, in cases of meningitis originating from injuries of the skull, lymph will be chiefly found on the dura mater and in the cavity of the arachnoid ; while in those cases which originate from injury of the brain (as after concussion), the pia mater is chiefly affected, the arachnoid cavity often escaping. Inflamma- tion of the brain substance itself, chiefly affects the gray matter and superfi- cial white substance, and is marked by great congestion, a dusky leaden hue, and softening, which comparatively seldom affects the central white parts, such as the fornix. Traumatic encephalitis may end in suppuration, cerebral abscesses not unfrequently following upon seemingly slight injuries, and oc- curring after long intervals of apparent health. Symptoms of Traumatic Intra-cranial Inflammation. — These are pain (especially referred to the seat of injury), heat of head, fever, contraction of pupils, photophobia, and intolerance of sound; at a later period there are added vomiting, jactitation, delirium, convulsions, stupor, subsultus, paralysis, and coma. The occurrence of suppuration is frequently marked by repeated rigors. The period at Avhich encephalitis is devoloped varies in different cases; thus, after general and wide-spread concussion, inflammation may come on in a few hours ; after limited laceration, probably not for several days—while inflammation resulting from contusion or fracture of the skull may occur at a still later period. TRAUMATIC ENCEPHALITIS. 319 No very trustworthy information as to the precise seat of inflammation can be derived from the symptoms. The researches of Callender would seem to sIioav that pain is especially connected with lesion of the gray matter, and convulsions with'disease about the track or distribution of the great vessels, especially the middle cerebral arteries. Solly, hoAvever, looks upon convul- sions as characteristic of inflammation of the tubular portion of the hemis- pheres, and Dr. Watson, of the pia mater or arachnoid; while Brodie and Hewett have seen convulsions follow injuries of the head Avhen there Avas no evidence of any inflammation at all. Death may result from pressure of lymph or pus on the surface of the brain (in cases of arachnitis), from soften- ing of the brain tissue, from the occurrence of intra-cranial hemorrhage, or from an abscess bursting into the ventricles; or it may result secondarily from thrombosis and pyaemia. Intra-cranial Suppuration may occur betAveen the skull and dura mater (subcranial), in the cavity of the arachnoid and the meshes of the pia mater {inter-meningeal), and in the substance of the brain itself (intra-cerebral). Subcranial suppuration results from lesion of the bone, and is only met with at the seat of injury ; the other varieties may also result from counterstroke, and may therefore be found at a distance from the point at Avhich the violence was applied. The first and third forms of intra-cranial suppuration are cir- cumscribed, the latter constituting the ordinary cerebral abscess, which may last for an indefinite time without producing any marked symptoms. Inter- meningeal suppuration is commonly widely diffused, occupying the region of the vertex, usually on the side of the external injury, but occasionally oppo- site to it. The symptoms of intra-cranial suppuration are those of cerebral irritation and compression ; but I do not know of any signs which will enable the sur- geon positively to distinguish the presence of suppuration from that of arachnitis. The prognosis in all these cases is very unfavorable; pus has, however, been occasionally evacuated from beneath the cranium, the patient recover- ing ; and incisions have been made through the dura mater, and even into the brain substance, in search of pus. Operations of this kind have been recorded by La Peyronie, Dupuytren, Guthrie, Dunville, Detmold, Noyes, Clark, Weeds, Holden, Maunder, Tiilaux, Hulke, Chinault, Lloyd, Cour- voisier, Morehouse, Bontecou, Stimson, Peck, Jalland, Elcan, and myself, and 13 of the 22 cases are said to have terminated successfully. Treatment of Traumatic Encephalitis —Intra-cranial inflammation is to be treated on the general principles laid doAvn in Chapter II. Bleeding was formerly considered absolutely necessary in these cases, and is still resorted to by some surgeons. I have already expressed my vieAvs so fully as to the employment of venesection in the management of inflammation, that I shall not revert to the subject here, further than to say that I have never had oc- casion to bleed for encephalitis, though I have Avith advantage drawn blood, locally, by cupping. Purging is doubtless a most valuable means of treat- ment in those cases, but should be employed with due caution, and not pushed so far as unnecessarily to weaken the patient. Desault derived ad- vantage from the use of large doses of tartar emetic, but the remedy is a dangerous one, and is nowr seldom employed. Calomel and opium are, I think, of great service in the treatment of these cases, and may be given in doses of a quarter of a grain of the former, with a sixth of a grain of the latter, every three hours, till the gums are slightly touched, when the mercu- rial should be suspended, and iodide of potassium may be substituted. Cold to the head is a valuable remedy, and is very grateful to the patient, as re-1 Iieving the headache, which is one of the most painful symptoms of intra- 320 INJURIES OF THE HEAD. cranial inflammation. In the latter stages, a blister to the nape of the neck, or even to the entire scalp, is recommended by some authorities. The diet should consist of fluids, and should be light and unirritating ; if the general condition of the patient require it, hoAvever, the surgeon must not hesitate to administer concentrated nutriment, or even stimulus. After injuries of the head, the brain often appears to be left in an irritable condition, the patient suffering from headache, vertigo, insomnia, etc. Under these circumstances, I have derived benefit from the use of the bichloride of mercury (in very small doses), or of the bromide of potassium, which may be ghren freely, and seems to act Avell as a hypnotic. The state of the boAvels should ahvays be looked to, in these cases, care being taken to avoid consti- pation. The question of trephining, for intra-cranial suppuration, Avill be discussed in its proper place. Injuries of the Skull. Contusion.—Contusion of the skull, without fracture, is a very serious injury, being commonly accompanied with grave lesions of the brain; the part of the skull which is bruised may become necrosed, and eventually ex- foliate ; or, from separation of the dura mater, subcranial suppuration may occur and prove fatal. These injuries are chiefly met with as the result of gunshot Avounds, though occasionally resulting likeAvise from the accidents of civil life. The treatment consists in combating cerebral irritation, by the means already described, and in removing sequestra, in case of exfoliation. If a patient with contused skull become comatose, it is usually recommended to apply a trephine, Avith the hope of being able to evacuate pus from beneath the skull; the facts already referred to, viz., that it is impossible to distin- guish intra-cranial suppuration from arachnitis, and that, even if the exist- ence of pus were certain, its locality could not be determined, are, however, sufficient to shoAV how slight would be the prospect of benefit from such an operation. Thus, in a case of gunshot contusion of the left parietal bone, which proved fatal at Cuyler Hospital, there were found after death arach- nitis of the right side, and abscess of the left hemisphere of the brain, at a point corresponding to the seat of injury—showing that trephining on either side would have been utterly useless. The operation was, according to Dr. Otis, resorted to in twelve cases of gunshot contusion of the skull, during the late Avar, but in every instance unsuccessfully. Fracture of the Skull.—Fractures of the skull may be simple or com- pound, comminuted, etc. They may be conveniently classified as fractures without displacement (fissured fractures), and fractures with displacement (depressed fractures), the latter class being again subdivided into impacted and non-impacted depressed fractures.1 In some rare cases, the fracture may be limited to the outer table, which is depressed upon the inner; in other instances, the inner or vitreous table is alone broken, the outer escaping. As a rule, the inner table is more extensively shattered than the outer, the exception being when the force is applied from within, as in the discharge of a pistol into the mouth. The cause of this difference is to be found, as pointed out by Teevan, in the Avell-known fact in mechanics, that fracture begins uniformly in the line of extension, and spreads further in this than in the line of compression, and that (in the case of gunshot fracture) the bulk of the fracturing body is absolutely augmented in its passage through the bone. 1 Other subdivisions are sometimes made, such as the starred fracture, and the camerated fracture (a form of the depressed variety). FRACTURE of the skull. 321 Any part of the skull may be broken by either direct or indirect violence, the parietal and frontal bones being most often affected in fractures of the vault, and the temporal and sphenoid bones in those of the base of the skull. Fracture of the base of the skull is the most fatal form of simple fracture, usually resulting from indirect violence, such as a bloAV on the top or side of the head, or a fall from a height on the feet or hips; it is generally, if not (as believed by Aran and HeAvett) universally, complicated by one or more fissures extending upA\ards into the vault. Depressed fracture of the skull is very rarely met with except in the vault, and results from direct violence. C. B. Ball, an Irish surgeon, has, however, collected several cases in Avhich the base of the skull was driven in, and the condyle of the jaw impacted in the opening, by force transmitted through the lower maxilla. Symptoms of Fractured Skull.—A Simple Fissured Fracture of the vault of the skull presents no symptoms which can be considered diagnostic. If there be an external wound, the line of fracture can be usually recognized, though a mistake has arisen, even under these circumstances, from an abnor- mal position of one of the cranial sutures. Fracture with Dlsjjlacement, if compound, is readily recognized; but, if unaccompanied by an external wound, may, as already mentioned, be con- founded Avith a simple scalp contusion (p. 310). In some rare instances the displacement is outwards, but much more commonly inwards, constituting the ordinary depressed fracture of the skull. The displacement in the impacted fracture is slight, the depression being less than the thickness of the skull; in the non-impacted variety it is usually much greater, fragments being often deeply imbedded in the substance of the brain itself. Fracture of the Base of the Skull may be suspected in any obscure case of injury to the head, which presents marked brain symptoms; and there are tAvo signs in particular, Avhich, though they cannot perhaps be considered pathognomonic, are unquestionably very significant, and render the exist- ence of fracture at least extremely probable. These signs are the occurrence of intra-orbital ecchymosis and of bloody and watery discharges from the ear. 1. Fracture, involving the anterior fossa of the base of the skull, may cause hemorrhage from tlie nose, or into the deep parts of the orbit. The blood may Aoav backAvards through the posterior nares into the mouth, and, being SAvallowed, may subsequently cause hsematemesis, giving rise to a suspicion that some lesion of the abdominal viscera may have occurred. Hemorrhage into the orbit and areolar tissue of the eyelids, constituting in the former position what is known as Intra-orbital Ecchymosis, is commonly considered as presumptive evidence of the existence of fracture of the anterior fossa, though this symptom may, of course, be due to the giving Avay of a blood- vessel, Avithout lesion of the bony structures, and may e\ren, as pointed out by Lucas, result from a superficial injury, the blood passing backwards from the eyelids to the subconjunctival ocular tissues. This form of ecchy- mosis may, however, be distinguished from the subconjunctival and subcuta- neous palpebral ecchymosis Avhich constitutes the ordinary " black eye," by the fact that it is unaccompanied by contusion of the superficial structures, and that it is not a primary phenomenon; it is, indeed, caused by the gradual leakage of blood from Avithin (the subconjunctival tissue being involved before the eyelids), and frequently does not reach its point of greatest intensity until several days after the time of injury. The hemor- rhage is usually venous, probably resulting from laceration of the cavernous sinus, though it may be arterial, going on to the formation of a circum- scribed traumatic aneurism, and eventually requiring ligation of the carotid artery—an operation Avhich has been successfully resorted to under such circumstances by Busk, Scott, and others. 21 322 INJURIES OF THE HEAD. Fig. 164. 2. Hemorrhage from the Ears cannot, of itself, be considered a sign of much importance, as it may arise from any injury which ruptures the mem- brane of the tympanum, without necessarily implying the existence of frac- ture. If, however, it be profuse and long continued, the blood Avhich remains in the meatus pulsating, and other symptoms of cerebral injury being simul- taneously present, it becomes probable that a fracture of the petrous portion of the temporal bone has occurred, and that the blood proceeds from one of the large venous sinuses in that neighborhood. The occurrence of a Discharge of Thin Watery Fluid from the ear or nose, or through a wound of the scalp, is very significant of fracture: this discharge appears, in most cases, to be due to the escape of cerebro-spinal fluid, though instances have occurred in Avhich the secretion of the tympanic cavity, and even saliva (leaking backwards through a perforation of the meatus, produced by the fragment of a broken jaw), have been mistaken for the characteristic discharge of fracture at the base of the skull. If, hoAvever, a profuse Avatery discharge occur from the ear immediately after the accident, or if it follow a profuse and continued aural hemorrhage, there can be little doubt that the cerebro-spinal fluid is indeed escaping, and that a fracture, therefore, is neces- sarily present.1 Watery discharge from the nose is, of course, much less sig- nificant, and as an accompaniment of fracture is less often met with than that from the ear. Compound fracture of any part of the cranial vault may be attended by a discharge of cerebro- spinal fluid, provided that there be a communication between the external wound and the sub-arachnoid cavity. It is stated by Robert, who has given much attention to this subject, that cases of fracture accompanied Avith discharge of cerebro-spinal fluid are ahvays fatal; this is probably a mis- take, for several well-authenticated cases are on record, in which recovery has taken place in spite of the occurrence of these discharges, though, of course, in any case which recovers, there is always the possibility of an error hav- ing been made in the diagnosis. A sudden cessation of the watery discharge is apt to be quickly followed by fatal coma. Prognosis.—As far as the injury to the bone is concerned, there is very little risk from fracture of the skull: osseous union commonly occurs without difficulty, unless there has been loss of substance, in Avhich case the gap is filled by means of a firm and dense membrane, as shown in Fig. 164, from a photograph kindly sent me by Dr. Charles E. Slocum, of Defiance, Ohio. If necrosis takes place, the sequestrum is thrown off by a process of exfolia- tion, and, if both tables of the skull be involved, the dura mater may be seen Fracture of skull with great loss of substance. (From a patient under the care of Dr. Charles E. Slocum.) 1 Koser, however, believes that, if the meninges be ruptured, cerebro-spinal fluid may leak through the pores of the cranial bones without these being broken. HERNIA CEREBRI. 323 covered Avith healthy granulations, and pulsating at the bottom of the wound. Very large portions of the skull may be lost, either at the time of the acci- dent, or at a later period by necrosis, Avithout injury to the patient; and, in- deed (paradoxical as it may seem), those cases often appear to do best in Avhich the skull has suffered most extensively, the force of the blow or other injury spending itself, as it Avere, upon the bone, and the brain escaping with comparatively little harm. The danger in any case of fractured skull de- pends upon the amount of injury done to the cranial contents, this injury consisting in contusion, laceration, and subsequent inflammation, conditions which have already been considered. Treatment.—The treatment of a fracture of the skull must have reference to the condition of the cranial contents. The question of trephining in these cases will be most conveniently considered hereafter; after the operation, if it be resorted to, or in cases in which operative measures are not required, the treatment should be conducted on the principles already laid down for the management of cerebral contusion and laceration, and traumatic en- cephalitis. Cold to the head, opium, purgatives, liquid food, calomel (in cases of arachnitis), with perhaps blisters or local bloodletting, if coma be threatened, will be found the most useful remedies in the majority of these cases. In cases of compound fracture, loose fragments and foreign bodies should be removed if possible, and depressed but adherent portions of skull elevated, provided this can be effected without too much disturbance. The danger is, however, less from compression than from inflammation, and hence rough handling or careless probing of the brain must be rigorously avoided. Injuries of the Cranial Contents. Wounds of the Brain and Meninges.—The brain or its membranes may be wounded, and portions of the cerebral mass itself driven out of the skull in cases of fracture, recovery yet ensuing; it is indeed surprising to see what serious wounds may occasionally be inflicted upon the brain and its mem- branes, without a fatal result. I saAv, at Cuyler U. S. A. Hospital, a soldier who had survived a perforating gunshot fracture of the skull, and Dr. O'Cal- laghan gives the case of an officer, who lived seven years with the breech of a foAvling-piece within his cranium; perhaps, however, the most remarkable cases on record, of recovery after wound of the brain, are those narrated by Dr. Harlow and Prof. Bigelow, and by Dr. Jewett; in the former case an iron bar, three and a half feet long, and weighing thirteen pounds, passed through the head, and in the latter, a somewhat similar injury was produced by a gas-pipe. The symptoms and prognosis of brain wounds will of course vary with the particular part involved. Lesion of the optic tract may cause blindness ; or a Avound in the neighborhood of the fourth ventricle, saccharine diabetes. Wounds of the base of the brain are more dangerous, and more quickly fatal, than those of its convexity. The treatment of brain wounds consists in the adoption of the measures Avhich have already been so often referred to, as appropriate in all cases of injury to the contents of the cranium. Hernia Cerebri.—Under this name have been included several distinct conditions, Avhich have merely in common the protrusion of a fungous-looking mass through an opening in the skull. This mass may be merely a collection of coagulated blood, or may consist of exuberant granulations, proceeding from the dura mater or from the wounded brain itself, but the true hernia cerebri consists of softened and disintegrated brain matter, mixed Avith lymph, 324 INJURIES OF THE HEAD. pus, and blood. The mass projects through the dura mater and skull, and the superficial portions, Avhich slough and are cast off, are usually replaced by fresh protrusions, until the patient dies exhausted. More rarely the patient may recover, the Avhole projecting mass being disintegrated and re- moved, or sloAvly shrinking Avithout the occurrence of sloughing. It was taught by Guthrie that hernia cerebri Avas more likely to occur through small openings in the skull, than through large apertures. This view, however, is not confirmed by the experience of all observers, and the occurrence of the affection appears to depend more upon the condition of the brain, than upon that of the skull. Hernia cerebri usually manifests itself in the course of the first or second Aveek of the injury, the period varying with that of the development of cerebritis. The treatment is that of encephalitis in general. I doubt if advantage can be obtained from any local treatment, though it is said that in the early stages slight pressure has proved useful. Avulsion, excision, and ligation are all to be reprobated, as more apt to add fresh irri- tation than to be productive of benefit. As the affection seems often to re- sult from the imbedding of spiculae of bone in the brain, we should be careful to remove all loose fragments that can be detected ; Avhile, on the other hand, as hernia cerebri cannot occur without Avound of the dura mater, this mem- brane should be scrupulously respected in all our operations upon the skull. Trephining in Injuries of the Head. The objects sought to be attained by the use of the trephine are the removal of compression, Avhether caused by extravasation, by displaced bone, or by the presence of pus, and the prevention of inflammation, by the removal of foreign bodies, such as sharp spiculse of bone, musket-balls, etc. Trephining is also occasionally employed in the treatment of epilepsy, when it appears probable that the disease is caused by a morbid condition of the skull. Sedillot recommends trephining as a prophylactic in many cases of fractured skull, but his vieAvs are not shared by surgeons generally. Trephining for Extravasation.—If it were possible to be sure that the seat of extravasation Avere between the brain and dura mater, and that there were no other lesions, operative interference might be employed Avith some hope of benefit. When it is remembered, hoAvever, that the seat of ex- travasation can very rarely be determined, and that these cases are almost hwariably complicated Avith graATe injury of the brain substance, it ceases to be a matter of surprise that, as Mr. Hutchinson puts it, " the modern annals of surgery do not . . . contain any cases in Avhich life has been saved by tre- phining for this state of things." There are, indeed, a few cases on record, in which blood has been evacuated from between the dura mater and skull, or even from the cavity of the arachnoid, the patients recovering; but in the immense majority of instances, the operation, which is noAv seldom performed under these circumstances, has been useless, or has even hastened death. Hence, I cannot but think that, as a rule, the surgeon will do Avisely to ab- stain from the use of the trephine in these cases, relying upon medical treatment, as in dealing Avith ordinary apoplexy. If the trephine be em- ployed, a large circle of bone should be removed, in order to give room for the evacuation of coagula, and to afford a fair opportunity to secure any vessel that may be found bleeding. Trephining for Depressed Bone.—Probably few surgeons, at the present day, would think of operating in a case of Simple Depressed Fracture, Avith- TREPHINING FOR DEPRESSED BONE. 325 Fig. 165. out symptoms of compression. Even if there be such symptoms, the advan- tages to be derived from trephining are, at least, very problematical, for (1) the symptoms, if due to the depressed bone, will probably pass off by the brain accustoming itself to the pressure ; and (2 j if the compression persist, it will, most probably, be found to be due to extravasation from laceration of the brain itself, a condition Avhich evidently would not be benefited by trephining. Indeed, Hutchinson goes so far as to consider compression of the brain as the result of depressed fracture "an imaginary state," and declares that he has " never seen a case in which there seemed definite reason to think that depression produced symptoms." Although the rule is still given, in most of our surgical Avorks, that trephining is indicated in simple fracture accompanied with marked symptoms, there can be no doubt that hospital surgeons are becoming more and more averse to operating in these cases; and for my own part, I can only say that I never seen a case of this kind in which I thought the use of the trephine justifiable, nor an autopsy which showed that the operation could possibly have saved life. With regard to Compound Depressed Fractures, it seems to me that the course to be pursued should vary, according as they are or are not impacted. In an impacted fracture, the depression is neces- sarily inconsiderable, and if symptoms of compression are present in such a case, they are due to extravasation or lacer- ation, and not to the depression; moreover, the impaction prevents the access of air to the cranial contents, and thus lessens the risk of disorganizing inflammation following the injury. Hence, in impacted fracture, though compound and depressed, I would not advise an operation, even if symptoms of compression were present. For one case like Keate's, in which by a happy accident the operator might discover a wound of a large artery, and thus relieve the compression, there are many cases in which trephining could be productive of no benefit, but would, by admitting the atmosphere, seri- ously complicate the prospects of recovery. If, however, in a case of compound impacted fracture, convulsions or other symptoms of cerebral irritation come on at a later period, the surgeon should explore the wound, and if it appear that sup- puration has occurred between the tables of the skull, may prop- erly apply the trephine, as I have myself done with advantage under these circumstances. In the case of a non-impacted frac- ture, the rule has already been given, to remove the loose fragments, and elevate the remainder. In most cases this can readily be done by means of the elevator and forceps, Avithout enlarging the opening in the skull. If, however, the aperture be too small to admit of safe manipulation, there can be no objection to enlarging it, either Avith a Hey's saAV, with cutting pliers, or Avith a small trephine. The risks of atmospheric contact are unavoidable in such a case as this, and the best that the surgeon can do is to clear the wound as Avell as possible, by the re- moval of osseous spiculse and foreign bodies. It will thus be seen that I Avould restrict the use of the trephine Avithin very narrow limits; it is not to be used Avith the idea of relieving compression, nor Avith the idea that there is any special virtue in the operation, to prevent encephalitis. The trephine should be used merely as Hey's saAV is used, mechanically, to enlarge an opening which Avould be othenvise too small to alloAv the surgeon to carry out plain therapeutic indications. The surgeon should cautiously explore every compound non-impacted fracture, and if there be loose spiculse, remove them, Avhether there be symptoms of compression or not. As the inner table Hey's Saw. 32(j INJURIES OF THE HEAD. is often more extensively involved than the outer table (especially in punc- tured fractures), it may be necessary slightly to enlarge the opening in the skull in order to remove these spiculse, and this enlargement may be done with or Avithout the trephine, according to the nature of the case. All this must be accomplished, however, with the utmost caution and gentleness; and I believe, with Brodie, that it is better to leave, imbedded in the brain, a foreign body, or even a fragment of bone, than to add to existing irritation by reckless attempts at its removal. Trephining for Intra-cranial Suppuration. — Some years ago, under the influence of the teaching and example of the celebrated Percival Pott, this operation Avas more frequently resorted to than it is at the present day. As we have already seen, there is, in the large majority of cases, no symptom which renders it certain that pus is present; and, as Hutchinson remarks, if we adopt the rule of trephining in all cases in which, after bruise or fracture of the skull, the patient has become hemiplegic or comatose, with inflam- matory symptoms, Ave will operate in twenty cases of arachnitis, for one in which we will find any pus to be evacuated; while even if pus be found, and can be removed, in the immense majority of cases arachnitis will coexist, and cause death in spite of the operation. "I have repeatedly," says Hewett, " seen the trephine applied under such circumstances, and matter evacuated, but Avithout any permanent benefit. Indeed, the successful issue of a case of trephining for matter betAveen the bone and dura mater is, I believe, all but unknown to surgeons of our own .time." When the chances of a successful issue after operative measures are so slight, the surgeon will, I think, in most cases, do wisely to abstain from the operation;x more especially as these cases will occasionally recover, at least temporarily, under expectant treatment. Even if pus be present, it is impossible to know that it is within reach, and cerebral abscess may continue for many years, producing little or no disturb- ance ; Avhile, though recovery has occasionally folloAved trephining under these circumstances,2 the operation has in many more cases but superadded a new injury to those already existing. Chassaignac has proposed to trephine as a,prophylactic againstpyozmia,.in cases of contused skull; but the opera- tion is surely not justified, either by experience, or by what we know of the etiology of the affection meant to be prevented. With regard to Trephining for Epilepsy, I can only say that I consider the operation usually unadvisable.3 Its risks are not inconsiderable, 16 out of 72 cases collected by Billings, and 28 out of 145 collected by Echeverria, having proved fatal; and when we remember the well-known fact that epi- lepsy is apparently and temporarily curable by very various remedies, which have at least the merit of being harmless, Ave should pause before recom- mending an operation which may not improbably itself cause death, and of Avhich the prospective benefits, as regards permanence, are certainly doubtful.* 1 Unless, as in cases successfully trephined by P. H. Watson, N. K. Smith, and Cras, an orifice in the skull should plainly communicate with an intra-cranial ab- scess. Under such circumstances, if the opening were insufficient, the operation would of course be indicated. 2 See page 319. s According to Broca, in epilepsy from cranial injury, the temperature is raised upon the affected side; hence, if the temperature be highest on the uninjured side, then epilepsy is not due to traumatic causes, and will not be relieved by an operation. * Broca and Championniere have given rules for selecting the point of trephining by "localizing" the seat of cerebral injury. I hope that I may be pardoned for expressing the opinion that their interesting investigations are more ingenious than practically useful. OPERATION OF TREPHINING. 327 Operation of Trephining.—The form of trephine ordinarily employed is shoAvn in the accompanying illustration (Fig. 166). It is to be applied evenly on the surface of the skull, with the centre pin1 slightly projected, and is to be Avorked cautiously by light turns of the Avrist from left to right and from right to left, until a groove is formed, Avhen the centre pin must be withdraAvn, lest it puncture the skull and wound the dura mater. The surgeon then pro- Fig- 166. ceeds sloAvly and gently, brushing away the bone-dust, from time to time, and testing the progress made by means of a fine probe or toothpick. When the diploe is reached (if there be any), the trephine works more freely, and blood escapes with the bone-dust. As the inner table is approached, the surgeon must reneAv his precautions, lest undue pressure, or an accidental slip of the instrument, should wound the dura mater, an occurrence Avhich would be very apt to prove fatal. The disk of bone Avhich has been separated Avill often come aAvay in the croAvn of the trephine, or may otherwise be readily removed Avith the elevator (Fig. 167) and forceps. If the exter- Common trephine. nal Avound be not large enough to allow the application of the trephine, more room may be afforded by means of a cru- cial or T incision, the flaps of the scalp being held out of the Avay, and care- fully replaced Avhen the operation is completed. The wound should then Fig. 167. Different forms of elevator. be lightly dressed, and the constitutional treatment of the patient carried out in accordance Avith the principles already laid down for the management of cerebral injuries. There are certain regions of the skull to Avhich the trephine should not be applied, if it can be avoided; these are the various sutures, the lines of the large venous sinuses, the anterior inferior angle of the parietal bone (wdiere there would be risk of Avounding the middle menin- geal artery), and the frontal sinus; if it should be necessary to operate in the latter situation, the outer table should be removed with a large trephine, and the inner table Avith a smaller instrument. The Conical Trephine (Fig. 168) is an old instrument, the use of which has been, in modern times, revived by Gait, of Virginia. It has the advan- tage over the common instrument, that its peculiar shape prevents the possibility of its unexpectedly plunging into the brain; it, hoAvever, has the disadvantage that it divides the skull obliquely, and thereby exposes the part to greater risk of necrosis. 1 If the use of the centre pin be undesirable, the crown of the trephine may be steadied by applying it through a piece of perforated pasteboard, as suggested by Dr. P. H. Watson, of Edinburgh. 328 INJURIES OF THE HEAD. Fig. 168. The results of the operation of trephining are very unfavorable, the pro- portion of recoveries having been in the NeAV York Hospital only about 1 in 4, and in University College Hospital (London) 1 in 3, while in Paris almost every case operated on of late years, has, according to Xelaton, proved fatal. I have myself been compelled to trephine in 9 cases, but in only 1 has the operation been followed by permanent recovery. The majority of deaths after trephining are, hoAvever, due, not to the operation, but to cerebral lesions on which the operation could have no effect, so that statistics are yet wanting to show the absolute mortality of the operative pro- cedure. In only one of my own nine cases did the operation seem to hasten death, while in two which ultimately proved fatal great relief Avas afforded, and life was prolonged for several Aveeks. One case ended in complete reco\Tery, and in the remaining five the effect of the operation appeared to be entirely indifferent. During our late Avar, 227 ter- minated cases of trephining gave 126 deaths and 101 re- coveries ; 451 cases of removal of splinters or elevation of fragments, without trephining, gave 176 deaths and 275 recoveries; Avhile 3447 cases treated by expectancy gave 2159 deaths and only 1288 recoveries. (Otis.) As, hoAv- ever, the latter group of cases contained almost all the instances of penetrating and perforating fracture, as well as those which proved fatal before any treatment could be adopted, it Avould be manifestly unfair to found upon these statistics any argument as to the value of the opera- tion of trephining. The most elaborate statistics of trephining yet published are those of Dr. Bluhm, who has collected 923 cases, with 450 recoveries and 473 deaths, a total mortality of 51.25 per cent. The death-rate varies according to the period at which the operation is performed, the primary cases being the most fatal. The following table is condensed from that of Dr. Bluhm, in Langenbeck's Archives (Vol. XIX., Part 3). Conical trephine. Primary, . . . Secondary,. . . Late, . . . . Period unknown, Aggregate, . . Total. 114 158 59 592 923 Recovered. 51 94 39 266 450 Died. 63 64 20 326 473 Mortality, per cent. 55.26 3924 33.90 55.07 51.25 Perhaps we can most nearly approach a correct estimate of the risks of the operation itself, by considering Billings's and Echeverria's statistics, al- ready referred to, of trephining for epilepsy. In these cases the only trau- matism, to borrow a Gallicism, is that due to the operation itself, and here we find that the mortality is about 20 per cent. But, even with this com- paratively small figure, it behooves the surgeon to be very cautious not un- necessarily to employ an operation Avhich of itself kills one out of every five patients, more especially as, upon consideration of the pathology and natural history of brain injuries, the probability of benefit from the operation is seen to be limited to an exceedingly small number of cases. INJURIES OF THE SPINAL CORD. 329 CHAPTER XVI. INJUKIES OF THE BACK. Wounds or other injuries of the soft tissues of the back present no pecu- liarities requiring special comment. It is, indeed, only in consequence of the liability of the \rertebral column and its important contents to be involved in lesions of the back, that injuries of this region acquire the interest Avhich they possess in the eyes of the surgeon. In entering upon the important subject of spinal injuries, I shall consider, first, the traumatic lesions of the spinal cord itself, reserving for a later page what I have to say Avith regard to sprains, fractures, and dislocations of the vertebral column. Injuries of the Spinal Cord. Concussion of the Spinal Cord.1—This may vary, like concussion of the brain, from the slightest jarring or shaking, up to complete disorganization. Unlike concussion of the brain, hoAvever, it is very seldom that the spinal injury is so severe as to prove immediately, or even rapidly, fatal (except when accompanied by fracture or dislocation), death as a result of spinal concussion usually occurring after a considerable interval, and being pre- ceded by inflammation of the spinal meninges or of the cord itself, or by progressive softening Avithout inflammatory symptoms. The reason for this difference is, as pointed out by Lidell, Shaw, and others, that the spinal cord floats loosely in an elastic medium (the cerebro-spinal fluid), and is therefore not so readily exposed to injury as the brain, Avhich fits comparatively closely to its bony investment. I do not believe it possible for death to occur from concussion of the spinal cord, Avithout lesions demonstrable by post-mortem inspection. Though several cases have been recorded by Boyer, Frank, and others, in Avhich such an event has been supposed to occur, it is probable that, Avith the more accurate means of examination which are now possessed, positive lesions could have been discovered. Death may, of course, occur from shock, which is an occasional complication of spinal injuries; or from concomitant lesions of other organs—lesions Avhich may readily escape detec- tion, if attention be directed chiefly to the condition of the spine.2 The post- mortem appearances, in fatal cases of spinal concussion, may be classed as (1) extravasation of blood—Avhich may occur in the substance of the cord itself, betAA'een the cord and its membranes, or between the latter and the vertebral column ; ( 2) laceration of the membranes, or of the cord ; (3) in- flammatory changes—meningitis or myelitis—with or Avithout compression of the cord from the so-called products of inflammation, lymph, pus, etc.; and (4) degeneration of the structure of the cord, without any eAridences of pre-existing inflammation. 1 The term concussion is retained from motives of convenience. It is not, however, scientifically correct, the various conditions which are designated by the term con- cussion, being really instances of contusion, partial rupture of the cord fibres, etc. See remarks on Concussion of the Brain, in Chap. XV. 2 See, in connection with this subject, an interesting paper by Dr. W. Moxon, on thrombosis of the renal vessels through injurv to the lumbar spine (Guy's Hosp. Re- ports, 3d s., vol. xiv., pp. 99-111). 330 INJURIES OF THE BACK. Hemorrhage into the Vertebral Canal is a not unfrequent occurrence in severe cases of spinal injury. If in small amount, it may give rise to but transient paralysis, the effused blood becoming coagulated and partially ab- sorbed, and the compressed cord becoming gradually accustomed to its pres- ence ; in other cases it may remain in a fluid condition, or may possibly be clotted and subsequently reliquefied. In some cases it Avould appear that slow extravasation may continue for a considerable period, fatal paralysis not coming on for some time after the injury (in Mr. Heaviside's case nearly a year), and death thus resulting, as pointed out by Aston Key, from the cumu- lative effect of spinal compression. I do not knoAV of any sign by Avhich the surgeon can positively determine the exact seat of extravasation in cases of spinal hemorrhage; in the majority of instances the effused blood is found outside of the membranes, or between the latter and the cord ; and it is prob- ably in one of these positions that extravasation usually occurs, when the symptoms are sIoav and progressive in their development, and when the poAver of motion is more affected than that of sensation. Extravasation into the substance of the cord itself, would probably cause instant paralysis, both motor and sensory, which might be permanent, or in a favorable case might subsequently disappear. This is the most plausible explanation of the symp- toms in the remarkable case recorded by Hughes, of Dublin, in Avhich an injury of the cervical spine caused instant but temporary loss of both motion and sensation, in the loAver extremities, folloAved by gradually developed but long-persistent motor paralysis, in the upper extremities. Instant loss of both motion and sensation, if temporary, may be supposed to be due to a slight hemorrhage into the substance of the cord itself; while gradually de- veloped paralysis, especially affecting the motor power, may be reasonably attributed to hemorrhage upon the surface of the cord, or even outside of the membranes. The upper limit of paralysis will, of course, indicate clearly the height at Avhich the extravasation has occurred. Laceration or Rupture may occur in the spinal membranes (particularly the pia mater, alloAving a hernia of the medulla), or in the fibres of the spinal cord itself. These lesions are, hoAAever, more frequently produced by violent tAvistings or bendings, or by fractures or dislocations of the spinal column, than by any injury to Avhich the term concussion can be properly applied. Inflammation of the Spinal Membranes (Meningitis), and of the Cord (Myelitis), are very frequent secondary occurrences in cases of spinal injury. In spinal meningitis there is great congestion, and often effusion of serum, or formation of lymph or pus. Myelitis may affect the whole thickness of the cord, or principally the gray matter; though, if consecutive to menin- gitis, the Avhite portion may alone be involved. Inflammation of the cord substance is commonly attended with softening, which may end in total dis- appearance of the nervous structures at the part affected—nothing but con- nective tissue remaining; more rarely induration occurs, the nervous sub- stance being increased in bulk, and of a dull Avhitish color. The occurrence of inflammation, in cases of spinal injury, is attended Avith great pain, dis- tressing sensations, as of a cord tied around the waist or limbs, tetanic' spasms, general convulsions, etc. Progressive Disorganization of the Cord may occur as the result of injury to the spine, without the manifestation of any evidence of inflamma- tion, either during life, or upon post-mortem inspection. Paralysis, both motor and sensory, sometimes accompanied with muscular rigidity, gradually SYMPTOMS OF SPINAL INJURIES. 331 creeps upwards, until death ensues from interference with the respiratory function. The autopsy shows diffused Avhite softening of the spinal cord, without evidence of either meningitis or myelitis. In other instances the cord, to the unaided eye, appears perfectly healthy, though marked changes are subsequently discovered by careful microscopic inspection (H. C. Bastian, Med.-Chir. Trans., vol. 1., pp. 499-542). Wounds of the Spinal Cord.—The spinal cord may be Avounded by sharp- pointed or cutting instruments, by pistol-balls, etc., Avithout any, or with very slight injury to the vertebral canal. The symptoms of such a lesion are those Avhich we shall presently consider as common to all spinal injuries, though there may be some modifications, owing to the greater limitation of the injury to certain parts of the cord than in cases of spinal concussion, or of vertebral fracture or dislocation; thus, Avhile in the latter classes of cases paralysis is usually bilateral, and involves both motion and sensation, in cases of Avound of the cord Ave not unfrequently find paralysis only of the side injured, as in instances recorded by Vignes, Peniston, and others; or loss of motion on the injured, and loss of sensation on the opposite side, as in cases narrated by Boyer, and by Hughlings Jackson. Symptoms of Spinal Injuries.—The folloAving account of the symptoma- tology of injuries of the spine is to be understood as applying to all forms of injury in which the cord is involved, Avhether the vertebral column itself has or has not escaped : as Ave shall see hereafter, the differential diagnosis of the various forms of spinal injury is often impracticable, and ahvays difficult, a fact Avhich is not surprising when we reflect that the rational symptoms are the same in the various forms of lesion. I shall adopt the classification of symptoms which I employed in my monograph on Injuries of the Spine, published in 1867, and which is pretty much the same as that used by Brodie, in his classical paper in the Medico-Chirurgical Transactions, vol. xx. Motor Paralysis.—The most striking, and probably the most constant, symptom in cases of spinal injury, is paralysis of the voluntary muscles be- low the seat of lesion. When the injury is below the second lumbar vertebra, there may be no paralysis, or, if it exist, it is usually partial and temporary, the spinal cord itself not usually extending beloAV this point, and the cauda equina appearing to be comparatively free from risk of injury. In lesions below the eleventh dorsal vertebra, the paralysis is usually less complete than in those at a higher point, the cord being protected in this part by the roots of the cauda equina. Paralysis, ordinarily, does not extend to parts Avhich derive their nervous supply from the portion of the cord above the seat of injury, and the exact point of lesion can be thus determined in most cases; the apparent exceptions reported by Stafford, Brodie, and others, are probably explicable by the fact that a second lesion, such as contusion or extravasa- tion, existed at the higher point, as the result of indirect violence to Avhich the older Avriters Avould have given the name of counterstroke. The extent of the spinal lesion in a dowmvard direction, may be determined by means of the electrical test, proposed by M. Landry. This surgeon found, in a case of luxation of the fifth dorsal vertebra, that the muscles of the thigh ceased to respond to electricity, while those of the leg, though equally paralyzed, con- tinued to contract in response to the electric stimulus. The autopsy shoAved that the part of the cord Avhich supplied nerves to the femoral muscles was disorganized, Avhile that Avhence arose the nerves going to the leg Avas quite healthy. Thus the fact that each segment of the cord constitutes a separate nerve centre, affords a means of accurately determining the extent of that portion Avhich has been injured. Motor paralysis is usually symmetrical; 332 INJURIES OF THE BACK. when unilateral (as in a case of fractured spine observed by Liston), it indi- cates that one side only of the cord is involved, as in the instances of wound of the cord already referred to. Motor paralysis after spinal injuries may be due to various causes, as to diArision of the cord fibres, to compression (either from extravasation, or from the products of inflammation), or to progressive disorganization of the nervous structures. If the paralysis be immediate, complete, and permanent, the cord is probably divided; if the paralysis be immediate, but not permanent, the case is one of so-called " concussion"— the lesion probably being a slight extravasation into the substance of the cord, though this is, of course, mere matter of conjecture ; paralysis coming on gradually, and subsequently diminishing, is probably due to compression on the surface of the cord, from extravasation or from inflammatory changes; while slowly but continually extending paralysis gives reason to fear progres- sive disorganization of the cord—a condition Avhich, almost always, ultimately proves fatal. A few cases are referred to by Velpeau, in Avhich the cord is said to have been completely divided, without any paralysis having existed during life; it is scarcely necessary to say that these cases admit of but two explanations— either, as believed by Brodie, that they Avere incorrectly observed, the division of the cord fibres not being .complete—or, as suggested by Prof. Brown-Sequard, that the division was at a point below the origin of most of the spinal nerves. Muscular Spasms or Convulsions after spinal injuries Avere believed by Brodie to indicate compression of the cord, and I believe this statement to be correct, as regards the spasms met with in the early stages of these cases. The value of this symptom for diagnostic purposes is, hoAvever, diminished by the fact that the cord is often found compressed, after death, Avithout spasms having been observed during life. The occurrence of convulsions, at a later period (as already mentioned), may denote the onset of spinal meningitis; Avhile again, in cases which recover, muscular twitchings not unfrequently accompany the return of motor power. Loss of Sensation usually accompanies and is coextensive with motor paral- ysis, in injuries of the spine. So complete was the loss of feeling in a case recorded by Purple, that the patient submitted to amputation of both thighs, without the use of an anaesthetic, and Avithout manifesting any emotion during the operation. Occasionally sensory precedes motor paralysis, Avhile, on the other hand, in favorable cases, the power of feeling is not unfre- quently regained while that of motion is still very imperfect. Hypercesthesia is occasionally observed in connection with motor paralysis. South saw a case of fracture of the cervical spine in Avhich there Avas loss of motion Avith hyperesthesia on the right side, and anaesthesia on the left. On the other hand, in a case reported by Gama, intense hyperaesthesia followed a bayonet wound of the posterior columns of the spinal cord, there being absolutely no paralysis; a circumstance which, as pointed out by Brown- Sequard, would indicate that the anterior portion of the cord had escaped injury. A zone of hyperesthesia sometimes marks the upper limit of sensory paralysis, due probably to irritation of the spinal nerves, before their exit from the vertebral canal. Pain is a symptom of frequent occurrence in spinal injuries ; it may be felt at the seat of lesion, or may be referred to various other parts of the body. Unusual and often most distressing sensations, as of burning, constriction, etc., may be referred to parts, the nervous connection of Avhich with the sensorium is entirely destroyed. Dyspnoea.—This is a marked and distressing symptom of injuries of the cervical and upper dorsal regions of the spine. It is often said that, in lesions SYMPTOMS OF SPINAL INJURIES. 333 of the cervical cord, respiration is performed by the diaphragm alone; this is not strictly correct, for, as pointed out by Shaw, in many cases the diaphragm is helped by the serratus magnus muscle (supplied by the external thoracic nerve, Avhich, Avhen the shoulders are fixed, tends to lift and expand the chest. If the spinal cord be destroyed above the origin of the phrenic nerve, death is instantaneous. The occurrence of dyspnoea in dorsal injuries depends upon tAvo causes: first, the abdominal muscles being paralyzed, the act of expiration is necessarily incomplete; and, secondly, paralysis of these mus- cles allows the boAvels to become distended Avith gas, thus thrusting the dia- phragm upwards, and mechanically impeding its motion. The occurrence of dyspnoea at a late period of spinal injuries is attributable to progressiAe disorganization of the cord extending upward to the cervical region. Dysphagia and Vomiting have been observed in injuries of the cervical spine, as has Jaundice in those of the dorsal region, Avithout any hepatic lesion haA^ing been discovered after death. Involuntary Fecal Discharges are met Avith in those cases in which the in- jury has involved the lowest portion of the cord—that Avhich presides over the sphincter muscle of the rectum; Avhen the lesion is at a higher point, this part, having escaped injury, continues to act, for a time at least, as a separate nerve centre, and Costiveness ensues. In some cases there may be temporary fecal incontinence, depending on shock, Avhich is coincident Avith, though not necessarily dependent upon, the spinal lesion. Retention of Urine is present in most cases of spinal injury, being followed after a time by Overflow, and subsequently by true Incontinence. A few cases are recorded by Morgagni and others, in Avhich incontinence was pre- sent from the outset. Suppression of Urine is a more serious, but fortunately a rarer, symptom than retention. Several remarkable instances of this occurrence have been recorded by Brodie, Dorsey, Comstock, and others. Hanuduria, from coincident contusion or partial lacertion of the kidneys, is not unfrequently met with in cases of sprain of the lumbar spine. This symptom is not usually one of serious import, though Mr. ShaAv reports a case in which the bleeding Avas so profuse as to render the patient anaemic. There is, according to Le Gros Clark, no reason to believe that organic dis- ease of the kidney ever ensues in these cases. Glycosuria has been met with in connection Avith injury of the cervical spine; the circumstance is interesting, in vieAv of the experiments Avhich have been made as to the artificial production of diabetes. Change in the Urine Occurring after Spinal Injuries.—Within a short time, varying from the second to the ninth day after a severe injury to the spine has been received, the urine, from being clear and acid, becomes turbid, am- moniacal, and loaded Avith mucus, and at a later period Avith phosphate of lime. This condition may continue indefinitely, or may disappear, or acidity and alkalinity of the urine may alternate, Avithout any very obvious reason. In some rare cases, according to Brodie, the urine first secreted after a spinal injury, though acid, and free from mucus, has a peculiarly offensive and disgusting odor. In other cases it is highly acid, having an opaque yellow appearance, and depositing a yelloAV amorphous sediment, Avhich, in one instance, stained the mucous membrane of the bladder, though the latter presented no marks of inflammation. Cystitis is an almost constant sequence of severe spinal lesions ; it is prob- ably due, chiefly, to the mechanical injury to the bladder from over-disten- tion and the frequent use of the catheter, but is, no doubt, further aggra- vated by the altered character of the urine. This alteration, hoAvever, is itself usually secondary, depending on the inflamed state of the lining mem- 334 INJURIES OF THE BACK. brane of the bladder, though, in some cases, according to Hilton, the urine is alkaline as it comes from the kidneys. Priapism.—This curious symptom is occasionally met Avith in connection with lesions of all portions of the spinal cord, except the loAvest. It is totally unconnected Avith any voluptuous sensation, and is only found in cases accom- panied by motor paralysis. In some cases, particularly when the injury is in the cervical region, priapism may occur spontaneously, immediately after the accident, and is then due (as pointed out by Hilton) to the excito-motor function of the portion of the cord below the lesion being unduly excited, because deprived of the regulating influence of the brain. In other instances this symptom is developed—also spontaneously—at a later period, owing to central irritation, generally from slight extravasation into the substance of the cord ; Avhile in still other cases it occurs merely as a reflex phenomenon, and may be excited by touching the scrotum, or by passing the catheter. The existence of priapism is usually evidence of severe and permanent injury to the spinal cord, though that this symptom may occur in connection with simple concussion is shown by a case recorded by Le Gros Clark, in which sensation returned on the ninth day, though the poAver of motion Avas not restored for several months. Flushed Face, usually accompanied by Lachrymation, and by Contracted or merely Myotic Pupils, is, I believe, only met with in cases of injury in- volving the cervical portion of the cord. It appears to be due to a partial paralysis of the sympathetic nerve, which derives its cervico-cephalic branch from the so-called " cilio-spinal region " of the spinal cord. This symptom is one of very grave import. Alteration of Vital Temperature is a symptom which has been particularly investigated by Chossat and Brodie. The temperature of the paralyzed parts frequently rises much above the normal standard, this symptom being prob- ably most frequent in lesions of the upper portion of the cord, though a tem- perature of 100° has been noted by Hutchinson, in a case of fracture of the lumbar spine. In a case of injury of the cervical region, observed by Brodie, the thermometer placed between the thighs rose to 1110 Fahr., and this ele- vated temperature persisted even after the patient's death.1 This symptom, to Avhich Hutchinson gives the name of Paralytic Pyrexia, is probably due, like the flushing of the face, to a paralyzed condition of the sympathetic or vaso-motor nerve. Persistent elevation of temperature, in spinal injuries, is a very grave symptom, and always affords grounds for a gloomy progno- sis. In the later stages of spinal injuries, the temperature of the paralyzed parts often becomes greatly reduced ;2 and even when there is no real dimi- nution of temperature, the patient often experiences a distressing sensation of coldness. Nutritive Changes in Paralyzed Parts.—In patients who survive the first risks of spinal inj ury, the paralyzed extremities usually, but not ahvays, become 1 J. W. Teale has reported a case of spinal injury in which the temperature is said to have ranged during nearly nine weeks from 108° to 125° Fahr., and in which the patient ultimately recovered; but, as in cases recorded by Schliep, Sellerbeck, Ma- homed, and S. Mackenzie, deception may have been practised by the patient making friction upon the bulb of the thermomter, or in other ways. Dr. Donkin has col- lected eight cases of various kinds in which recovery followed, though the tempera- ture ranged from 108° to 117° Fahr. In a case of spinal concussion under Dr. Lit- tle's care, in the Adelaide Hospital, Dublin, the temperature is said to have risen to 133.6° Fahr., without evil result to the patient. 2 Temperatures of 82° Fahr., 81.75° Fahr., and 80.6° Fahr., were observed in fatal cases reported by Van der Kolk, Wagstaffe, and Nieden. Kosiirew has recorded a fatal case of cranial injury, in which the temperature ranged from 79.7° Fahr. to 84.2° Fahr. CONCUSSION OF THE SPINE. 335 flabby and atrophied; the skin assumes a sallow hue, and often desquamates in iiakes; the joints are often contracted and stiff. Partly from the lessened vitality of the tissues, but more particularly from the patient's insensitive- ness to pain and inability to change his position, gangrene and sloughing are apt to occur in parts that are exposed to pressure; large bed-sores are thus formed over the sacrum, hips, knees, or any part that touches the bed, and may slowly exhaust the patient's strength, or, more rarely, may give rise to pyaemia, and thus quickly induce a fatal result. Bed-sores are most frequently met Avith in cases of injury of the lower portion of the cord, sim- ply, I believe, because in these cases life is more often prolonged than Avhen the upper part of the spine is involved. Tetanus, contrary to what might a priori be expected, is rarely met Avith in cases of spinal injury; in a case at St. Thomas's Hospital, it occurred three weeks after a blow on the spine, the patient recovering; while in one of seven cases which occurred during our late war, the autopsy showed, in addition to the spinal lesion, a contusion of the anterior crural nerve. Teta- nus folloAved a punctured wround of the cord in a case observed by Tadlock, of Tennessee. Cerebral Complications.— Concussion of the Brain may complicate injuries of any portion of the spinal cord, resulting either from direct violence sim- ultaneously inflicted on the head, or from counterstroke. Delirium, Coma, and Insomnia, have each been occasionally noted in cases of spinal injury; the latter symptoms, however, I believe, only in instances in which the cer- vical region has been involved. Cerebral Meningitis, as observed by Ollivier, often complicates inflammation of the spinal membranes. Concussion of the Spine from Indirect Causes; Railway Spine.—Under these, or similar names, is described by Erichsen, and other English sur- geons, a peculiar morbid condition characterized by very varied nervous symptoms, both physical and mental, which, according to these authors, are all directly traceable to the state of the spine. This subject has excited a great deal of interest, and a great deal of controversy, chiefly because of the numerous suits for damages, which have been brought against railway com- panies, on account of alleged injuries received in collisions. The symptoms appear to be rather those of general nervous prostration and debility, than the definite spinal symptoms which have been discussed in the preceding pages, and are often accompanied by remarkable perversions of the special senses, double vision, photophobia,1 tinnitus aurium, loss of tactile sensibility, etc. Many of the symptoms resemble those of ordinary progressive loco- motor ataxia. " The state of the spine," says Mr. Erichsen, " will be found to be the real cause of these symptoms. On examining it by pressure, by percussion, or by the application of the hot sponge, it will be found that it is painful, and that its sensibility is exalted at one, two, or three points. These are usually the upper cervical, the middle dorsal, and the lumbar regions. The exact vertebrae that are affected vary necessarily in different cases; but the exalted sensibility always includes tAvo, and usually three, at each of these points. It is in consequence of the pain that is occasioned by any movement of the trunk in the way of flexion or rotation, that the spine loses its natural suppleness, and that the vertebral column moves as a whole, as if cut out of one solid piece, instead of Avith its usual flexibility." Other Avriters of eminence are disposed to doubt the necessary connection of these symptoms Avith any particular morbid condition of the spine, looking upon " these cases of so-called raihvay spinal concussion as, generally, instances of Hypenemia of the optic disk has been observed by W. Bruce Clark. 336 INJURIES OF THE BACK. nervous shock, rather than of special injury to the spinal cord."1 There is, as far as I know, but one case in Avhich the post-mortem appearances after death from "raihvay concussion" have been recorded, and that is Mr. Gore's case, which has been successively published by Dr. J. Lockhart Clarke, Mr. Erichsen, Mr. Le Gros Clark, and Mr. Shaw. The condition of the cord in this case closely resembled, as pointed out by Le Gros Clark, that Avhich, according to Dr. Radcliffe, is found in ordinary cases of locomotor ataxia, so that there is at least room for suspecting, with Mr. ShaAv, that the spinal injury Avas a mere coincidence—particularly as Mr. Gore, the attending sur- geon, did not see the patient until a year after the injury. " On the Avliole, it may be affirmed," says Mr. ShaAv, "that Avhat is most wanted for the better understanding of those cases commonly known under the title of' concussion of the spine' is a greatly enlarged number of post-mortem examinations. Hitherto our experience has been derived almost wholly from litigated cases, deformed by contradictory statements and opinions; and the verdicts of juries have stood in the place of post-mortem reports." In view of the great obscurity which is thus seen to surround this subject, I think that the sur- geon Avill do Avisely to exercise great caution in declaring that a patient is suffering from " concussion of the spine from indirect causes," Avhether the result of railway, or of other injury; at the same time there can be no doubt that grave morbid changes in the spinal cord do result from comparatively slight blows upon the back, and, of course, in a railway collision, it is very possible that an injury might be received, Avhich would induce such changes. This fact has long been recognized in a general manner, but is clearly proved by a case wdiich Dr. H. Charlton Bastian has published in the fiftieth vol- ume of the Medico- Chirurgical Transactions, and which has been already referred to (see page 331). Injuries of the Vertebral Column. Sprains.—When we consider the number of joints in the vertebral column (nearly eighty), it is not surprising that twists and sprains in this part are occasionally met Avith, but rather that they are not more frequent than expe- rience shows them to be. The part of the spine most exposed to sprains is the lumbar region, next the cervical, and lastly the dorsal, which is rarely affected. Apart from the risk of concomitant lesion of the cord, these in- juries, though quite painful, are not commonly attended with danger. They may be caused by various forms of accident, as by falls or sudden twists, and are not unfrequently met Avith as the result of railway collisions. The symp- toms, provided that the cord be not involved, are those of sprains in other parts of the body, local tenderness, pain on motion, etc. In most instances the liga- mentous and other affected tissues gradually return to a healthy condition, but under other circumstances, if great stretching and laceration have occurred, permanent weakening of the part may ensue, requiring the constant employ- ment of artificial means of support. An occasional but more dangerous con- sequence is the extension of inflammation to the structures within the vertebral canal, fatal meningitis or myelitis thus sometimes supervening upon what at first was a simple sprain. In other instances, particularly in the case of the occipito-atloid and atlo-axoid articulations, the accident becomes the exciting cause for the development of chronic disease (white SAvelling) of the joint, an affection which in this situation may prove suddenly fatal, through the occur- rence of secondary dislocation. The treatment of \Tertebral sprains, unaccom- panied by cord lesion, is essentially that of sprains in other parts of the body. ' Le Gros Clark, Lectures on the Principles of Surgical Diagnosis, etc., p. 152. INJURIES OF THE VERTEBRAL COLUMN. 337 Rest, mechanical support, soothing applications at first, and at a later period stimulating embrocations, Avith friction, and perhaps the cold douche, will usually be found sufficient to effect a cure. It is often desirable to continue the use of mechanical means of support, such as a moulded gutta-percha splint, or leather belt, for some time after apparently complete recovery. The treatment of the cord complications, Avhen present, is the same as in other forms of spinal injury, and will be considered Avhen we have disposed of the remaining varieties of mechanical injury to the vertebral column. Fractures and Luxations of the Vertebral Column.—I shall consider these two forms of spinal injury together, because, in the first place, they are very commonly associated in the same case, and because, secondly, it is often quite impossible to determine whether a given injury of the spine be a fracture or a dislocation, until a post-mortem examination reveals the exact nature of the lesion. The possibility of luxation occurring in the vertebral column has been denied by many surgeons, and Sir Astley Cooper, with his large experience, declared that he had never met Avith a case of this nature; other writers, hoAvever, have considered them comparatively frequent, and Mr. Bryant says that of seventeen autopsies made at Guy's Hospital in cases of spinal injury, during six years, no less than six showed the lesion to have been pure dislocation. I have not myself met Avith any instance of abso- lutely uncomplicated spinal dislocation, but the elaborate tables which I have published in the monograph already referred to, show that 124 of 394 recorded cases of spinal injury were believed by the surgeons Avho reported them to have been of this nature. I cannot help suspecting, however, that in many, if not most, of these cases there Avas some slight bone lesion which escaped attention, so that perhaps the term diastasis Avould, in many instances, be more strictly applicable than dislocation. The large majority of reported cases of vertebral luxation have involved the cervical spine, the smallest proportion being found in the lumbar region. Causes.—The causes of these injuries of the vertebral column are very various: in most of the instances met with in civil practice, the alleged causes have been falls or blows, acting sometimes by direct, but probably more often by indirect violence. In the cervical region, these injuries have resulted from falls upon the head or the buttocks, from plunging headlong into shallow Avater, from falls in turning somersaults, from the head being twisted in executions by hanging, etc. It is popularly believed that hanging usually causes death by dislocating the cervical spine—breaking the neck, as it is called—but this is an error. Unless the head be after suspension Avrenched to one side (as, according to Louis, Avas formerly done by the Lyons hangman, Avho sat on the shoulders of his victims, and tAvisted their necks until he heard a crack), dislocation does not commonly occur. Fractures and luxations of the vertebrae are, as might be expected, more frequent among men than women, in the proportion of nearly seven to one. No age is entirely exempt from these injuries, though most cases occur among those in early adult life. Maschka has recorded a case of dislocated axis, in a child killed by its mother, when it was only eight days old, Avhile Arnott saAV a fracture of the same bone, produced by falling doAvn stairs, in a man aged seventy- four. Symptoms.—The rational symptoms of vertebral fracture and dislocation are due to the accompanying lesions of the spinal cord, and are those which have already been described as common to all forms of spinal injury. The physical signs, or those Avhich are peculiar to the mechanical disturbance of the vertebral column, are deformity, increased or diminished mobility, and crepitus. Local pain and tenderness on pressure, though often present in these 22 338 INJURIES OF THE BACK. cases, are in no Avise distinctive, for they are frequently more strongly marked in sprains than in these more serious injuries. (1.) Deformity is usually more perceptible in the dorsal or lumbar, than in the cervical region. A depression in the position of one or more spinous processes may be generally taken to indicate fracture, Avhich may involve the vertebral arches, or merely the spinous processes themselves. Fracture of the body of a vertebra, by alloAving the approximation of the vertebrae above and below, usually causes angular deformity marked by undue promi- nence of the spinous process of the affected vertebra, or of that next above. Rotatory deformity, or tAvisting of the spinal column upon its long axis, may be considered indicative of luxation, which may or may not be accompanied by fracture: it is seldom recognized, I believe, during life, except in the cer- vical region. Bilateral dislocation, an in- Fig. 169. jury almost exclusively confined to the neck, Avould be marked by angular de- formity, and, if in a backward direction, probably could not in most cases be dis- tinguished from fracture of the vertebral body. Though deformity, when present, is probably the most significant of all the physical signs of these varieties of injury, its absence by no means proves that fracture or luxation has not occurred. Indeed, my tables of spinal injuries show that deformity has only been noted in about one-fourth of the whole number of cases, and it is easy to understand, in view of the deep-seated position of the vertebral column, that fatal displacement might occur, which yet might not be revealed except by careful post- mortem dissection. (2.) Undue Mobitity has been occasion- ally observed in cases of vertebral injury, chiefly in the cervical region, and, on the other hand, Immobility has been noted in about the same number of instances. I do not know that either of these symptoms Bilateral forward dislocation of the fifth can be relied upon to distinguish the injury, cervical vertebra. (Ayres.) in any given case, from simple sprain of the vertebral column, and the surgeon should exercise great caution in his tactile investigations upon this point, as very slight force, or even an unwary movement, might induce displacement, which in the cervical region might probably cause instant death. (3.) Crepitus, if present, would of course warrant the diagnosis of fracture, though it could no't indicate in what part of the vertebra the lesion existed. Statistics show, however, that crepitus has been observed in about tAvo per cent, only of recorded cases. Diagnosis.—From what has been said, it Avill be perceived that, as already observed, the differential diagnosis of spinal injuries is always difficult, and often impossible. This is, however, fortunately a matter of no practical moment, for, as we shall presently see, the treatment is essentially the same, whatever may be in any case the exact nature of the injury. Prognosis.—The prognosis of fracture or luxation of the vertebrae, Avhile always grave, is not by any means so gloomy as is ordinarily represented. Sir Astley Cooper, and more lately Prof. Brown-Sequard, have surmised that INJURIES OF THE VERTEBRAL COLUMN. 339 Fig. 170. the proportion of recoveries in these cases is less than one per cent., while Mr. Erichsen goes so far as to declare that "fractures of the spine through the bodies of the vertebrae, Avith displacement, are inevitably fatal." The opinion of these authors is not, however, borne out by the results of statistical investigation, which shoAV that the mortality of terminated cases met with in civil practice varies from 78 per cent, in injuries of the cervical region to so Ioav a figure as 61 per cent, in those of the lumbar spine, the corresponding proportions of recoveries being 18 per cent, in the former, and 27 per cent. in the latter region. The chances of a fatal issue in these cases vary inversely Avith the distance of the point of injury from the brain. Lesions above the third cervical vertebra prove usually immediately, or very quickly, fatal, though instances of long survival, or even of complete recovery, after fractures of the atlas or axis, have been recorded by Phillips, the elder Cline, Willard Parker, W. Bayard, Stephen Smith, C. S. May, and several other surgeons. The prognosis in cases of gunshot injury of the vertebrae is, also, less un- favorable than has been commonly supposed. Many such cases no doubt prove fatal upon the field of battle, but of 642 tabulated by Dr. Otis, as having been treated during our late war, only 349 terminated in death, while 279 ended in more or less perfect recovery. Duration of Life in Fatal Cases.— With regard to this point, it may be said, in general terms, that of cases of fatal injury in the cervical region, two- thirds die during the first week ; in the dorsal region, two-thirds during the first month ; and in the lumbar region, about the same proportion during the first year. Condition after Recovery.—Bony union is, according to Rokitansky, rarely met with after fracture of the vertebrae, though instances of its occurrence have been recorded by Cloquet, Aston Key, and others. The accompanying cuts (Figs. 170,171,172), from photographs given me by Dr. Richard A. Cleemann, of this city, illustrate very beautifully the occurrence of osseous union after spinal fracture. The specimen, which Avas derived from the body of a patient whom I saAV in consultation with Dr. Cleemann, is one of very great interest, shoAving, in addition to a fracture of the lumbar vertebrae, unilateral dislo- cation, Avhich is a rare lesion in this region of the spine. The case illustrates the difficulty of diagnosis in these injuries, for careful examination during life revealed merely prominence of one vertebral spine, with a corresponding depression below it—thus indicating fracture of a vertebral body, but giving no reason to suspect the existence of luxation. With regard to the general condition of patients, after recovery from in- juries of the vertebral column, the prognosis will, of course, depend chiefly upon the nature and extent of the lesion to the spinal cord. If any portion of the cord be completely divided or disorganized, the parts of the body which derive their nervous supply from below the seat of the injury will Bony union of fractured vertebrae. 340 INJURIES OF THE BACK. necessarily be permanently paralyzed. Prof. Eve has collected seven cases, in which the cord was found by post-mortem inspection to be for a greater or less space entirely deficient, and in Avhich life Avas yet prolonged for periods varying from a few days to tAventy-two years ;* and the only instance of these in which paralysis was not constant from the time of the injury, Avas Mr. Shaw's case, in Avhich the cord appears at first to have been comparatively slightly injured, its want of continuity, as found at the autopsy, having been due to subsequent disorganization, which produced a return of paraplegia before death. The only case with which I am acquainted, in Avhich complete recovery is supposed to have followed complete division of the cord, is one reported by Dr. Eli Hurd, of NeAV York, in which, however, the diagnosis was not confirmed by post-mortem inspection. When the injury to the cord is less severe, the prognosis is of course more Fig. 171. Fig. 172. Fracture of vertebral body, and unilateral dislocation of a lumbar vertebra. favorable. The proportion of recoveries, with restoration to a useful and comparatively active life, is, for injuries of the dorsal and lumbar regions, about 23 per cent, of terminated cases, but in injuries of the cervical region, if instances of partial luxation be excluded, the proportion is much less. Treatment of Spinal Injuries. The treatment of injuries of the spine involves attention to the state of both the vertebral column and the spinal cord. Treatment as regards Vertebral Column.—If in any case there be evi- dent vertebral displacement, or marked deformity, with paralysis, so that the surgeon has reason to believe that he has to deal Avith a spinal luxation, whether complicated or not with fracture, he should at once proceed to attempt reduction by means of extension and counter-extension, aided by cautious manipulation, rotation, and pressure. I am aAvare that this advice 1 Am. Journ. of Med. Sciences, July, 1868, pp. 103-112. TREATMENT OF SPINAL INJURIES. 341 will be looked upon by many as injudicious; but statistical investigation shoAvs that while there is but one case recorded (Petit-Radel's), in Avhich efforts at reduction Avere the cause of death, there are many perfectly authen- tic instances, in Avhich such efforts have been folloAved by the most gratify- ing success ; and Ave should no more be deterred from attempting reduction, by the fatal result in one case of vertebral luxation, than we are from at- tempting to reduce dislocations of the shoulder or hip, by the fact that death has occasionally folloAved such attempts, in the hands of the most skilful surgeons. The mortality after spinal dislocation has been about four times as great Avhen reduction has not been attempted, as Avhen this treatment has been employed. If manual extension and counter-extension should fail to remove the de- formity, in a case of injured spine, it would, I think, be right to apply per- manent extension (to both legs), by means of the ordinary weight apparatus; the surgeon should, hoAvever, in such a case take great care, lest, from the pressure of the adhesive plaster or bandages, excoriations or sloughing should occur, and seriously complicate the patient's condition. I have not had oc- casion to employ splints in cases of fractured spine, but have adopted, Avith advantage, Hodgen's suggestion to give support by means of a plaster-of- Paris jacket, a mode of treatment Avhich has also been adopted by Konig, of Gottingen, and by Coskery, of Baltimore. Treatment as regards Spinal Cord.—In every case of spinal injury, the patient should be placed in bed, and kept at complete rest, both physical and physiological: a Avater-bed, if it can be obtained, or down pillows, will be found of great use in preventing the formation of bed-sores. If the vertebral column itself be not affected, the prone position, as advised by Erichsen, Avill probably be found the best, as facilitating the application of local remedies to the spine. In cases of fracture, however, the supine posi- tion is preferable, and the patient should not be incautiously turned upon his side, lest sudden displacement should occur, which might prove fatal. The patient should be kept scrupulously clean, and parts exposed to pressure should be frequently bathed Avith astringent or slightly stimulating washes. The bowels should be emptied from time to time by the use of enemata. It is usually recommended to draAV off the urine at stated intervals, by means of a flexible catheter, and such has always been my own practice. It has, hoAvever, recently been recommended by Mr. Hutchinson, to dispense with the catheter, except in the rare cases of spinal injury in Avhich retention is painful, alloAving the bladder to become distended, and then trusting to the mechanical overfloAv to prevent injurious consequences. Fatal ulceration of the bladder has undoubtedly been occasionally traced to the use of the cathe- ter, which in any case must aggravate the cystitis produced by distension and the ammoniacal state of the urine; and hence, though not prepared to go quite as far as Mr. Hutchinson. I would urge the importance of great gentleness in catheterization, which should only be done Avith a, flexible in- strument, used without the stillette. If bed-sores form, they should be carefully and frequently dressed, with as little disturbance as possible to the patient. The alternate application of ice and hot poultices, has been highly recommended by Prof. Brown- Sequard. Topical remedies are not of much value in the early stages of spinal in- juries, though, if there were much tenderness and local pain, ice-bags might perhaps be used Avith advantage; at a later period, various forms of counter- irritation may be employed, Avith a vieAV to a derivative action on the spinal cord and membranes. 342 INJURIES OF THE BACK. Constitutional Treatment.—The general treatment during the early stages, should be such only as is indicated by the constitutional condition of the patient. Opium may be given at any period, to relieve pain or nervous irri- tation. Dr. McDonnell highly recommends the administration of bella- donna as a sedative to the spinal cord, and advises that it should be com- bined with opium, whenever the latter remedy is prescribed in these cases. On the onset of inflammatory symptoms, small doses of calomel, or of the cor- rosive chloride of mercury, may be employed, or the iodide or bromide of potassium. Ergot has proved useful, in the hands of Prof. Hammond, in cases of myelitis folloAving spinal injury. After the subsidence of inflam- mation, strychnia has often proved of the greatest benefit; at the same time, electricity, systematically applied to the paralyzed parts, with friction, and cold or warm douches to the spine, may often be serviceable. Tonics, es- pecially iron, quinia, and cod-liver oil, Avhich may be required at an early period, are peculiarly indicated in the latter stages of spinal injuries. The diet throughout should be nutritious but unirritating, Avith or without stimu- lus according to the circumstances of each individual case. Trephining or Resection in Injuries of the Spine.—This operation has been suggested and described by surgical Avriters for a very long period, its history reaching back, indeed, to the days of Paulus iEgineta. The first surgeon, however, who actually practised the operation on the living sub- ject, was the elder Cline,1 in the early part of the present century, and his example has been followed by other surgeons from time to time, the Avhole number of cases noAv on record amounting to over forty. The object, of course, is to remove the vertebral arches at the seat of injury, and thus, if possible, relieve the cord from pressure, which is supposed by the advocates of the operation to be the cause of paralysis in these cases. But, as a matter of fact, post-mortem inspection has shown that compression exists in but a small number—less than one-third—of fatal cases, and that even in these instances the cord is usually so much lacerated or disorganized as to preclude any benefit from operative interference ; moreover, compression, when it does exist, is almost always due to the pressure exercised by the body of the ver- tebra, so that all that resection could possibly do would be, as Dr. McDon- nell, has phrased it, to take aAvay the '• counter-pressure." The operation is by no means an easy one,2 and is in itself attended with no small danger to the patient; beside the inevitable risks which must folloAV the conversion of the injury into a compound fracture, the exposure of the delicate structures within the vertebral canal, and the permanent loss of firm- ness and strength in the spinal column, consequent on the removal of one or more of the vertebral arches, the operation entails immediate peril upon the patient, death having occurred in one case (Willett's) before the operation could be completed. Finally, the statistics of the operation show beyond question that, far from increasing, it positively diminishes the chances of re- covery. The following table embraces a record of 41 cases, being, as far as I can ascertain, all in which the operation of spinal resection for fracture3 has been hitherto performed. 1 Louis's operation, in 1762, often referred to as an instance of spinal resection, con- sisted merely in the removal of detached fragments in a case of gunshot injury; a perfectly legitimate and conservative procedure, which was resorted to twenty-four times during our late war, with fourteen recoveries. 2"I am satisfied," says Prof. Eve, "that this operation, in the dorsal vertebrae, if not almost impracticable, is certainly one of the most difficult in surgery " (Am. Journ. Med. Sciences, July, 1868, p. 106). 3 Kesection of the spine for disease has been performed by various surgeons, includ- RESECTION IN INJURIES OF THE SPINE. 343 Cases of Resection of the Spine. No. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Result. Operator's name. Reference. Died. Relieved. Died. Died. Not improved, Died. Relieved. Died. Died. Not improved. Died. Relieved. Died. Cline, Sr. Wickham. Oldknow. Tyrrell. Id. Barton. Boyer. D. L. Rogers. Attenburrow. Laugier. Holscher. A.G.Smith. Mayer. South. Blackman Edwards. Blair. Goldsmith. Stephen Smith. Hutchison. G. M. Jones. H. A. Potter Id. Id. R. McDonnell Sam'1 Gordon. Tillaux. Willett. H. J. Tyrrell. Maunder. Eve. Cheever. Id 41 | Not improved. Nunneley. Id. Id. Id. AVillard. Stemen. Lucke. Chelius's Surgery; ed. by South, i. 590. Lancet, 1827. Hutchison, in Am. Med. Times, 1861. Malgaigne, Fractures et Luxations, i. 425. Ibid. Malgaigne (Packard's translation), p. 343. Heyfelder, Traite des Resections (trad, par Boeckel), p. 244. Am. Journ. of Med. Sciences, o. s., vol. xvi. Chelius and Heyfelder, op. cit. Malgaigne, op. cit. Brown-Sequard, Central Nervous System, p. 256. N. A. Med. and Surg. Journ., vol. viii, p. 94. Heyfelder, op. cit. Notes to Chelius, vol. i., p. 591, etc. Hutchison, loc. cit. Brit, and For. Med. Review, 1838. Ballingall, apud Hutchison, loc. cit. Gross's Surgery, 2d edit., vol. i. Hutchison, loc. cit. Ibid. Brown-Sequard, op. cit., p. 255. Hurd, N. Y. Journ. of Med., 1845. Am. Journ. of Med. Sciences, n. s., vol. xlv. Ibid. Ibid., vol. 1. Med.-Chir. Trans., vol. xlix., p. 21. Brit, and For. Med.-Chir. Review, 1866. Med. Times and Gazette, Feb. 2, 1867, and St. Barth. Hosp. Rep., vol. ii., p. 242. Dub. Quart. Journ. of Med. Sci., Aug., 1866. Med. Times and Gazette, Feb. .23, 1867. Am. Journ. of Med. Sciences, n. s., vol. lvi. Boston City Hosp. Reports, 1870, p. 577. Ibid., p. 580. St. Bartholomew's Hosp. Reports, vol. vi. Med. Times and Gazette, Aug. 7, 1869. Ibid. Ibid. Ibid. Am. Journ. of Med. Sciences, n. s., vol. lxiii. Clark, Clinic, June 5, apud Monthly Abstract of Med. Science, August, 1875. Revue des Sciences Medicales, Avril, 1880. In 36 of the above 41 cases the result is known: 30 patients died; 3 were relieved, and 3 received no benefit from the operation. The most successful cases Avhich the advocates of spinal resection have yet been able to produce, are those of Dr. Gordon and of Mr. Nunneley; in the first, more than a year after the operation, the patient Avas " unable to stand or Avalk," Avhile in the second, the patient, during the two and a half years which he survived, Avas, though strong in the arms, " weak and partially paralyzed ing Heine, Roux, Holscher, Dupuytren, and Jacobi, of New York. Dr. Blackman is reported to have operated more than once, but I can find no record of his other cases. He excised a portion of the sacrum, upon one occasion, but without benefiting his patient. Dr. J. B. Walker, of Boston, excised a spinous process. 344 INJURIES OF THE FACE AND NECK. in the legs." Considering, therefore, the not infrequent favorable issue of these cases under expectant treatment, and in vieAV of the fact that the mor- tality after the operation has been over 83 per cent, of terminated cases, and that no well-authenticated instance of complete recovery after its employment, has yet been recorded; surely we are justified in declaring Avith Le Gros Clark, that we " cannot regard trephining the spine as brought within the pale of the justifiable operations in surgery." I would respectfully invite the reader, Avho is interested in the further in- vestigation of the subject, to consult the elaborate statistical tables, embraced in my monograph on Injuries of the Spine, already referred to. If the operation of spinal resection is to be done at all, it can, probably, be best accomplished, as recommended by Dr. McDonnell, by making a free and deep incision, and then dividing the bony lamina?, on either side of the spin- ous process of the injured vertebra, with strong cutting forceps bent at an angle—an instrument w7hich would prove more serviceable, in this position, than either a trephine, or a Hey's saAV ; a single arch having been removed, any additional portions of bone may be readily taken away Avith the ordinary gouge forceps.1 Dr. McDonnell recommends very highly the internal ad- ministration of belladonna, or atropia, during the after-treatment of these cases, in order to prevent the development of inflammation of the membranes or spinal cord. CHAPTER XVII. INJURIES OF THE FACE AND NECK. Injuries of the Face. Wounds of the Face present no peculiarities requiring different treat- ment from that of similar injuries in other parts. The tissues of the face are so vascular, that primary union is usually attainable, at least in the case of incised wounds. As it is desirable to avoid any disfigurement, in a part which is constantly exposed to observation, I think it best to dispense with sutures, in the treatment of superficial Avounds of the face, approximating the parts as accurately as possible by means of the gauze and collodion dressing. In certain localities, hoAvever, as in the eyelids or eyebrows, nose, ears, and lips, the employment of sutures is usually indispensable: in penetrating Avounds of the cheeks, also, stitches, embracing almost the entire thickness of the parts, should be applied. Harelip pins, which may always be used with advantage in wounds of the lips, may be employed in any of these cases to control arterial bleeding, the pin being passed under the vessel, which is then compressed above it by means of the twisted suture. No matter how much contused and lacerated any part of the skin of the face may be, it should not be removed, but should be replaced, after having been carefully cleansed, in hope that reunion may occur. The deformity Avhich sometimes results from such an injury, may often be remedied by a plastic operation— which may also be required in cases of deformity from burn, in Avhich me- chanical extension has failed to procure relief (see p. 307). 1 See Dr. McDonnell's paper in the Dublin Quarterly Journal of Medical Sciences, for August, 1866, pp. 31-33. INJURIES OF THE ORBIT AND EYEBALL. 345 Orbit and Eyeball.—Injuries of the Orbit may prove fatal through im- plication of the brain, either primarily, or, at a later period, by the exten- sion of inflammation. Pointed instruments, such as a sword, a stick, or the end of an umbrella, may be thrust through the orbital plate of the frontal bone directly into the brain. In a case recorded by Dr. Wm. Pepper, a knife Avas thrust through the sphenoidal fissure, wounding a large meningeal vein, and causing death from intra-cranial hemorrhage. In other instances, again, Avounds of the orbit have been folloAved by the formation of arterio- venous aneurisms, as in a case of Nelaton's, in which the point of an umbrella Avounded the cavernous sinus and internal carotid artery of the opposite side— death ultimately resulting from the bursting of the aneurismal tumor. Deep- seated suppuration may occur as the result of orbital injury, the abscess point- ing in either eyelid, or proving fatal by extending backAvards to the brain. Fig. 173. Oblique illumination. (Wells.) Wounds of the orbit may cause blindness, without directly involving the eye- balls, either by injury to the optic nerves, or, possibly, by inducing a reflex condition, depending upon lesion of other neighboring nerves, as of branches of the fifth pair.1 In a case reported by Dr. Packard, immediate and total blindness folloAved a gunshot wound of both orbits, the patient surviving the injury for four years and a half, and eventually dying from other causes. Foreign Bodies lodging on the eye may be embedded in the cornea, or may be concealed betAveen the ball and either eyelid. From the cornea, the offend- ing particle may be removed without much difficulty, simply by picking or Fig. 174. gently prying it off with an ordinary cataract needle; if, in doing this, the cornea be superficially abraded, it is Avell, before dismissing the patient, to apply a drop of castor oil, Avhich will effectually protect the surface until the slight breach of continuity has been repaired. A foreign body on the cor- nea can usually be readily detected by carefully examining the part in a bright light; in any case of doubt, hoAvever, oblique illumination should be employed (Fig. 173), a second con- vex lens being used, if necessary, as a magnifier. The conjunctival fold of the loAver eyelid may be explored by simply draAving doAvn the lid, and directing the patient to look upAvards; to explore the fold of the upper lid 1 The possibility of such an occurrence is doubted by Holmes Coote, and other sur- geons, who attribute the amaurosis in these cases to a "concussion of the retina," rather than to the effect of sympathy. Eversion of upper lid for detection of foreign bodies. (Erichsen.) 346 INJURIES OF THE FACE AND NECK. it is necessary to evert tbe eyelid, which may be done either with the forefinger and thumb (Fig. 174), or Avith a probe, or the end of a pencil or quill, laid transversely across the lid. This little operation, Avhich is more difficult than it appears, is done by firmly but lightly seizing the edge of the lid betAveen the thumb and forefinger (the patient looking dowmvards, and the lid being drawn well down, and slightly away from the ball), and then by a quick movement turning up the edge of the lid over the point of the finger, which is simultaneously depressed. If the probe be employed, the central eyelashes, or the edge of the lid, must be taken betAveen the thumb and finger of one hand, while the probe is manipulated with the other. The eyelid being everted, its edge is pressed against the edge of the orbit, when almost the whole conjunctival fold comes into view. The foreign body may then be removed with delicate forceps, the smooth end of a probe, or a moistened camel's-hair brush; it is sometimes possible to feel the foreign body Avith the tip of the finger, Avhen, from its transparency, it cannot be seen. In some cases, in which the offending object has eluded both touch and vision, I have succeeded in dislodging it by sweeping out the fold of the eyelid Avith a camel's- hair brush; and in one instance, after I had failed to detect the foreign body by everting the lid, I succeeded by placing the patient in a bright light, with his head throAvn very far backAvards, when, by simply draAving the lid away from the ball, I was enabled to see almost up to the sulcus. Contusion of the Eyeball may cause temporary blindness by inducing a condition of the retina analogous to concussion of the brain; in other cases, the loss of sight may be permanent, from detachment of the retina, hemor- rhage, or inflammatory changes. The ordinary "black eye" of pugilists consists in an extravasation of blood beneath the conjunctiva, and into the loose areolar tissue of the eyelids. In this situation absorption is often very slow, the subconjunctival stain sometimes persisting for several Aveeks; the best application is cold water, or a mild alcoholic lotion. Contusion of the eyeball is sometimes accompanied by rupture of the cornea or sclerotic, allowing the escape of the humerus of the eye, and causing permanent loss of vision; in other cases the rupture may be internal, extravasation occurring, and filling the anterior chamber of the eye with blood, the iris being some- times torn from its ciliary attachment, or the lens dislocated from its position. The treatment consists in the frequent instillation of a solution of atropia, gr. ij-iv to f 3jj, and in the administration of calomel and opium, while the patient is kept in bed, in a darkened room, and upon milk diet. After the absorption of the effused blood, which is usually soon effected, vision may be restored, though it is often rendered imperfect by bands of lymph crossing the anterior chamber and the pupil. A dislocated lens usually becomes cataractous, and often causes intense pain and frequent attacks of iritis, by pressing upon the ciliary bodies and iris; in either case, extraction should be promptly resorted to. From the anterior chamber, the lens may be removed by simple corneal section, and from the posterior chamber, by a similar operation, a preliminary iridectomy having been first performed. If suppurative disorganization of an eyeball occur, excision may be necessary to prevent the other eye from becoming sympathetically involved. Non-penetrating Wounds of the Eyeball are not usually of a serious nature. The treatment consists in the removal of foreign bodies, followed by the ap- plication of a drop or two of castor oil, Avith the use of cold compresses if the injury be attended Avith much pain. Penetrating Wounds are attended Avith much greater risk, the chief dangers being from prolapse of the iris, escape of vitreous humor, and, at a later period, from inflammation. If the iris protrude, an effort should be made to replace it by means of a fine probe; if this be impossible, the projecting portion should be snipped off Avith curved INJURIES OF THE NOSE AND EAR. 347 scissors, and if a staphyloma be subsequently formed, an iridectomy should be done opposite the most transparent part of the cornea; this operation is, according to Soelberg Wells, much preferable to the old mode of treatment, bv the repeated application of nitrate of silver. Incised wounds of the scle- rotic, if not very large, may be brought together Avith one or tAvo fine sutures, any protruding portion of iris or vitreous humor being first cut aAvay. In cases of extensive Avound, Avith escape of a large portion of the contents of the eye, excision should, as a rule, be immediately performed, especially in pa- tients of the poorer class, to whom the time required for treatment is a matter of importance. If an attempt be made to save the ball, cold compresses should be applied, atropia being very freely used, and calomel and opium administered internally. It may be necessary at a later stage to make an artificial pupil, to extract the lens (if this have become the seat of traumatic cataract), or to perform excision, if vision be lost and suppurative disorgani- zation of the eyeball have occurred, particularly if sympathetic implication of the other eye be threatened. The lodgment of a foreign body in the deeper parts of the eye usually requires excision of the globe, though it may occasionally be possible to remove the offending substance Avhile pre- serving useful vision. Dr. McKeoAvn, of Ulster, has recorded several cases in Avhich fragments of steel were removed by the aid of a pointed magnet in- troduced through the wound, and recommends the use of a large magnet, moved about externally to the eye, as a means of diagnosis. Magnets have also been successfully employed in cases recorded by McHardy, Hirsch- berg, Hnell, Appleyard, GalezoAvski, Oppenheimer, Chven, Reid, and Jeffries. A convenient instrument for the purpose has been devised by Gruening, of NeAV York. Nose.—Foreign bodies, such as beads, peas, bits of sponge, etc., are often introduced by children into the nostrils, where they occasionally become firmly fixed, and, if allowed to remain, cause a troublesome form of ozsena. The foreign body may usually be removed without much difficulty, by means of delicate forceps, a bent probe, or a small scoop (such as is often placed at one end of a grooved director), or by means of Thudichum's douche, the current being of course directed through the opposite nostril. Politzer's air- bag is used for the same purpose by J. 0. Tansley, of New York. Ear.—Foreign bodies may be removed from the external ear with for- ceps, scoop, wire loop (as advised by Hutchinson), or, which is certainly the safest means, by long-continued, and, if necessary, repeated syringing Avith tepid Avater, the pinna being drawn upwards, or, in the case of very young infants, dowmvards, so as to straighten the auditory canal. Prof. Gross uses a steel instrument, spoon-shaped at one end, and provided at the other Avith a delicate tooth, placed at a right angle. This instrument is doubtless very efficient and safe in skilful hands, but the general practitioner will, I think, do Avisely to be satisfied Avith simple syringing, Avhich is indeed, according to Dr. Roosa, and to Gruber, of Vienna, much preferable to any other means of treatment. An ordinary hard rubber syringe of the capacity of three or four ounces may be used, the returning water being received in a bowl held be- neath the ear. When there is much inflammation, Gruber advises that at- tempts at removal should be postponed until the subsidence of acute symp- toms, Avhen the auditory passage may be dilated Avith sponge tents, and shrinking of the foreign body promoted by the use of astringent solutions. (iiiersant prefers to ordinary syringing, irrigation, Avhich may be conve- niently effected Avith a Thudichum's douche, or by means of the double hand- ball syringe used for the administration of enemata. Should syringing fail, 348 INJURIES OF THE FACE AND NECK. or should a perforation of the membrana tympani render its employment unadvisable, Lowenberg's agglutinative method may be properly tried; this, which is a revival of the plan long since taught by Paulus iEgineta, con- sists in the introduction of a delicate pencil, tipped with glue or plaster of Paris, Avhich is allowed to remain in contact Avith the foreign body until adhesion takes place, when both may be withdraAvn together. Cheek.—Wounds of the cheek occasionally result in the formation of troublesome fistula?. If small, a cure may be effected by pressure and the application of nitrate of silver, a red hot wire, or the electric cautery; if larger, the edges of the fistula should be pared, and closely approximated with sutures and a compress. If the wound involve the parotid duct, its opening into the mouth may be obliterated, and a true Salivary Fistula re- sult. The treatment consists in establishing an artificial inner opening by H. Morris's plan of introducing a fine catgut or whalebone bougie from the mouth into the affected duct; by forming a seton, by means of a small trocar and canula passed in the natural direction of the duct, the external opening being subsequently closed; by turning the fistulous orifice, with or without the surrounding integument, into the mouth, as practised by Van Buren, Langenbeck, J. R. Wood, and E. Mason; or by the ingenious operation of the late Prof. Horner, which consists in cutting out the diseased tissues with a large and sharp saddler's punch, pressed firmly against a wooden spatula previously introduced into the mouth, the external wound being then immediately closed with the twisted suture. J. Allan reports tAvo cures by the application of belladonna and glycerine over the parotid gland, so as to arrest the secretion, and thus permit the healing of the wound. Mouth.—Wounds of the Lips should be treated by the application of harelip pins, with additional points of the interrupted suture, special care being taken to secure accurate adjustment of the prolabium. Additional firmness may be afforded by the use of broad adhesive strips, passing from side to side, or of Hainsby's cheek compressor, as after the operation for harelip. Wounds of the Tongue do not require sutures, unlesss a considera- ble portion of the organ be nearly detached. Hemorrhage may require the application of ligatures, or of the hot iron. Wounds of the Soft Palate, unless very small, require stitches, which may be applied as after the opera- tion of staphyloraphy. Foreigh bodies, such as pistol-balls, teeth, or pieces of tobacco-pipe, may be lodged deeply in the tongue or pharynx, giving rise in the latter situation to suppuration, and sometimes to fatal secondary hemorrhage. Injuries of the Neck. Wounds.—These injuries, which are usually of the character of Incised Wounds, are most commonly inflicted in attempts to commit suicide. It is occasionally a matter of some importance, in a medico-legal point of view, to be able to determine whether a given wound of the neck has been self-in- flicted, or received at the hands of another; it is, of course, impossible to arrive at absolute certainty upon this point, but it may be said, in general terms, that suicidal wounds commonly begin on the left side of the neck (the person being right-handed), and pass transversely or obliquely down- wards across the part, the extent of the wound on the right, being usually less than that on the left, side. They rarely penetrate so deeply as to divide the great vessels; hence the prima facie probability Avith regard to a very deep wound, " penetrating as by a stab perpendicularly towards the spine," and perhaps involving the vertebral column, Avould be that it was not self- INJURIES OF THE NECK. 349 inflicted.1 Wounds of the neck may be divided into—1. Non-Pen etrcding Wounds, which do not involve the air-passage or oesophagus; and 2, Penetrating Wounds, which do involve one or both of those important organs. 1. Non-Penetrating Wounds.—The danger of non-penetrating wounds of the neck, is chiefly from hemorrhage, which is often very profuse ; if the carotid artery or internal jugular vein be wounded, death may be almost in- stantaneous, and even bleeding from comparatively small vessels may prove fatal in the depressed state, both physical and mental, which is usually present in patients who have attempted suicide. Another danger is from the entrance of air into the large veins in this region, Avhich may cause sudden death, or, as in a case recorded by Le Gros Clark, may prove fatal at a later period, by the air becoming gradually mixed with the blood, and thus interfering with the heart's action. The pneumogastric or phrenic nerve may also be Avounded in these cases, and either event would of itself almost certainly cause the death of the patient. The treatment of non-penetrating wounds of the neck, consists in arresting hemorrhage, and in approximating the edges of the cut, in such a way as to favor union. Every bleeding vessel, Avhether artery or vein, should be secured by ligatures abo\re and below the opening in its coats, or to either extremity if it be completely divided. In cases of arterial bleed- ing, in which the precise source of hemorrhage cannot be detected, the sur- geon should not hesitate, if necessary, to ligate the common carotid, an operation which, according to Pilz, has been done, in cases of punctured and incised wounds, in 44 instances Avith 20 recoveries, and, according to Cripps, in 51 instances Avith 23 recoveries (to which may be added a successful case in my own hands), the total number of cases in Avhich the carotid has been tied for hemorrhage being, according to the first-named author, 228, with !)4 recoveries. Whenever it is practicable, however, an effort should be made to substitute ligation of the external carotid, Avhich Cripps has shoAvn to be a much safer operation. Approximation of the lips of the wound is best effected by numerous points of the interrupted suture, the ligature threads being brought out at the angles of the wound, Avhere they serve to secure drainage. The sutures should embrace the skin and superficial fascia only, and the deeper parts of the wound should be approximated by means of broad strips of adhesive plaster, brought obliquely around the neck. The parts should be further relaxed by bending the head forwards, with the chin almost touching the sternum, and by securing it in this position, by means of a nightcap, or sling, Avhich should pass from the occiput to a circular band around the chest. Primary union, though always to be sought, is rarely attained in cases of cut-throat, the whole surface of the wound not unfre- quently sloughing, and eventually healing by granulation. 2. Penetrating Wounds of the neck may involve any portion of the air- tube, though the larynx is the part usually affected. The relative frequency of these Avounds, in different situations, may be seen from the folloAving table of 158 cases, collected by Mr. Durham:— Situation of wound. Number of cases. Above the hyoid bone.........11 Through the thyro-hyoid membrane......45 Through the thyroid cartilage ........ 35 Through the crico-thyroid membrane or cricoid cartilage . . 26 Into the trachea .......... 41 1 See upon this point a paper by Dr. Taylor, in Guy's Hosp. Reports, 3d s., vol. xiv., pp. 112-144. 350 INJURIES OF THE FACE AND NECK. The special dangers of penetrating wounds of the neck, apart from such as are common to these injuries and to those which are non-penetrating, are the occurrence of asphyxia, or more correctly apnoza, emphysema, dysphagia, and, at a later period, bronchitis and pneumonia. Difficulty of Breathing, ending, perhaps, in complete Suffocation or Apnoza, in Avounds of the throat, may depend upon several causes. It may result directly from the accumulation of blood, either liquid or clotted, in the air- passages ; from displacement of divided parts, as from a portion of the tongue, the epiglottis, or a fragment of cartilage, falling backwards and obstructing the rima glottidis; or, if the rings of the trachea be Avidely sepa- rated, from the external soft parts being sucked imvards, and producing val- vular occlusion of the air-tube. Again, suffocation may result from oedema of the glottis, from submucous emphysema, or from the pressure of an abscess. Emphysema is not usually a grave complication; it may, however, as already mentioned, produce suffocation, when seated beneath the laryngeal mucous membrane, or, according to Hilton, may prove directly fatal by pressure on the phrenic nerves. Dysphagia, sometimes amounting to complete inability to swallow-, is occa- sionally a source of great danger. Either from a wound of the oesophagus— or, Avithout this part being involved, from insensibility of the glottis—saliva, and even particles of food, may escape into the air-tube, and make their appearance at the external wound. Bronchitis and Pneumonia may arise from the irritation produced by the presence of blood, pus, or food, in the air-passages, from the admission through the wound of cold and dry air to the lungs, or possibly from the direct ex- tension of inflammation from the seat of injury. Among the occasional remote consequences of penetrating wounds of the throat may be mentioned alteration or loss of voice, and the formation of a traumatic stricture of the trachea or gullet, or of an aerial or oesophageal fistula. Treatment.—After the arrest of hemorrhage, as in cases of non-penetrating wound, the surgeon may apply a few sutures to either extremity of the incision, leaving, however, the central portion, as a general rule, to heal by granulation; an exception should be made in those cases in which the air- tube is completely cut across, when, to prevent Avide separation, it may be necessary to apply a stitch on either side, so as to hold the parts in apposition. The sutures, which in such a case should be of fine thread, may be passed through the superincumbent connective tissue, or even superficially through the cartilages themselves, one end being cut off, and the other brought like a ligature through the external wound. In other cases, from the persistence of venous oozing, or from the occurrence of dyspnoea on attempting to close the wound, it may be necessary to introduce, for a time at least, a tracheal tube, as after the operation of tracheotomy. If, at any time, apncea be threatened, the wound should be instantly reopened, and, if necessary, arti- ficial respiration resorted to. Tracheal or laryngeal stricture may, at a later period, require the performance of tracheotomy, followed by systematic dilatation or even external division, as in a case recorded by Trendelenburg, or by excision of portions of the tracheal rings, or cricoid cartilage, as prac- tised by H. Lee, of London, and by myself, in a case under my care at the University Hospital; aerial fistula may (provided the larynx be unob- structed) be closed by a plastic operation. INJURIES OF THE LARYNX AND TRACHEA. 351 Injuries of the Larynx and Trachea. A blow upon the larynx may prove fatal through shock, or by inducing spasm of the glottis; when the injury is less seA'ere, temporary insensibility only may result. The treatment, in slight cases, consists in the adoption of such measures as may prevent subsequent inflammation, but if breathing have stopped, laryngotomy should be performed, and artificial respiration at once resorted to. Fracture of the Larynx is an exceedingly dangerous accident, the mor- tality, according to Durham's statistics, being over 80 per cent. No age is exempt, though the injury usually occurs among young adults; five of fifteen cases analyzed by Hunt were in children, and only one in a person over forty-five years of age. The usual causes, apart from gunshot Avounds, are, according to the same writer* "falls against hard and projecting sub- stances, blows, kicks, and pressure." The symptoms are local pain and tender- ness ; swelling of the neck, with an alteration of its form, consisting either of flattening or of undue prominence; mobility of the cartilages, and occa- sionally crepitus. There are besides, often, dyspnoea and lividity of face, with the ordinary evidences of collapse, emphysema, and expectoration of bloody mucus; the_ latter symptoms are considered by Hunt particularly unfavorable, as indicating laceration of the laryngeal mucous membrane. The annexed table, from Durham, gives a summary of 62 recorded cases, 52 collected by Henoque, and 10 added by Durham himself. It will be ob- served that death folloAved in every case in which the cricoid cartilage1 was involved. Cartilages fractured. No. of cases. Deaths. Recoveries. Thyroid and os hyoides,........ Thyroid and cricoid,........ Thyroid, cricoid, and os hyoides,..... Thyroid, cricoid, and trachea,...... 24 11 4 9 2 2 2 1 7 18 11 2 9 2 2 2 1 3 0 2 Cricoid, trachea, and os hyoides,..... "Fractures of larynx,"........ "i Total,.......... 62 50 12 The treatment, in cases in Avhich the displacement is slight, and in which there is no dyspnoea, may consist simply in supporting the parts with com- presses and strips of adhesive plaster. If, hoAvever, the respiration be em- barrassed, and particularly if there be bloody expectoration, no time should be lost in resorting to tracheotomy, which, under such circumstances, affords almost the only chance of saving the patient. Eight of the tAvelve cases of recovery Avere saved by operation, Avhile in the remaining four, from the absence of haemoptysis and emphysema, there is reason to believe, as remarked by Hunt, that the fractures Avere in the median line, and did not involve * A remarkable case has been recently recorded by S Treulich, in which both thy- roid and cricoid cartilages were broken—the latter in two places—and the trachea ruptured by the bite of a horse; life was saved by tracheotomy. 352 INJURIES OF THE FACE AND NECK. the mucous membrane. After the operation, an attempt may be made to restore the displaced parts to their proper position by manipulation. Panas and Caterinopoulos recommend, instead of tracheotomy, a section of the thyroid cartilage, followed by the introduction of a large tube, so as to keep the fragments in position. Dr. E. Holden, of NeAvark, N. J., has recently recorded a remarkable case of dislocation of the inferior cornu of the thyroid cartilage. Luxation of the arytenoid cartilage has been observed in tAvo cases by Stoerk. Fracture or Rupture of the Trachea, without injury of the larynx, and without external Avound, is an extremely rare and usually fatal accident. Cases are reported by Lonsdale, Berger, Beck, J. L. Atlee, Jr., Robertson, Corley, Long, Drummond, and Wagner—those seen by the three last-men- tioned surgeons being the only instances of recovery. In Long's case, life was saved by tracheotomy, supplemented by removal of blood from the air- passages by suction, and by artificial respiration. A case Avas under my care a few years since, at the Episcopal Hospital, in which an injury of the neck was folloAved by emphysema and passage of fluids from the oesophagus into the trachea, thus rendering probable the existence of a slight rupture of this organ; life Avas maintained for several weeks by means of nutritive enemata, and the patient eventually recovered. Dr. Lang, a German sur- geon, has reported a remarkable case of intussusception of the trachea, Avhich proved fatal at the end of ten weeks. Burns and Scalds of the mouth, pharynx, and glottis are occasionally met with, especially among children, the most usual form of the injury resulting from an attempt to drink boiling water from the spout of a tea-kettle. It is probable that, in some cases, steam may reach the larynx itself, but in the majority of instances the air-passages become secondarily involved, by the extension of inflammation from the mouth and glottis. The dangers are those of submucous laryngitis and oedema glottidis, and the treatment consists in the application of leeches and ice to the throat, and in the administration of antimony, or of calomel and opium. Free mercurialization is considered by BeATan and Corley, of Dublin, to be the most important measure, and the latter surgeon reports a successful case in a child less than three years old, who in seventeen hours took tAventy-four grains of calomel, and had six drachms of mercurial ointment rubbed into his groins and axillse. The oedematous mucous membrane of the fauces and epiglottis may be scarified with a long needle, or with a curved bistoury, Avrapped almost to its point with a strip of sticking plaster, and, if suffocation appear imminent, trache- otomy must be performed, as a last resort, though its results under these circumstances are far from satisfactory, 23 out of 28 cases collected by Mr. Durham having ended in death. A similar injury may result from drinking corrosive liquids, such as the stronger mineral acids, or caustic alkalies. The treatment should be the same as in the case of scald of the glottis or larynx. Of three cases men- tioned by Durham, in Avhich tracheotomy was performed for such an injury, two died and one recovered. Foreign Bodies in the Air-Passages.—A great variety of substances have been met Avith as foreign bodies in the air-passages, the most common being, according to Prof. Gross, grains of corn, beans, melon-seeds, pebbles, and cherry-stones. Several such objects, sometimes of a dissimilar character, have been occasionally met Avith in the same case. In four instances leeches have been extracted from the larynx, by Marcacci, Trolard, Massei, and FOREIGN BODIES IN THE AIR-PASSAGES. 353 Clementi. Foreign bodies usually enter the air-passages through the glot- tis, being draAvn in, in the act of inspiration, or simply dropping in, as in the case of coins tossed in the air and caught in the mouth, or—as has prob- ably happened in some cases, in Avhich suffocation having occurred during sleep or intoxication, the air-passages have been found to contain partially digested food—the foreign body may be regurgitated from the stomach, and may then make its way through the glottis, the sensibility of Avhich is ob- tunded by the patient's condition. In other instances foreign bodies have entered the air-passages through accidental Avounds or ulcerations of the oesophagus, of the tissues of the neck, or of the Avails of the chest. Finally, in one case referred to by Prof. Gross, a lymphatic gland passed through an ulcer in one of the bronchi, and caused death by becoming impacted in the rima glottidis. Situation.—A foreign body may be arrested in any portion of the air- passages, or, more rarely, may be movable, changing its position from time to time. The parts in Avhich extraneous substances are most apt to become impacted are the larynx and one of the bronchi, usually the right. Symptoms.—The primary symptoms, or those of Obstruction, are similar to those of inflammatory or spasmodic croup, only, if possible, more violent. The patient feels a sense of impending death, and is, indeed, for the time, in most imminent danger. The face becomes livid, the eyes apparently start from their sockets, the patient gasps and utters piercing cries, foams at the mouth, is perhaps convulsed, or falls insensible. The first paroxysm passing off, the symptoms of Irritation become prominent. There is a short, croupy cough, with pain, especially referred to the top of the sternum, and mucous or bloody expectoration. Paroxysms of dyspnoea, with a sense of suffocation, recur from time to time, and are due to the dislodgment of the foreign body, and to its being impelled against the larynx by the act of coughing. Aus- cultation will reveal various signs, according to the position of the foreign body; if this be loose in any part of the tube, it may be heard moving up and down with a flapping sound, and occasionally striking the wall of the trachea; if fixed in the larynx, there will be a harsh, rough sound in respi- ration, coinciding Avith croupy cough and the other symptoms of obstruction; if impacted in a bronchus, or one of its subdivisions, the respiratory mur- mur Avill be usually deficient, or quite absent, in the corresponding portion of the lung, and probably puerile on the opposite side, percussion giving an equally clear sound in both localities. Occasionally peculiar rales are due to the nature of the foreign body, as in a case referred to by Gross, in Avhich an impacted plum-stone, perforated through its middle, gave rise to a strange Avhistling sound. Diagnosis.—The diagnosis, though often very obscure, may, in most in- stances, be made by careful inquiry into the history of the case, and investi- gation of its symptoms. From croup the diagnosis can be made, as pointed out by Prof. Gross, by observing that in that affection the dyspnoea is most marked in inspiration, Avhile expiration is most affected in obstruction from a foreign body. Aphonia is, according to the same author, the most trust- worthy sign of impaction in the larynx, as distinguished from impaction in other portions of the air-tube. From pharyngeal, or oesophageal obstruction, the diagnosis is to be made by careful exploration with the finger and pro- bang. In some cases, by means of the laryngoscope, the foreign body has been actually seen lodged in the larynx. Prognosis.—As long as a foreign body remains in any portion of the air- passages, the patient is in imminent danger; the causes of death are suffoca- tion (Avhich may occur at any moment), hemorrhage, inflammation, ulcera- tion, abscess, or simple exhaustion. The annexed summary, taken from 23 354 INJURIES OF THE FACE AND NECK. Mr. Durham's essay, shoAvs compendiously the results in 554 cases—these being, I believe, the most comprehensive statistics which have yet been published. 1. Cases in which no operation was performed:— Result. Total number of cases. Re-coveries. Deaths. Expulsion after emetics (recorded as useless in 46 cases) . Discharge at a late period through thoracic abscess, . 95 164 5 7 149 5 2 95 15 5 271 156 115 2. Cases in which operative measures were adopted:— Opekation. 14 3 231 20 3 12 13 170 15 3 12 1 3 61 5 Total of cases operated upon,....... 283 213 70 Total number of cases operated upon or not,. . 554 369 185 The mortality therefore is, in general terms, as nearly as may be, 1 in 3, the death-rate after operation being less than 1 in 4 (24.8 per cent.), but without operation more than 2 in 5 (42.5 per cent.). The period during which a foreign body may remain in the air-passages, and yet be spontane- ously expelled, varies from a few hours up to many years ; in 64 of 124 cases of spontaneous, expulsion Avith recovery, collected by Mr. Durham, this period Avas between one and twelve months. Treatment.—In a case in which the dyspnoea is not urgent, a careful laryn- goscopy examination should be made, and, if the position of the foreign body be recognized, attempts may be made to remove it by direct extraction with suitable forceps; the same means may be employed after opening the trachea, and will then be more likely to succeed, as the risk of strangulation is removed. Voltolini proposes to search for the foreign body by introducing, through the tracheal wound, a speculum modelled after the ear. speculum of Brunton. Inversion and succussion, which, though occasionally successful before tracheotomy, are under such circumstances both dangerous and pain- ful, may, after the operation, be of much service in facilitating the escape of the offending substance. In the large majority of cases the surgeon should, as soon as he is satisfied as to the nature of the case, perform tracheotomy, or, if the symptoms be very urgent, laryngotomy, the latter operation being more quickly and more easily accomplished. If the foreign body be now found in the larynx, it should be dislodged and extracted, the surgeon, if necessary, dividing the thyroid cartilage in the median line (thyrotomy), or this and the cricoid as well (crico-thyrotomy). If the foreign body be in the trachea or bronchi, it may be immediately expelled through the tracheal wound, or more rarely through the mouth—though in other cases it may not FOREIGN BODIES IN THE AIR-PASSAGES. 355 be ejected until several hours or days, or even a much longer period after the operation. There is some difference of opinion, among surgeons, as to the propriety of endeavoring to extract foreign bodies through the tracheal Fig. 175. Application of the laryngoscope. (Erichsen.) wound, by means of forceps. Mr. Durham's statistics show, I think, con- clusively, that such attempts are not only justifiable, but eminently proper, 41 cases, in which removal was effected by forceps, having given 39 recov- «a Pig. 176. 3= Throat-mirror used in laryngoscopy. eries, and but 2 deaths, neither of which appears to have been due to the use of the instrument. The best forceps for the purpose are those devised by Prof. Gross (Fig. 177), the blades of which are five inches long, and Pig. 177. Gross's tracheal forceps. which, being made of German silver, can be bent to suit any particular case, while they are so delicate as not materially to interfere with the passage of air during the necessary manipulations. After the exit of the foreign body, the Avound may usually be closed at 356 INJURIES OF THE FACE AND NECK. once; but, if there be much laryngeal irritation, a tube may be introduced for a few days, until this has subsided. Subhyoidean pharyngotomy (see Chapter XXXVIII.) may, in some cases, be preferred to either laryngotomy or tracheotomy, and has been successfully resorted to in a case of foreign body impacted in the larynx, by Lefferts. Surgical Treatment of Apncea. Apnoea, or, as it is more commonly called, Asphyxia, may arise from various causes, such as drowning, inhalations of chloroform or of poisonous gases, spasm or oedema of the larynx, or the presence of false membrane, of a morbid growth, or of a foreign body in any portion of the air-passages. The surgical operations employed in the treatment of apncea are, artificial respiration and the various procedures which are included under the general term of bronchotomy.1 Bronchotomy is applicable to cases in which the air- passages themselves are in any Avay obstructed ; Artificial Respiration to cases in which the air-passages are free, or in which apncea continues after the performance of bronchotomy. Artificial Respiration.—This may be effected in seATeral ways:— 1. Mouth to Mouth Inflation, though objectionable as furnishing air which has already been expired, is occasionally the only method Avhich can be employed in an emergency, and may be resorted to, in any case, while more efficient means are being procured. 2. Inflation with Bellows, provided with a suitable mouth or nose piece, may be efficiently used, provided that care be taken to secure expiration by manual compression, and that the instrument be worked gently, and not more than ten or tAvelve times in the minute. 3. Inflation with Oxygen Gas might be tried in extreme cases, or when other means had failed: the gas might conveniently be administered from a bladder, fitted with a mouth-piece. 4. Artificial respiration may readily be practised by alternately Compress- ing the Chest and Abdomen with the Hands, to imitate expiration, and then allowing the natural resiliency of the thoracic walls to produce expansion, and thus imitate inspiration. This method is very easily applied, and is particularly suitable in cases of apparent death from chloroform. 5. Silvester's Method, Avhich is that adopted by the Royal Humane Society, of England, consists in placing the patient in a supine position, with the head and shoulders slightly elevated, then grasping the arms above the elbows, drawing them gently but steadily upwards till they meet above the head, keeping them thus for two seconds, and, finally, bringing them downwards, and pressing them for two seconds more against the sides of the chest. This manipulation is to be repeated, fifteen times in the minute, until natural respiration is established, or until a sufficient time has elapsed to show that further efforts are useless. 6. Dr. B. Howard's "Direct Method," for cases of apparent death from drowning, consists in turning the patient downwards with a roll of clothing under the chest and abdomen, and making pressure on the back so as to force the water out of the lungs and stomach; then reversing the patient's position, putting the roll of clothing under the back, placing his hands to- gether above his head, which is kept low, and practising artificial respiration 1 Macewen, Paton, and Sanctuary recommend catheterization of the larynx through the mouth, as preferable to bronchotomy in obstruction from causes other than the presence of a foreign body. BRONCHOTOMY. 357 by compressing the lower part of the chest, and letting go with a jerk so as to alloAV the parts to expand by their natural resiliency. 7. Marshall Hall's "Ready Method."—This mode of treatment, which is, upon the Avhole, probably the best yet suggested, is thus described by its dis- tinguished author, under the name of " Prone and Postural Respiration:"— "(1.) Treat the patient instantly, on the spot, in the open air, exposing the face and chest in the breeze (except in severe weather). "I. To Clear the Throat. "(2.) Place the patient gently on the face, with one wrist under the forehead. [All fluids, and the tongue itself, then fall forwards, leaving the entrance into the windpipe free.'] If there be breathing, wait and watch; if not, or if it fail— "II. To Excite Respiration. " (3.) Turn the patient well and instantly on his side, and "(4.) Excite the nostrils with snuff, the throat with a feather, etc., and dash cold water on the face previously rubbed warm. If there be no success, lose not a moment, but instantly— "III. To Imitate Respiration. "(5.) Replace the patient on his face, raising and supporting the chest and abdo- men well on a folded coat or other article of dress. " (6.) Turn the body very gently on the side and a little beyond, and then briskly on the face, alternately; repeating these measures deliberately, efficiently, and perse- veringly fifteen times in the minute, occasionally varying the side. [When the patient reposes on the chest, this cavity is compressed by the weight of the body, and expiration takes place; when he is turned on the side, this pressure is removed, and inspiration occurs.] "(7.) When the prone position is resumed, make equable but efficient pressure, with brisk movement, along the back of the chest, removing it immediately before rotation on the side. [The first measure augments the expiration, the second com- mences inspiration.] " The result is respiration ; and, if not too late, life ! "IV. To Induce Circulation and Warmth. "(8.) Rub the limbs upwards, with firm grasping pressure and with energy, using handkerchiefs, etc, [By this measure, the blood is propelled along the veins towards the heart.] " (9.) Let the limbs be thus dried and warmed, and then clothed, the bystanders supplying coats, etc. " (10.) Avoid the continuous warm bath, and the position on or inclined to the bach." Whatever mode of treatment be adopted, should be perseveringly continued for three or four hours, unless sooner successful; if secondary apnoea come on after apparent recovery, artificial respiration should be again resorted to, together Avith the application of electricity to the base of the brain and upper part of the spinal cord. Bronchotomy.—Under this name are embraced the operations of Laryn- gotomy and Tracheotomy, together Avith their modifications, Thyrotomy, Crico- thyrotomy, and La ryngo-tracheotomy, the names of Avhich sufficiently express their nature. 1. Laryngotomy.—In this operation the Avindpipe is opened through the crico-thyroid membrane. The larynx being steadied between the thumb and fingers of the left hand, the surgeon makes a longitudinal incision of about an inch, in the median line, over the loAver half of the thyroid cartilage, the crico-thyroid space, and the cricoid cartilage. The sterno-hyoid muscles being noAv separated, and the intervening fascia and connective tissue divided to 358 INJURIES OF THE FACE AND NECK. the full extent of the cutaneous Avound, the knife is at once thrust, with its edge upAvards, through the crico-thyroid membrane and its mucous lining, into the larynx. The opening is then enlarged transversely as much as may be required, and the tube introduced. The only vessel likely to be cut is the crico-thyroid artery, which should, as a rule, be secured before opening the larynx. This operation, which is by no means difficult, may be performed either Avith or Avithout the aid of anaesthesia, the patient being in a recum- bent position, with the head thrown backwards, and the neck rendered prominent by means of a pillow beneath the nucha. 2. Tracheotomy.—In this operation two or more of the tracheal rings are divided, or an elliptical portion of their anterior face cut aAvay. The patient being in the position already described, and preferably under the in- fluence of an anaesthetic, the surgeon, standing at his left side, or, Avhich I prefer, at his head, makes a longitudinal median incision, extending from the bottom of the cricoid cartilage to an inch and a half or more below, according Fig. 178. Tracheotomy. (Liston.) to the length of the neck. The subcutaneous fat and areolar tissue are simi- larly divided, care being taken to avoid any superficial veins; the sterno- hyoid and sterno-thyroid muscles being then cautiously separated with the handle of the knife, or Avith the director, the trachea, crossed by the isthmus of the thyroid gland, is exposed. The trachea, which may be recognized by its white appearance, may be opened above, through, or beloAV the thyroid isthmus, the first being, in the case of children especially, the point to be preferred; if it be necessary to cut through the isthmus, a ligature must be first applied on either side of the point of division. Hemorrhage having been arrested, the surgeon draws forwards the trachea with a tenaculum, and thrusting in his knife, edge upwards, divides the necessary number of rings. Any false membrane which presents itself having been gently with- drawn, the tube is introduced, and, when the respiration has become tran- quil, the surgeon may, if it be thought proper, temporarily remove it, and proceed to cut away an elliptical portion of the front wall of the trachea; this step, though not, I think, in itself objectionable, is, hoAvever, seldom necessary. The above description presupposes that the surgeon has time to make a careful dissection of the superincumbent parts, before opening the windpipe— and, in the immense majority of instances, enough time is afforded for this AFTER-TREATMENT OF CASES OF BRONCHOTOMY. 359 purpose. I believe, hoAvever, with Mr. Durham, that cases are occasionally met Avith in Avhich it is very important to hasten the steps of the operation ; and, in such an emergency, would recommend a plan described by that author, and Avhich he assures us he has advantageously employed in nineteen instances. In this method the operator (standing on the patient's right side) places the forefinger of the left hand on the left side of the trachea, and the thumb on the right, pressing steadily backAvards until he feels the pulsation of both carotid arteries. By slightly approximating the finger and thumb, he feds that the trachea is firmly and securely held between them, and knoAvs that the safety of the great vessels is insured, Avhile the tissues over the Avind- pipe are rendered tense. The finger and thumb thus placed are not to be moved until the trachea is reached. By a succession of careful incisions, the surgeon iioav cuts boldly down on the Avindpipe, the finger and thumb on either side helping him to judge of the position of the median line (from Avhich the knife must not deviate), and, by their pressure, causing the Avound to gape, and the trachea to advance. The forefinger of the right hand is passed from time to time into the wound, to make sure that no important ves- sel is in the way, and when the trachea is reached the knife is introduced (guarded by the right forefinger), or the Avindpipe may be seized Avith a tenaculum and opened as in the ordinary operation. The chief danger from tracheotomy is from hemorrhage; instances are on record in Avhich the carotid, or even the innominate, artery * has been wounded, while fatal bleeding has not unfrequently occurred from the division of large veins. Arterial hemorrhage should, of course, be checked before opening the trachea, and bleeding veins should also be secured, provided that death from suffocation be not likely to occur while this is being done. It must be remem- bered, however, that the venous congestion is due, in great measure, to the obstruction of the patient's breathing, and Avill be lessened as soon as free respiration is established ; hence the surgeon should not fear, if necessary, to open the Avindpipe even Avhile venous bleeding continues, introducing the canula, as has been forcibly said, " even through a very pool of blood." In order to avoid the risk of hemorrhage, Verneuil, Bourdon, and FoAvler, of Brooklyn, recommend the use of a knife heated by the galvanic cautery,2 and report several cases in which tracheotomy has been thus bloodlessly per- formed. I cannot but doubt, however, Avhether this mode of treatment Avill ever supersede the ordinary operation with the simple scalpel. Laryngo-traeheotomy is, as its name implies, a combination of laryngotomy Avith tracheotomy above the thyroid axis. Its mode of performance requires no special description. After-treatment of Cases of Bronchotomy.—In almost all cases, except those of foreign body in the air-passages, it is necessary to introduce a tracheal canula or tube, Avhich must be Avorn until the poAver of breathing through the larynx is restored. The tube should be made of silver, Avith a curve of rather less than a quarter of a circle, double, so that the inner canula may be re- moved and cleansed, AA'hile the outer retains its position, the two being secured 1 Secondary hemorrhage from the innominate artery, resulting from ulceration due to pressure of the canula, proved fatal in tAvo cases reported to the Anatomical Society of Paris, and referred to in the British Medical Journal for April 2, 1881. Hemorrhage from the tracheal mucous membrane proved fatal in one of my own cases, by giving rise to broncho-pneumonia. a Amussat had previously employed the galvanic cautery, dividing the trachea from within outwards with a platinum wire previously introduced by means of a curved needle. Paquelin's thermo-cautery has been recently employed in trache- otomy by Poinsot, of Bordeaux. 360 INJURIES OF THE FACE AND NECK. by means of a button attached to the neck-plate of the outer one. The neck-plate itself should be so arranged as to allow the canula to move freely with the motions of the trachea, and the inner tube should project beyond the outer one for about a quarter of an inch, Fig. 179. at either extremity. The canula should be from tAvo to three inches in length, and, as advised by Mr. Howse and Mr. Parker, as large as can be conveniently introduced into the trachea. For use after laryngotomy the canula may be a little flattened, the transverse being somewhat greater than the antero-pos- terior diameter of its section. The canula above described, which em- braces the improvements of both Obre and Roger, is, I think, preferable to either the Tracheal tube. ordinary double tube, or the bivalve canula of Fuller. Mr. Durham has suggested a still further modification, by which the length of the tube can be regulated, by means of a screw, to meet the emergencies of any particular case. Mr. Parker employs a tube, the shape of Avhich he compares to that of a Gothic rather than a Roman arch. To facilitate the introduction of a tube, the edges of the wound may be held apart with two- or three-bladed dilating forceps, or, which is better, a blunt-pointed pilot trocar, as suggested by Dr. Gairdner, or a fenestrated tubular trocar, as employed by M. Pean, may be thrust in with the canula, to be withdrawn, of course, as soon as the latter is in place. Mr. Durham employs a " lobster-tailed " trocar, constructed on the same principle as Squire's " vertebrated" catheter. Flexible tubes are used by Mr. Morrant Baker. The canula being introduced, is held in position by tapes, attached to the neck-plate, and fastened around the neck. During the whole course of after- treatment, the atmosphere of the room should be kept moist and warm (from 75° to 80° Fahr.); the inner tube should be frequently removed and cleansed, and, if the operation have been done for pseudo-membranous croup or diph- theria, lime-water or dilute carbolic acid may, from time to time, be vaporized through the tube with an atomizer. Hypodermic injections of pilocarpine are recommended by Duliscourt and other French surgeons. The expecto- rated matters should be constantly wiped aAvay, and accumulations of mucus or false membrane removed with a camel's-hair brush, feather, or "elbow- forceps." As soon as the canula can be safely dispensed Avith, it may be remoA^ed, but this should not be done permanently until, by leaving it out for several hours at a time, it has been proved that the function of the larynx has been restored. If it be necessary to perform bronchotomy in an emergency, and Avhen a tracheal canula cannot be obtained, the surgeon must have recourse to excising an elliptical portion of the tracheal wall, and keeping the edges of the Avound apart Avith retractors made of bent wire (the hooks of ordinary large "hooks and eyes" Avill answer), secured by an elastic band passing behind the neck. If apncea persist after a free opening has been made into the Avindpipe, the surgeon must at once resort to one or other of the methods of practising artificial respiration already described. Dr. Beverley Robin- son, of NeAV York, has devised an ingenious " insufflator," by means of which the surgeon can directly inflate the patient's chest through the tracheal tube, Avithout incurring any risk from contact with the secretions of the part. This instrument, or a double-acting bellows, as recommended by Dr. B. W. Richardson, should be employed in case suffocation is threatened by false INJURIES OF THE CESOPHAGUS. 361 membrane accumulating below the opening in the trachea; or, if neither of these be at hand, an ordinary hand-ball syringe (reversed) may be used, as suggested by Dr. Green, of Brooklyn. Choice of Operation.—The relative advantages of laryngotomy and trache- otomy are still a matter of dispute among practical surgeons. Tracheotomy is preferred in all cases by Mr. Marsh, and laryngotomy, or laryngo-trache- otomy, by Mr. Holmes, especially among children. Mr. Erichsen recommends laryngotomy for adults, and tracheotomy, above the thyroid isthmus, for children; Avhile Mr. Durham considers that the advantages of opening the trachea below the isthmus, as compared with its risks and difficulties, are greater than those afforded by making the opening higher up. While I do not believe that any rule of universal application can be safely laid down upon this question, I Avould advise, in general terms, that tracheotomy above the isthmus should be preferred, in all cases in which time is afforded for a careful and deliberate operation, but that if great haste is essential, laryn- gotomy, which may readily be converted subsequently into laryngo-tracheotomy, should be performed instead. When the operation is required by the pres- ence of a foreign body in the Avindpipe, a more definite rule may be given. If the offending substance be lodged in the larynx, that part itself must usually be opened, though Dr. Lefferts, of New York, has under these cir- cumstances successfully employed Malgaigne's and Langenbeck's operation of sub-hyoidean pharyngotomy (see Chap. XXXVIII.), but if the foreign body be in any other part of the air-passages, tracheotomy is the operation to be chosen. The risks of tracheotomy, per se, are not very great, death in fatal cases usually resulting from a continuance of the disease rather than from the operation. The result of the procedure, in my own hands, has been to save six out of fifteen cases. Injuries of the (Esophagus. Wounds.—These have already been alluded to in describing penetrating wounds of the neck, the treatment of Avhich injuries is complicated by the oesophageal wound, through the difficulty thence arising in administering the necessary amount of nutriment. A patient with Avound of the gullet, may be fed through an elastic gum catheter, introduced through the mouth, or, if, Avith suicidal intent, he refuse to separate the jaws, through the nose. By this means a pint of beef-essence, or of " eggnog," may be introduced two or three times a day, until the poAver of deglutition returns. If the wound is above the position of the larynx, suffocation may occur from the super- vention of oedema of the glottis — an accident which would call for the im- mediate performance of laryngotomy. Rupture of the (Esophagus is a rare form of injury of Avhich Charles, of Belfast, has collected 15 cases; to these may be added one observed by Dr. William Hunter, and others recently reported by Dr. J. S. Bailey, of Albany, and Dr. G. O. Allen, of Boston. The accident has usually occurred during the act of vomiting, and the symptoms are intense pain Avith col- lapse, followed by death in the course of a feAv hours. According to Fitz, the affection is still rarer than Avould be indicated by the above figures, many of the reported cases being, in the opinion of this author, really in- stances of post-mortem softening and perforation. 362 INJURIES OF THE FACE AND NECK. Foreign Bodies in the Pharynx or (Esophagus.—Foreign bodies not un- frequently become impacted in some portion of the food-passage (usually, according to H. Allen, either at the position of the cricoid cartilage, or just above the crossing of the left bronchus), and produce not only great irrita- tion and difficulty of swalloAving, but may even induce suffocation by pres- sure on the windpipe. The symptoms vary with the nature, size, and position of the foreign body. A fish-bone, bristle, or pin may be caught between the tonsil and half-arches of the palate, and give rise to much discomfort, Avith tickling cough, dysphagia, and nausea. A pointed body in this situa- tion may even perforate an important vessel, and thus cause death by hem- orrhage. A bolus of food, arrested at the summit of the oesophagus, may suffocate the patient by pressure on the larynx ; or, again, a hard body, such as a bone or tooth-plate, may, if impacted, produce ulceration of the oesoph- ageal walls, and penetrate into the larynx, or other important structures in the neighborhood. The diagnosis is usually sufficiently evident from the sensations of the patient, but in any case of doubt, the surgeon, besides carefully inspecting the pharynx in a good light, should sweep his finger around the part as far as he can reach, and cautiously explore the oesophagus Avith a Avell-oiled pro- Fig. 180. wlmJJ h.j_.j------s^amim^i^m ¥ Burge's oesophageal forceps. bang. In some cases the laryngoscope may be used to facilitate the exami- nation of the upper portion of the gullet. Though the foreign body can thus usually be discovered, if present, a small substance, such as a fish-bone, may, from the peculiarity of its position, elude detection even after careful and repeated exploration; on the other hand, the sensations of the jiatient may continue to indicate the impaction of a foreign body for a long period, when none is really present, and cesophagotomy has actually been performed, on more than one occasion, without any substance being found Avhich could account for the patient's symptoms. Fig. 181. Swivel probang. Treatment.—If suffocation be threatened, unless the foreign body can at once be seized and removed, tracheotomy should be resorted to Avithout delay. In every case an effort should be made to extract the foreign body through the mouth, and this can usually be done, either by simply hooking it out with INJURIES OF THE OESOPHAGUS. 363 the finger (if lodged in the pharynx), or by the cautious use of oesophageal forceps (Fig. 180), or of the horse-hair, or SAvivel probang. Dr. Lamm, a Swedish surgeon, has succeeded in washing out a foreign body from the oesophagus by syringing Fig. 182. through a flexible catheter. If the foreign body be of such a nature that it will not be likely to produce injurious consequences in the stomach and boAvels, as a lump of meat, or even a small coin, it may, if its extraction prove difficult, be pushed onwards into the stomach, Avith a sponge or ivory-headed pro- bang.1 If, as occasionally though rarely happens, a foreign body in the gullet can be neither extracted, nor otherAvise disposed of, it should be removed through an external incision, by the operation known as pharyngotomy or oesophagotomy. (Esophagotomy.—If the foreign body can be felt externally, the operation should be done on that side which is the most prominent; otherwise the left side is to be chosen, as the oesophagus naturally inclines somewhat in that direction. The patient should be anaesthetized, and placed in a supine position, Avith the head and shoulders a little raised, and the face someAvhat averted. An incision, four or Aa^c inches long, is made in the space betAveen the trachea and the sterno-mastoid muscle, beginning above, on a level Avith the top of the thyroid cartilage. This in- cision is cautiously deepened, the omo-hyoid mus- cle, and the outer fibres of the sterno-hyoid and sterno-thyroid, being divided if necessary; the carotid sheath is carefully draAvn outwards, and held with a blunt hook, the trachea and thyroid gland being similarly draAvn inwards. If the foreign body can now be felt, the oesophagus may be incised directly upon it; otherwise a sound or curved forceps should be introduced through the mouth, and made to pro- ject in the Avound, thus affording a guide to the point at Avhich the gullet should be opened. The incision may be subsequently enlarged either upAvards or doAvnAvards, and the foreign body extracted Avith the finger or forceps. Special care must be taken in this operation not to Avound either the inferior thyroid artery or the recurrent laryngeal nerve. The incision should be alloAved to heal by granulation, the patient being Horsehair probang, or Ra- fed through a catheter, as after an accidental wound moneur. of the oesophagus. This operation is essentially that Avhich has been successfully performed by Syme, Cock, and Cheever, and seems to me in every A\aAr preferable to that by a median incision, Avhich Avas recommended by Nelaton. The results of oesophagotomy for the removal of foreign bodies are quite encouraging, 44 cases to which I have references having given 35 recoveries and only 9 deaths. 1 An English surjjeon, Dr. Stewart, has recorded a case in which a live fish was thus successfully disposed of. 364 INJURIES OF THE CHEST. Cases of CEsophagotomy for Removal of Foreign Bodies. No. Operator. Result. No. 23. Operator. Result. 1. Alexander. Recovered. Goursauld. Recovered. 2. Antoniesz. " 24. Hitchcock. k 3. Arnold. u 25. Inzani. ii 4. Arnott. Died. 26. Hodgen. ii 5. Atherton. Recovered. 27. Id. I! 6. Id. u 28. Kronlein. U 7. Begin. II 29. Langenbeck. U 8. Id. u 30. Id. [< 9. Billroth. " 31. Id. Died. 10. Id. u 32. McKeown. Recovered. 11. Id. 11 33. Maclean. If 12. Id. Died. 34. McLean. 11 13. Cazin. Recovered. 35. Id. 11 14. Cheever. <( 36. Martini. Died. 15. Id. u 37. Pean. Recovered. 16. Id. u 38. Roland. i< 17. Id. Died. 39. Sonnenberg. u 18. Cock. Recovered. 40. Sonrier. (! 19. Id. (i 41. Stanley. Died. 20. De Lavacherie. u 42. Syme. Recovered. 21. Demarquay. Died. 43. Westmoreland. Died. 22. Flaubert. u 44. Wheeler. Recovered. Note.—Twenty-two of the above cases are derived from Dr. D. W. Cheever's table, in the Medical and Surgical Report of the Boston City Hospital, first series (1870), page 522. In the cases numbered 16, 24, 30, 33, and 43, no foreign body appears to have been found. I have not included in the table two operations by Mr. Syme, and one by Dr. Gay, in which the foreign bodies had already made their way through the oesophagus by ulceration, and which cannot, therefore, strictly speaking, be con- sidered as cases of oesophagotomy. CHAPTER XVIII. INJURIES OF THE CHEST. Contusions. Contusions of the Thoracic Parietes, Unaccompanied by Visceral Injury, are usually of but trifling importance; if there be much pain attending the act of respiration, the surgeon should fix the injured side Avith broad strips of adhesive plaster, precisely as in a case of fractured ribs. An occasional consequence of severe contusion of the chest is the formation of an abscess beneath the pectoral muscle ; suppuration in this situation may continue for a considerable time without being recognized, pointing at last probably in the axilla. The local symptoms are necessarily obscure, consisting mainly in great pain, and general swelling of the whole pectoral region; should, however, these symptoms follow an injury, and coincide with the constitu- tional evidences of the existence of deep-seated suppuration, the proper treat- ment Avould be to cut doAvn in the direction of the muscular fibres, enlarging the exploratory incision subsequently as much as might be necessary. Contusion, Accompanied by Rupture of the Thoracic Viscera, Avithout corresponding fracture, and without external wound, is a rare and danger- CONTUSIONS OF THE CHEST. 365 ous accident, Avhich may result from the contact of a spent ball or piece of shell, from being run over, from falls from a height, etc. Rupture of the Lung has been occasionally observed, under these circum- stances, and cases are recorded by several Avriters, in which, in spite of the severity of the injury, the patients recovered. The symptoms are those of wounded lung—pneumothorax, with, perhaps, emphysema, hemothorax, haemoptysis, and, at a later period, pleurisy and pneumonia, with accumula- tion of pus or serum in the pleural cavity. The mechanism of the lesion in these eases is, doubtless, as pointed out by Gosselin, that, at the moment of injury, the lung is distended by inspiration, and the glottis spasmodically closed, thus preventing the lung from yielding to the sudden pressure. I have seen tAvo cases of this kind—one at the Pennsylvania Hospital, under the care of Drs. E. Hartshorne and C. C. Lee, in which the left lung was ruptured and which proved fatal on the third day; and another Avhich was under my OAvn care at the Episcopal Hospital, in which the injury affected the right lung, death following on the fifth day. In the latter case the rup- ture was superficial, and there was no haemoptysis, though the symptoms of hemothorax, pneumothorax, and pleurisy, were well marked. This rare form of injury is chiefly met with in young persons.1 It appears to be less fatal in military than in civil life; 35 cases which I have collected, and Avhich resulted from various forms of violence other than gunshot injury, having given only 11 recoveries, while 25 cases recorded by Dr. Otis as having occurred during our late war, gave the same number. The treatment of this form of injury is that which will be presently described as appropriate to wounds of the lung. Cases of Rupture of the Lung without Parietal Injury. No. Reporter. Result. No. Reporter. Result. 1. Adams. Died. 19. McDonnell. Died. 2. Ashhurst. u 20. Marsh. u 3. Bermond. u 21. Nelson. << 4. Bouilly. Recovered. 22. Poland. I! 5. Butlin. Died. 23. Pollock. Recovered. 6. Id. (i 24. Saussier. it 7. Id. Recovered. 25. See. u 8. Churchill. a 26. Senfft. u 9. DaCosta. (< 27. Smith. Died. 10. Gosselin. t< 28. Id. << 11. Id. << 29. ild. ii 12. Gould. it 30. Watson. k 13. Gross. Died. 14. Harlan. u a. Hewson. n 15. Hilton. CI b. Nankivell. S. Little, and is of such a nature (as a table knife, or fork) that it cannot probably be either dis- solved by the gastric and intestinal juices, or naturally evacuated, the sur- geon would, I think, be justified, provided its position could be ascertained by external palpation, in attempting its removal by operation. Gastrotomy has, including Labbe's case, been successfully performed under these circumstances in at least seven instances;: and, as death would be, sooner or later, almost inevitable without operation, the attempt would be at least permissible.2 The incisions, in such a case, should be regulated by the size and shape of the body to be removed, and the after-treatment should be the same as for an incised wound accidentally inflicted. Enterotomy might be similarly re- sorted to, if the foreign body, having reached the bowel, should cause com- plete intestinal obstruction (see Chap. XLIL). J. C. McKee has recorded a remarkable case in Avhich a piece of Avire Avas accidentally sAvallowed, and, having made its Avay into the abdominal parietes, Avas safely removed by external incision nearly four months afterwards. 1 Dr. Otis has collected 12 cases, not including Labbe's; the histories of 5 are more or less open to question, and, of the remaining 7, 1 terminated fatally. Poulet refers to 15 cases, of which 10 are said to have ended in recovery. Another case, the result of which has not been ascertained, has since been recorded by Fleury and Jurkowski. 2 See, however, this question discussed by Poland (who considers the operation unnecessary) in Guy's Hosp. Reports, 3d s., vol. ix. 384 INJURIES OF THE ABDOMEN AND PELVIS. Injuries of the Pelvic Organs. Injuries of the Bladder.—The bladder may be ruptured (Avithout external wound) by violence,1 as a kick, applied to the abdomen. This accident is only likely to happen if the organ be distended with urine, as Avhen empty it sinks beneath the pubic arch, and is thus measurably protected from ex- ternal injury. The rupture usually occurs in the posterior wall of the bladder, involving the peritoneal as well as the other coats of the organ, and allowing urinary extravasation into the peritoneal cavity, an event which is almost inevitably fatal, 98 cases collected by Bartels having given but 4 recoveries. More rarely the rent is confined to the anterior wall of the bladder, urine then escaping into the pelvic areolar tissue, and inducing a condition Avhich, though very grave, is not so uniformly fatal as the one previously referred to, 12 out of 54 such cases collected by Bartels having terminated favorably. The symptoms, in the former case, consist of intense epigastric pain, collapse, urgent but fruitless efforts to urinate, and in a short time the ordinary signs of peritonitis ; the introduction of the catheter serves to evacuate either none or a very small quantity of bloody urine. If the peritoneum be not involved, the symptoms are less urgent, the patient being, in these cases, gradually worn out by diffuse inflammation and slough- ing of the areolar tissue. The treatment consists in the introduction of a large flexible catheter, Avhich (as a general rule) should be secured in place, the urine being alloAved to run off constantly, by means of an attached India- rubber tube, into any convenient receptacle. The patient should be got as soon as possible under the influence of opium, a warm poultice may be placed over his epigastrium, and concentrated food or stimulants adminis- tered, if indicated by his general condition. Diaphoresis should be encour- aged by external applications, it being an obvious indication to promote the vicarious action of the skin, and thus diminish the amount of urine secreted. It has been suggested to perform cystotomy (as in the median or lateral ope- ration for stone), in these cases, and if it were found impossible to keep the bladder empty by means of a catheter, the operation, which has been suc- cessfully resorted to, under these circumstances, by Walker, of Massachu- setts, and by Parker and Mason, of New York, would be certainly proper, and would, I think, be preferable to opening the bladder either through the rectum or above the pubes, though the latter procedure also has been successfully employed by a New York surgeon, Dr. Williams. Holmes suggests that it might be justifiable to open the abdomen and close the vesical wound with sutures, but the cases in which Willett and Heath tried the operation terminated fatally. A similar operation Avas suggested some years ago by Prof. Gross, and is said to have been successfully resorted to by Dr. Walter, of Pittsburg. Free incisions should be made on the first outward manifestation of urinary infiltration having occurred. A few instances are on record, in Avhich the bladder has been ruptured by the accumulation of its own secretion; such an accident, however, is very rare, the urethra usu- ally giving Avay, in such cases, rather than the bladder. Wounds of the Bladder are amongst the most serious complications of fractures of the pelvis. The bladder may also be wounded by gunshot pro- jectiles, by pointed instruments, by the horns of infuriated animals, etc. When the wound is in that part of the organ Avhich is covered with peri- toneum, these injuries are usually fatal, but there are numerous instances of recovery from wounds of the bladder inflicted in the perineal region. The 1 Assmuth reports two cases of rupture from muscular action. INJURIES OF THE PENIS AND MALE URETHRA. 385 treatment of these cases is essentially that which has been described in the preceding paragraph; any foreign body that may have lodged in the bladder should be removed, as its continued presence would produce great irritation, and probably cause the formation of a calculus. If the wound be through the rectum or vagina, a troublesome fistula may result, requiring, perhaps, the performance of a plastic operation. Foreign Bodies, such as slate pencils, pins, etc., may be introduced into the bladder, through the urethra, through an external wound, or, more rarely (by the process of ulceration), from another viscus—as in a remarkable case recorded by Dr. Kingdon, in which a pin, having been SAvallowed, lodged in the appendix vermiformis, from which it subsequently made its Avay into the bladder, where it formed the nucleus of a calculus ; the ulceration by AA'hich this process Avas attended gaATe rise to the formation of an intestino-vesical fistula, through Avhich no less than six round Avorms entered the bladder, and were at different times discharged from the urethra. Foreign bodies may occasionally be spontaneously expelled from the bladder—or may be ex- tracted Avith urethral forceps, or a small lithotrite, if the surgeon succeed in catching them in the direction of their long axis. In the male, hoAvever, it is usually necessary to resort to lithotrity (if the nature of the body admit of its being crushed), or to lithotomy, the median being in such a case the prefer- able operation. From the female bladder, foreign bodies may be conve- niently removed, in most cases, by dilating the urethra Avith two- or three- bladed forceps, or with graduated bougies, until the forefinger can be intro- duced, Avhen it is very easy with forceps to seize and extract the foreign body, the finger serving to adjust it into a favorable position for removal. It occasionally happens that, in using the female catheter, the instrument slips from the fingers, and is sucked into the bladder. In the event of such an unfortunate occurrence, the surgeon should at once dilate the urethra and remove the foreign body. I have known fatal ulceration to result, under these circumstances, from the delay of only a feAv days. Injuries of the Rectum.— Wounds of the rectum, provided that they are uncomplicated, usually heal without much difficulty, as is seen after the operation for fistula, or Avhen the bowel is accidentally wounded in lithotomy. If the lesion involve the bladder or vagina, recto-vesical or recto-vaginal fistula Avill probably result, and may require the performance of a plastic operation. Death may folloAv perforation of the rectum (from the peri- toneum being opened), as has occasionally happened from the incautious use of syringes, or of rectal bougies. Foreign Bodies are occasionally found in the rectum, and must be remo\red Avith scoop or forceps, as the ingenuity of the surgeon, and the exigencies of each particular case, may suggest. Linear rectotomy may be required, as in cases recorded by Raffy and Turgis (see Chap. XLIL). The removal of masses of impacted feces, of seeds or fruit-stones, etc., may often be accom- plished simply by the repeated use of warm enemata. A fish-bone, or similar article, may be caught in one of the pouches of the rectum, and, by the resulting ulceration, give rise to a fistula in ano. Injuries of the Penis and Male Urethra.— Wounds of the Penis, if limited to the skin, are not attended Avith any particular risk; they ahvays require the use of sutures, on account of the retractile tendency of the part. In deeper Avounds there may be profuse hemorrhage, which may require a liga- ture, if it proceed from any recognizable artery, but Avhich, if of the nature of general oozing, may be checked by cold and pressure, the latter being best applied by introducing a full-sized catheter, and then compressing the 25 386 INJURIES OF THE ABDOMEN AND PELVIS. organ upon this Avith adhesive strips. Contusion, or Partial Rupture, of the corpora cavernosa, is followed by interstitial extravasation of blood, attended by marked induration, and sometimes by priapism, which may persist for several days. Such an injury is best treated by the continued application of evaporating lotions. Strangulation of a portion of the penis is sometimes produced in children by tying a string round the part, or, in adults, by the introduction of the organ into a metallic ring, the neck of a bottle, etc. If gangrene has not been induced, the symptoms will usually quickly subside upon the removal of the source of constriction. Nelaton, Heyenberg, and Moldenhauer have reported remarkable cases of luxation of the penis, the organ being completely separated from its cutaneous covering, and buried in the adjoining tissues. In Nelaton's case reduction was effected by the use of forceps. The Urethra may be Wounded by cutting instruments, or gunshot projec- tiles, or may be Lacerated by falls or bloAvs upon the perineum or penis, by injuries received during coitus, or even by violent straining efforts at mictu- rition in cases of stricture. It may also be wounded in rude attempts at cathe- terization, giving rise to the formation of "false passages." The symptoms of laceration of the urethra are pain, considerable swelling from interstitial bleeding, hemorrhage from the meatus, and inability to urinate. If the pa- tient, by straining, succeed in passing water, Urinary Extravasation will usually occur, giving rise to extensive destruction of tissue, and the formation of perineal fistulse. This is less likely to happen in cases of "false passage" than in those of other varieties of urethral laceration, because in the former the direction of the passage is away from the course of the urine. The treat- ment consists in the immediate introduction of a full-sized catheter (flexible, if possible), which must be retained for several days, until the subsidence of pain and swelling renders it probable that the laceration has healed; the catheter should not be plugged, lest the accumulating urine find its Avay by the side of the instrument. If it be impossible to introduce a catheter, the surgeon must at once open the urethra in the perineum, Avhen, if the instru- ment still cannot be passed, a flexible tube may be introduced through the wound into the bladder. This I believe to be safer, in these cases, than puncture through the rectum or prostate, or above the pubes. If extrava- sation of urine have occurred, free incisions must be made in the perineum, scrotum, and inside of the thighs, or wherever the urine may have reached, to permit the escape of the irritating fluid, and facilitate the separation of sloughs. Laceration of the urethra, according to its extent, will probably result in an intractable form of stricture, or even in complete obliteration of a portion of the tube, Avith the persistence of an incurable perineal fistula. Foreign Bodies in the urethra may be extracted through the meatus, Avith urethral scoop or forceps (or, in some cases, as suggested by Keyes, of NeAV York, Avith a Thompson's stricture expander), or through an incision in the median line. If this incision be in the perineum, the wound may be allowed to heal by granulation, a full-sized catheter, or bougie, being passed every other day: but if in the penile portion of the urethra, sutures will be required, and in this case a flexible catheter should be retained until union has oc- curred. When the foreign body is long and soft (as a bit of catheter), an ingenious plan of removal, suggested by Van Buren and Keyes, may be adopted: this consists in transfixing the foreign body Avith a stout needle passed through the floor of the urethra, and pushing back the canal as far as possible, like a glove over a finger, then withdrawing the needle and trans- fixing again, and so gradually coaxing the foreign body forAvards until it can be seized at the meatus. INJURIES OF THE VULVA AND VAGINA. 387 Injuries of the Scrotum and Testes.— Wounds of the Scrotum require the application of sutures; if the wound be extensive, the testis may be ex- truded, owing to the great contractility of the dartos muscle. In order to effect relaxation of the part, Mr. Birkett adA'ises the use of warm fomenta- tions before the application of stitches, cold lotions being afterwards substi- tuted to produce contraction and prevent bagging. Contusion of these parts is folloAved by great SAvelling and ecchymosis, and often results in the forma- tion of a hydrocele, or hematocele. Wounds of the Testis usually heal readily, the tunica vaginalis, in such cases, commonly becoming obliterated by inflammation. Atrophy of the organ is said to occasionally follow these injuries. Injuries of the Prostate.—Incised wounds of the prostate heal without trouble, as is seen in cases of lithotomy. The prostate is sometimes Avounded in rude attempts at catheterization, causing retention of urine and urethral hemorrhage ; the treatment consists in introducing a large flexible catheter, or, if this be impossible, in tapping the bladder through the rectum or above the pubes. Injuries of the Spermatic Cord andVas Deferens.— Wounds of the Sper- matic Cord require the use of the ligature, or other means of checking hemor- rhage, and the divided segments of the cord should be brought together Avith a stitch, in hope of procuring union. Mr. Hilton has met Avith several cases of Rupture of the Vas Deferens, marked by arterial hemorrhage from the urethra, Avith great pain and fever, and followed by atrophy of the corre- sponding testis. The treatment is that which is appropriate for ordinary deep- seated inflammation. Injuries of the Uterus.—Injuries of the Unimpregnated Uterus are very rare, and could scarcely occur except in combination with other more serious lesions. Injuries of the Pregnant Uterus, beside the risks of hemorrhage and peritonitis, are extremely apt to terminate in abortion. The treatment of such cases must be conducted upon the principles which have been laid doAvn for the management of cases of severe injury to the abdominal viscera in general. If the foetus be partially or completely extruded from the womb, it must be removed, per vias naturaks, or through the external wound, if there be one, according to the particular circumstances of the case. Rupture of the Womb, Occurring during Parturition, is not a subject properly within the scope of this work. Laceration of the Cervix Uteri is an accident of not unfrequent occur- rence during labor, and may require an operation, which consists essentially in freshening the edges of the rent Avith suitably curved scissors, and fixing them Avith metallic sutures which are allowed to remain for about ten days. Injuries of the Vulva and Vagina.— Contusions and Wounds of these parts are to be treated on the principles Avhich guide the surgeon in the management of similar injuries in other regions of the body. Women are sometimes seriously wounded, while in the act of micturition, by the breaking under them of chamber utensils, and fatal hemorrhage has occasionally resulted, under these circumstances, from a wound of the internal pudic artery. The treatment would consist in plugging the Avound with lint, dipped in a solution of the persulphate or perchloride of iron, and in the application of a compress and firm bandage. Foreign Bodies occasionally become im- pacted in the vagina, or may be thrust through its walls into the bladder, 388 INJURIES OF THE ABDOMEN AND PELVIS. Fig. II rectum, or peritoneal cavity. The treatment consists in the removal of the offending substance by such means as the ingenuity of the surgeon may suggest, and in the subsequent adoption ol measures to combat the resulting inflammation. Injuries of any portion of the "genital zone," received during pregnancy, are, as pointed out by Gueniot, apt to be folloAved by abortion. Injuries of the Perineum.—Wounds of the Male Perineum, not involving the urethra, commonly heal Avithout much difficulty. Lacerations of the Female Perineum occasionally occur during labor, and, if at all extensive, usually require an operation for their cure. If the case be seen Avithin twelve hours after the oc- currence of the laceration, it will proba- bly be sufficient to approximate the parts with deep and superficial sutures, main- taining the thighs in apposition until union has occurred, and insuring cleanli- ness by frequent syringing with a solution of permanganate of potassium. At a later period it will be necessary, after emptying the bowel by means of an enema, to draw aw7ay the anterior wall of the vagina with a duck-billed speculum, and freshen the edges of the opening (making a raw sur- face at least an inch in depth, and ex- tending the Avhole length of the fissure), then accurately adjusting the parts Avith the quilled suture, as recommended by BroAvn, or simply Avith the interrupted suture, as done by Sims, Emmet, and AgneAV. In either operation two sets of sutures may be properly employed; a deep set—entering an inch from the cut edge, passing as deep as the denudation extends, and coming out an inch from the cut edge on the opposite side—and a superficial set to insure more accurate adjustment of the cutaneous surfaces. When the sphincter is involved, care should be taken in passing the hind- most suture to let the needle enter and come out far back towards the coccyx, so as to insure the close approximation of the separated muscular fibres, and thus guard against fecal incontinence. This precaution is particularly in- sisted upon by Emmet, who finds that its neglect frequently allows the per- sistence of a recto-vaginal fistula. If the whole recto-vaginal septum be torn, it will be necessary to close this by numerous interrupted sutures passed from the vaginal surface, and, in these cases, it may be desirable to divide the sphincter ani on either side, as recommended by Brown. If there be great tension upon the deep sutures, a curved incision may be made on either side of the perineum, as recommended by Dieffenbach and T. Smith; Parker, of NeAV York, employs lateral incisions, through the bottom of Avhich he passes sutures of doubled Avire, secured over bits of catheter. If the quilled suture be employed, either strong Avhip-cord or flexible Avire may be used. The best material for the interrupted sutures, both superficial and deep, is strong silver wire. The deep sutures are most conveniently introduced by means of a needle fixed in a handle. In the after-treatment, constipation should be maintained by the administration of opium, for about two Aveeks, Surface denuded in complete perineal rup- ture, and first two sutures in position (Thomas.) ACUTE OR PHLEGMONOUS ABSCESS. 389 and the catheter should be used at regular intervals. Sims and Emmet ad- vise the employment of a short rectal tube, to allow the escape of flatus. The deep sutures may be removed from the sixth to the eighth day, and the superficial set a few days later. Catgut sutures are recommended by Dr. Brickell, of Ncav Orleans, Avho further modifies the operation by tying the deep sutures over metallic stays placed between the sides of the Avound. Dr. Hodgen, of St. Louis, instead of merely freshening the edges of the lacera- tion, dissects triangular flaps from both buttocks, and turns them imvards with their cutaneous surfaces toAvards the vagina, thus increasing the size of the raAV surfaces to be approximated, and furnishing an apron Avhich pre- vents the vaginal discharges and urine from irritating the Avound. A similar plan is adopted by Parker and by Stimson, of New York, and is by the lat- ter surgeon attributed to Langenbeck. CHAPTER XX. DISEASES RESULTING FROM INFLAMMATION. Abscess. An abscess is a collection of pus, surrounded by a wall or layer of lymph. Pus existing in a serous cavity (as in empyema), or in a joint, does not strictly constitute an abscess (though often so called), any more than pus Avidely diffused through the cellular tissue, or covering the granulations of an ul- cerated surface. Several varieties of abscess are described by surgical writers, as the acute or phlegmonous; the chronic; the cold, lymphatic, congestive, or scrofulous; the diffused (a contradiction in terms); the em- physematous; the metastatic or pysemic; and the residual. The division Avhich I shall adopt, and Avhich seems to me to be the simplest, is into (1) the acute or phlegmonous abscess, which may be considered the typical form; (2) the chronic or cold abscess; and (3) the residual abscess. Diffused Sup- puration (Avhich, according to the definition above given, does not constitute an abscess) will be described in a separate place, and the so-called Metastatic Abscess in the chapter on Pyasmia. The presence of gas in an abscess (con- stituting the Emphysematous variety) is a mere coincidence, depending on the locality of the affection, or on the occurrence of putrefaction. Acute or Phlegmonous Abscess.—When a part that has been inflamed becomes more swollen, the dull pain changing to one of a throbbing or pulsatile character, the skin assuming a deeper hue, and presenting a shining and glazed appearance, the surgeon knows that suppuration is impending, and that an abscess will probably be formed. If the seat of pus-formation be deep-seated, the superincumbent tissues become brawny and oedematous, from infiltration of lymph and effusion of serum, and, as the pus gradually approaches the surface (Avhich it has an almost invariable tendency to do), the overlying tissue becomes softened, the thinnest part bulges forAvards, the cuticle often desquamates, fluctuation (Avhich was at first obscure) becomes manifest, and pointing of the abscess is said to have occurred. A small circular slough is then formed at the thinnest part, and detached by the outAvard pressure of the pus, Avhen the abscess discharges its contents, its 390 DISEASES RESULTING FROM INFLAMMATION. Avails contract by their own elasticity, the cavity is filled by the process of granulation, the remaining superficial ulcer cicatrizes, and the part returns gradually to its normal condition—the scar and loss of substance, however, sometimes persisting for a very long time. The mechanism of pointing has never been explained in a perfectly satisfactory manner. The tissue Avhich intervenes between the abscess and the surface upon which it is to break, is usually said to yield by a combined process of absorption and disintegration : it seems more probable, howrever, that, under the influence of the inflamma- tory process, rapid cell-proliferation occurs in the abscess wall, with liquefac- tion of the intercellular substance, thus forming fresh pus-cells, the number of AAliich is probably still further increased by the direct transit of Avhite blood corpuscles through the parietes of the capillary vessels. The final step con- sists, as has been mentioned, in a small disk of skin becoming deprived of its vitality, and being then thrown off as a minute circular slough. Though an abscess usually tends toAvards the cutaneous surface, it may, under other circumstances, break into a mucous canal, into a joint, or even into one of the large serous cavities of the body. A happy provision of nature in the case of abscesses of internal organs (as of the liver), pointing externally, is that localized inflammation and adhesion may open the way for the escape of the pus upon the cutaneous surface, without the intervening serous cavity becoming involved. Diagnosis.—The diagnosis of phlegmonous or acute abscess can usually be made without difficulty, by attending to the history of the case, by observ- ing the disposition to point, by noting the presence of fluctuation and the other local signs above described, and lastly, if necessary, by using the ex- ploring-needle or trocar. Fluctuation, Avhich is the sensation communicated to the surgeon's hands by a Avave of fluid, can best be recognized by placing one or tAvo fingers of each hand on the suspected swelling, and making alter- nate pressure, first with one hand, and then Avith the other. The fingers should be placed longitudinally as regards the direction of the muscular fibres of the part, and it must be observed that in any region in which the muscular and connective tissue is abundant, as in the thigh or nates, or bound down by dense fasciae or ligaments, as in the temporal region or the back of the hand, a very slight increase of tension from inflammation or effusion will give a deceptive feeling closely analogous to fluctuation. Again, certain tumors, as the cystic, fatty, glandular, or encephaloid, are often attended with fluctuation, and have been frequently mistaken for abscesses. Finally, a partially consolidated aneurism may give the sensation of deep-seated fluc- tuation, and thus lead the surgeon into error. Hence, in any case of doubt, more especially if the suspected swelling be in the neighborhood of a large artery or other important part, the surgeon should, by all means, confirm his diagnosis by using the exploring-needle, before making a free incision. A better instrument, in some cases, than the ordinary exploring-needle, is the aspirator, or even the common hypodermic syringe. The temperature of abscess-cavities has been particularly investigated by Assaky, who finds that it ranges from 99.5° to 101.3° Fahr., gradually diminishing as the ab- scess heals. The skin over an acute abscess is from 1° to 4.5° hotter than the corresponding part on the other side of the body. This increase of temperature might sometimes prove of diagnostic value, but would not serve to distinguish an abscess from a rapidly growing sarcoma, Avhich affection, as pointed out by Estlander, and as I have found by personal observation, may cause a very considerable augmentation of local heat. The course of the temperature in an abscess is, according to Assaky, quite independent of that of the body in general. Prognosis.—An acute abscess, unless very large, is usually a comparatively ACUTE OR PHLEGMONOUS ABSCESS. 391 trivial affection. In certain situations, hoAvever, even a small abscess may not only, by pressure on nerves or other important structures, cause great pain and discomfort, but may even seriously endanger life. An abscess of the prostate or perineum may cause retention of urine; one of the fauces or throat, dyspnoea and even death; or one of the parotid or a cervical gland, fatal bleeding from the carotid artery or internal jugular vein. The drain from a very large abscess, or from numerous abscesses, may cause death by exhaustion, Avith or without the development of hectic fever, or by inducing the peculiar form of visceral disease which has received the name of amy- loid or albuminoid degeneration. Treatment.—This may be divided into the Prophylactic and the Curative treatment. The formation of pus, in acute phlegmonous inflammation, may be prevented: more than this, pus after formation may be absorbed. I have myself seen this in several instances, and a number of cases were collected in the Medical Times and Gazette, for 1858, which proved the possibility, at least, of this occurrence. Nor can this be considered at all unreasonable, if we accept the vieAvs of Cohnheim and his followers, who maintain the iden- tity of the pus cell with the Avhite blood corpuscle, and believe that they have actually seen the latter migrating through the capillary walls. Be this as it may, abscesses unquestionably disappear under treatment, though in many cases it is probably the fluid matter only Avhich is absorbed, the solid remain- ing as a caseous residue, or undergoing cretaceous degeneration. The old humoralistic doctrine looked upon suppuration and abscess as efforts of nature to rid the system of some peccant matter, and hence taught the propriety of promoting and hastening, rather than of endeavoring to prevent, suppuration. I suppose, however, that there are few surgeons at the present day Avho would not consider the prophylactic treatment of abscess at least permissible. The remedies to be employed for this purpose have been already referred to in the chapter on the Treatment of Inflammation: they are such as tend to pro- mote resolution. Sedative and anodyne applications are usually most appro- priate ; dry cold, or evaporating lotions, are often useful, the former, especi- ally, in cases in which the integrity of a joint is threatened. Warm and emollient fomentations, on the other hand, sometimes answer a better purpose than cold applications; gentle friction Avith laudanum and olive oil, and the use of cataplasms, Avill be found most efficient in the prevention of mam- mary abscess. Finally, it is sometimes possible, as it were, to stimulate aAvay an abscess: I have more than once succeeded in dispersing a bubo by the use of a blister, even after pointing had occurred. Curative Treatment.—The length of time during Avhich abortive measures, if not rapidly successful, may be persevered in, should depend a good deal upon the feelings of the patient. If the pain and febrile disturbance which accompany the formation of an abscess be very great, it will usually be wise to desist from such measures, and strive merely to relieve the patient's suffer- ings. I am not quite sure that we can often materially hasten the pointing of an abscess by treatment, but Ave can certainly make the patient more comfortable Avhile the pus is approaching the surface, and the best applica- tion for this purpose, in the immense majority of cases, is an emollient poul- tice. Though an abscess will eventually burst of itself, it is usually better to evacuate its contents artificially—this little operation giving great relief to the patient, and rendering the resulting scar less conspicuous. The time at which an abscess should be opened depends on the circumstances of the case: if the pus be deep-seated and bound doAvn by tense fasciae, the pain being great, an early incision, at the most dependent point, should be prac- tised, and will be found to afford the greatest comfort to the patient; if, on the other hand, the abscess be comparatively superficial, and the pain and 392 DISEASES RESULTING FROM INFLAMMATION. Fig. 189. constitutional disturbance not very intense, it is, I think, better to Avait until decided pointing has occurred. The reason for this is that, if the incision be made prematurely in another locality, pointing and spontaneous opening may still take place, the surgeon's interference in such a case being aftenvards thought by the patient, and not unreasonably, to have been uncalled for. An acute abscess should only be opened by incision, and this is best ac- complished, I think, with a straight, narrow, sharp-pointed bistoury. The surgeon, holding the knife in his right hand as a pen, but almost perpendicu- larly to the surface, Avith the edge toAvards himself, fixes the abscess with the thumb and fingers of the left hand, and resting the ring and little finger of the right hand upon the skin, quickly plunges the point of the knife into the cavity of the abscess, and rapidly drawing the blade towards himself, enlarges the puncture to the requisite extent as he withdraws the instrument. The depth to Avhich the knife is to penetrate having been mentally determined beforehand, the instru- ment is prevented from going too far by the pressure of the fourth and fifth fingers on the cutaneous surface. The incision should be made in a longitudinal direction as regards the part affected. Local anaesthesia has been sometimes used in these cases, but the freezing process is in itself not devoid of pain, while it renders the skin much more difficult of penetra- tion. If the abscess Avere situated very deeply, there might be some risk of wounding a large vessel in making the opening as above directed, and in such a case it would be better to adopt Hilton's plan, incising the skin and fascia, and then pushing a grooved director through the overlying muscles into the abscess, the opening being dilated by separating the blades of a pair of forceps introduced along the groove of the instrument. A free aperture having been made, the abscess may be allowed to evacuate its contents by the elastic contraction of its own walls; the surgeon may, if necessary, make very gentle pressure with soft sponges on either side of the incision, but all rude handling or squeezing should be strictly avoided. Hemorrhage into the cavity of an opened abscess may occur from a vessel accidentally divided, or Avhich subsequently gives Avay from the relief of pressure upon its walls. The treatment consists in exposure to the air, cold, pressure, or ligation, as in other cases of hemorrhage. After the evacuation of an abscess, poultices may be continued for a few days, until the surround- ing inflammation has subsided, when cerate or other simple dressing should be applied to the wound, and the walls of the cavity compressed by means of a bandage or adhesive strips. If, from the size or situation of the abscess, or from any other circumstance, there be a tendency to bagging of matter, a drainage-tube may be employed, being either simply introduced into the in- cision by means of a forked probe, or carried seton-like through the cavity, and brought out by a counter-opening. Instead of the ordinary drainage- tube, a flexible metallic probe may be substituted (the pus escaping by its side), or a coil of wire, as recommended by Mr. E. Ellis, or a self-retaining, India-rubber drainage-anchor, as suggested by Mr. Daw. The hygienic and constitutional treatment of abscess, and of suppuration generally, Drainage-tube and forked probe. RESIDUAL ABSCESS. 393 has already been considered in the chapter on the Treatment of Inflam- mation. Chronic or Cold Abscess.—The term chronic abscess is open to objection, as referring etymologically only to time, and being of course merely com- parative. A phlegmonous abscess, if deeply seated, may be of slower development than a chronic or cold abscess Avhich is superficial. The term cold abscess is borrowed from the Germans, and is significant, as referring to a prominent symptom in these cases, viz., the absence, in greater or less degree, of the increased temperature and other common signs of inflammation. These abscesses are chiefly met Avith in connection with diseases of the bones or joints, or of the lymphatic system. They are not attended Avith much pain, have little or no disposition to point, and sometimes extend Avidely beneath the skin, or among the planes of muscular tissue. Their development is sometimes very sIoav, resembling that of phlegmonous abscesses, only Avith less local and constitutional disturbance, the investing layer of lymph being occasionally so dense as to obscure fluctuation, and give the appearance of a solid tumor; at other times, the patient suddenly discovers in the groin or axilla a large fluctuating swelling, no symptom having been previously mani- fested to call attention to the part. These abscesses may persist, without undergoing any marked change, for months or even years. The diagnosis must be made with the precautions already pointed out, and often requires the use of the exploring-needle. The pus in these abscesses is usually thin and ill-formed, containing a larger proportion of granules and oil globules, and fewer pus corpuscles, than ordinary "laudable" pus. The treatment of these cases is somewhat different from that appropriate to those of the phlegmonous variety. If the abscess be quite small, it may be simply opened, healing of the cavity being subsequently promoted by the use of some stimulating application, such as the diluted tincture of iodine. In dealing Avith a larger abscess, it is better to wait until the skin threatens to give Avay, unless, from the situation of the abscess, it may be necessary to relieve adjacent organs from pressure. With regard to very large abscesses, particularly those which are connected with disease of the spine or bony pelvis, I am decidedly of opinion that it is better, as a rule, to leave them unopened ; a patient may carry a psoas or iliac abscess for years with com- paratively little annoyance, and maintaining very tolerable health, and yet sink in a very short time after such an abscess has been imprudently evacu- ated. Besides, there is ahvays the hope that complete or partial absorption may occur, Avhen the patient may remain Avell, if not permanently, at least for a A'ery long period. If it be determined to open a large chronic or cold abscess, this may be done with the aspirator, or, if preferred, by means of a simple incision made Avith antiseptic precautions in the manner recom- mended by Prof. Lister. If an abscess have been freely opened and Avill not heal, stimulating injections of iodine may be tried, or a seton of oakum or tarred rope may be used (as recommended by Dr. Sayre, in cases of caries), a method Avhich has the additional advantage of insuring drainage of the suppurating cavity. Callender advises hyperdistension of the abscess-sac Avith carbolized Avater, a plan which I have myself sometimes adopted Avith advantage, Avhile J. H. Webb suggests inflation with carbolized air. In all cases of chronic abscess it is necessary to pay great attention to the state of the general health, maintaining the patient's strength by the administration of nutritious food and tonics. Residual Abscess.—This term has been introduced by Sir James Paget, Avho proposes to include under it "all abscesses formed in or about the 394 DISEASES RESULTING FROM INFLAMMATION. residues of former inflammations." They may occur in the site of previous abscesses Avhich have been partially absorbed, or in the indurations and ad- hesions left by old inflammation Avhich had not reached the suppurative stage. Eesidual abscesses are chiefly met Avith in connection with diseases of the spine, of the bones and joints, and of the lymphatic glands. The prognosis is more favorable than that of ordinary chronic abscess, the heal- ing after e\racuation being, according to Paget, quicker, and attended Avith less constitutional disturbance, than that of a primary abscess of the same size and in a similar situation. The treatment is that already described as appropriate to chronic abscess arising under other circumstances. Sinus and Fistula.—These are narroAV, and often tortuous, suppurating canals or tubes, left by the incomplete healing of abscesses, or resulting from wounds Avhich have united imperfectly. The term fistula is also applied to abnorrfial communications betAveen external and internal parts (as gastric, aerial, or urethral fistula), or between adjacent mucous canals or cavities (as recto-vesical, or vesico-vaginal fistula). When applied to the condition re- sulting from an abscess, or ordinary wround, the term fistula should be re- served for those cases in Avhich there are two openings (as in a fistula in ano), the more general term, sinus, embracing all those tortuous suppurating tracks, Avhich have but one orifice. Sinuses may be kept from healing by the presence of a foreign body or a spicula of bone, by the passage of secre- tions, as of saliva or urine, or by the action of adjacent muscles. The treat- ment consists in removing all irritating substances, and in placing the part at rest, by position, bandaging, etc. In a recent case, healing may be pro- moted by keeping the walls of the sinus in contact by means of compres- sion, while, if the walls of the sinus be callous and indurated, they may be stimulated to greater activity by means of irritating or caustic injections, the tarred seton, or the galvanic cautery. Finally, it may be necessary to freely lay open the sinus through its entire length, by introducing a grooved director and slitting up the superincumbent tissues; the sinus may then be dressed as an open ulcer, and made to heal from the bottom. This mode of treatment is especially indicated Avhen healing is prevented by the action of neighboring muscles, as in cases of fistula in ano, or in the troublesome sinuses which are met with in the groin, in connection Avith suppurating buboes. It is often a good plan, after laying open a sinus, to wipe its whole track out with the solid stick of nitrate of silver, thus making a superficial slough, and preventing premature reunion of the cut edges. Diffused Suppuration, though ordinarily occurring in that form of diffuse inflammation of the areolar tissue Avhich is closely analogous to, if not iden- tical with, erysipelas, may, I believe, occur as a sequel of ordinary inflam- mation in persons in a low state of health, and whose vital powers have been from any circumstance much reduced. It may result from an acci- dental or other wound, or from the irritation of extravasated urine, but may also occur Avithout any apparent exciting cause. The surface in these . cases is but slightly red, the swelling is ill-defined, and rapidly spreads in various directions; there is a feeling of bogginess, rather than of fluctua- tion, and there is sometimes emphysematous crepitation, caused by the gases developed by the putrefactive process; the patient does not suffer very great pain, but is in a profoundly typhoid condition. The treatment consists in making numerous punctures, or small or even large incisions (to relieve tension, and facilitate the exit of pus and sloughs), and in the free admin- istration of stimulants and quinia. SLOUGHING ULCER. 395 Ulcers. The process of ulceration and the mode in Avhich ulcers heal by granula- tion and cicatrization have been considered in a previous chapter, and need not be again referred to. Ulcers have been variously classified by systematic writers, either according to the appearance of the ulcer itself, or according to the constitutional condition of the patient. Thus, we read of healthy, irrita- ble, indolent, weak, inflamed, exuberant, sloughing, varicose, and hemor- rhagic ulcers; and again, of eczematous, cold, senile, strumous, scorbutic, gouty, syphilitic, lupous, and cancerous ulcers. It is easy to understand that, in a person disposed to eczema, an ulcer may be seriously complicated by an attack of that disease, and that any treatment, to be successful, must have regard to the eczematous condition, as well as to the ulcer itself. So in a strumous subject, such remedies as iodine and cod-liver oil may be more im- portant than any local treatment. Scorbutic and gouty ulcers require medi- cines adapted to the scorbutic and gouty diatheses ; while it is quite idle to attempt to heal the ulcerated surface of a cancer as long as the cancerous mass itself is allowed to remain. For practical purposes, the classification usually adopted (Avhich has reference to the appearances of the ulcers them- selves, Avhen occurring in persons of ordinary good health, and not the sub- jects of any special morbid diathesis) is convenient and sufficiently satisfac- tory, it being remembered that there is no specific or essential difference be- tAveen these various forms of ulcer, but that the ulcerative process is identical in nature under all circumstances. Simple or Healthy Ulcer.—This may be considered the type of all the other varieties, and that to Avhich they must be brought in order to effect a cure: it is such an ulcer as is seen in a healing burn, or in a superficial wound Avhich is closing by the second intention. The natural tendency of such an ulcer being toAvards a cure, the only treatment necessary is to keep the part from being injured. AVater dressing, or a greased rag, Avith an elevated position of the part, is all that is usually required; if the granulations be- come exuberant, they should be touched Avith bluestone or lunar caustic; Avhile if too small and closely set, the resin or carbolic acid cerate may be substituted for the milder applications commonly employed. This variety of ulcer may be met Avith in any part of the body; those to be next de- scribed are most frequently seen in the leg. Inflamed or Phlegmonous Ulcer.—This variety is usually met with in those of full habit, and may arise from accidental irritation of a simple ulcer. One of the worst cases of this kind that I have ever seen, Avas in a gentle- man who, having a slight excoriation of the tibial region, rode for several hours on horseback, Avith the stirrup-leather constantly rubbing and chafing the injured part; as a consequence, the Avhole leg was attacked with phleg- monous inflammation, which obliged the patient to stay in the house, Avith the foot elevated, for a considerable period. The treatment of an inflamed ulcer consists in enforcing rest, Avith elevation of the part, in the use of soothing applications, either cold or Avarm, as most agreeable to the patient, and in the administration of laxatives, diaphoretics, etc., as may be indicated by his general condition. Sloughing Ulcer.—This may be considered as an aggravated form of the last variety, and is usually met Avith in cachectic or ill-nourished individuals. The treatment consists in the administration of opium and of concentrated 396 DISEASES RESULTING FROM INFLAMMATION. nutriment, with stimulus if required, and in the local application of anodyne fomentations, such as diluted laudanum. If there be much tendency to spread, the ulcer should be treated as a case of sloughing phagedaena or hospital gangrene. The " electric bath " is recommended by Weisflog. Weak or (Edematous Ulcer.—In this variety the granulations are large, pale, flabby, and apparently distended with serum. They are not unfre- quently detached in large masses by sloughing. This form of ulcer may be induced by long-continued application of poultices or of water dressing. I have frequently seen it in cases of neglected gtlnshot Avound. The treatment consists in improving the general tone of the patient, and in the local use of stimulating and astringent dressings, such as a solution of sulphate of zinc, or of sulphate of copper, zinc cerate, etc., with moderate support by means of a bandage. Roche, an East Indian surgeon, speaks very highly of applications of the bark of the acacia catechu, so as fairly to tan the ulcer and surrounding skin. Neuralgic or Irritable Ulcer.—This variety is characterized by the in- tense pain and hyperaesthesia which accompany it. It usually occurs about the malleoli, or anterior edge of the tibia, and is most frequent in women past the middle age, and who are in a depressed state of health, though I have seen it in young, and otherwise healthy, laboring men. The treatment consists in the use of anodyne fomentations, with the occasional application of a solution of nitrate of silver (gr. iv.-x. ad f 5j), as recommended by Skey for painful burns. The general health must at the same time be improved by the administration of tonics, especially quinia, nux vomica, etc. If the pain can be traced to any special nerve, this may be resected, as advised by Mr. Hilton. Indolent or Callous Ulcer.—This is by far the most common form of ulcer; it occurs usually in those of middle life, and is situated in the loAver half of the leg, and more often on the fibular than on the tibial surface. The floor of the ulcer is somewhat concave, with flattened granulations, furnishing a thin and scanty pus. The ulcer is surrounded by an elevated ring of very dense and indurated tissue, which seems to be a provision of nature to prevent the spread of the disease, acting, indeed, as a kind of natural splint to keep the ulcerated surface at rest. As long as this hard ring remains, hoAvever, healing will not occur, and hence to depress the edges is the first step in the treatment of an indolent ulcer. If the patient can remain in bed, Avith the foot elevated, a poultice may be applied for tAvo or three days, to soften and relax the tissues, pressure being then applied by means of a few adhesive strips, the positions of which are varied at each dressing, Avhile the edges of the ulcer are stimulated with the solid stick of nitrate of silver. A very good plan of hastening the disappearance of the indurated ring, is to make across it numerous radiating incisions, extending about a quarter of an inch into sound tissue, as recommended by Mr. Gay. Sappey's and Syme's method, which consists in the application of a blister to the whole ulcerated surface and a zone of the surrounding healthy skin, is occasionally very efficient. Finally, the indurated edges may be trimmed away Avith the knife, a pro- ceeding which, though apparently heroic, is almost painless, on account of the indolent nature of the sore. As soon as the ulcer has by these means lost its peculiar excavated appearance, it may be dressed Avith resin cerate, or some similar article, cicatrization being assisted by moderate compression with adhesive strips and bandage. The sulphuret of carbon has recently been recommended as a dressing in these cases by Guillaumet and other INDOLENT OR CALLOUS ULCER. 397 French surgeons. In case the skin is very irritable, the disease approaching in character to what is called the eczematous ulcer, wet strips of bandage may be advantageously substituted for those of adhesive plaster. It often happens that patients Avith indolent ulcers find it impossible to lie by, as above recom- mended, and, under such circumstances, I know of no better mode of treat- ment than that introduced by Baynton and Critchett, which consists in closely strapping the part, or even the whole limb, with strips of adhesive plaster laid on in an imbricated manner, a firm bandage being then applied over all (Fig. 190); or an India-rubber bandage may be used, as advised by H. Martin. The only constitutional treatment usually required in these cases is such as may be indicated by the patient's gene- ral condition. Mr. Skey rec- ommends the administration of opium, which may be given in doses of one grain, night and morning. In the eczematous eases, I have derived advantage from the persistent use of small doses of FoAvler's solution. In some cases an ulcer will heal readily up to a certain point, and there A\lll Stop, in Strapping an ulcer. (Liston.) spite of the most careful dress- ing—the tension upon the part appearing to be so great that further contrac- tion cannot take place. Under such circumstances, a longitudinal incision, as advised by Faure, may be made through the healthy skin on each side of the ulcer, the gaping of the incisions permitting the resumption of the heal- ing process; or circidar incisions, surrounding the ulcer, as originally sug- gested by Dolbeau and recently recommended by Niissbaum, may be sub- stituted. Plastic operations have been occasionally practised for the cure of obstinate ulcers of the leg, but, in my experience, have not proved very successful. It has been suggested by a French surgeon, M. Reverdin, to treat ulcers by the Transplantation of Cuticle. The operation consists in applying shav- Fig. 191. Scissors for skin-grafting. ings of the epidermis, or of this Avith a thin layer of the cutis—the latter plan has been most commonly adopted—to various points of the granulating surface, binding these grafts in position by means of adhesive strips. The 398 DISEASES RESULTING FROM INFLAMMATION. grafts may at first seem to disappear, but in a few days become converted into isolated cicatrices, from which, as from centres, the healing process rapidly spreads. It is essential for the success of the experiment that the granula- tions should be in a healthy condition, that no fat should be transplanted Avith the skin, and that the graft should be closely and accurately applied to the granulating surface. Berger advises the preliminary application of a poul- tice or mustard plaster, so as to increase the vascularity of the skin. This mode of treating ulcers has excited a good deal of attention, and has been tried with more or less successful results at numerous English and American hospitals. Dr. Leale, of New York, employs warts instead of ordinary skin. The transplantation of hairs has been suggested as a substitute by Dr. Schweninger, a German surgeon. Fischer, of Strasbourg, uses large grafts, from an amputated limb, in connection with the elastic bandage, Avhile grafts from a dead body have been successfully employed by Dr. Girdner. In some situations, as on the back, between the shoulder-blades, it is very difficult to apply equable pressure by the methods ordinarily employed. Here the application of a zinc plate, or disk of sheet-lead, cut to fit the ulcer, Avill often be attended by the happiest results—not, I believe, by the develop- ment of any galvanic current, as has been supposed, but simply by acting as an efficient means of applying mechanical compression. The use of a galvanic current is, however, recommended by Spencer Wells, Golding- Bird, and other Avriters. The virtues of sheet-lead have been recently ex- tolled by Dr. Van Blaeven, a Belgian surgeon, who claims by its use to have effected the restoration of parts carried aAvay by sabre-strokes, etc. Hemorrhagic and Varicose Ulcers.—Other varieties of ulcer, described by systematic Avriters, are the hemorrhagic and the varicose. The Hemor- rhagic Ulcer is one that bleeds from time to time, occasionally existing in connection Avith the hemorrhagic diathesis, but more often serving as a channel for vicarious menstruation. The treatment, in the latter case, con- sists in endeavoring to restore the normal Aoav by means of the remedies ordinarily used for amenorrhcea. The Varicose Ulcer is merely an ulcer coexisting with varicose veins. It is commonly taught that the varicose disease precedes and causes the ulcer, and obliteration of the veins is accord- ingly proposed as the only rational mode of cure. It has been shown, how- ever, I think, by Mr. Gay's researches, that the varicose condition is rather a consequence than a cause of the ulceration, and that hence less active measures will commonly suffice. The treatment should vary according to the condition of the ulcer, Avhether inflamed, irritable, or indolent. Borel- Laurez, a Swiss surgeon, employs a dressing of finely powdered charcoal. Hemorrhage from the bursting of a vein may be checked by position and pressure, or may occasionally require obliteration of the vessel, by the method Avhich will be described when Ave come to speak of varicose veins in general. After the cicatrization of an ulcer is completed, a great deal may be done by care and attention to prevent the scar from again giving Avay. The part should be kept scrupulously clean, and should be protected as much as possible from external injury. If the ulcer be situated on the leg, the patient may advantageously wear an elastic bandage or stocking, to counter- act the tendency to gravitation of blood Avhich necessarily exists in that part. Amputation for Ulcer.—It sometimes happens that an ulcer proves utterly incurable, either from extending completely around the limb, or from deeply involving a subjacent bone or neighboring joint '(as in the perforating ulcer which sometimes follows a bunion). In such cases the question of SPONTANEOUS GANGRENE. 399 amputation may arise, and the operation under such circumstances Avould be occasionally justifiable. It must be remembered, hoAvever, that amputation, in the lower extremity, is in itself attended Avith very great risk to life, and that the disease, in the instances mentioned, is often more a source of dis- comfort than of danger'or even positive suffering. Hence the surgeon should hesitate before proposing an operation Avhich is not imperatively required, and Avhich may be folloAved by the gravest consequences. When amputation is resorted to, it should be done at such a height as to insure the possibility of forming the flaps from perfectly healthy tissues. Ulcers occurring on Mucous Membranes present the ordinarv characters of healthy, Aveak, or irritable ulcers, as met with in the cutaneous structures. They usually require the free use of stimulating or caustic applications, the best being, probably, the nitrate of silver, Avhich may be employed either in substance or in solution. Gangrene and Gangrenous Diseases. The nature and treatment of the ordinary forms of gangrene have already been considered in the chapters on Inflammation, on AVounds in General, on Injuries of Bloodvessels, and on Amputation. There remain to be described certain forms of Spontaneous Gangrene, and those affections Avhich are com- monly classed together as Gangrenous Diseases. Spontaneous Gangrene may occur at any age, and is due to arrest of the circulation, caused either by disease of the arteries themselves, or by a morbid condition of the circulating fluid. Inflammation of the arterial coats may cause gangrene, as may arterial thrombosis Avithout inflammation, or embolism from the detachment of fibrinous concretions from the valves of the heart; the latter is, I believe, a more frequent occurrence than is usually supposed. Finally, the use of certain articles of food, as of spurred rye, has been fol- loAved by spontaneous gangrene. This form of gangrene is usually of the dry variety, though moist gangrene may occur after embolism, Avhen the main trunks which furnish blood to the part are suddenly occluded—the differ- ence probably depending, as remarked by Coote, upon the rapidity Avith Avhich the death of the part takes place. Senile Gangrene (which, as ordi- narily seen, may be considered the type of the dry variety of the affection, or mummification') is dependent upon calcification of the arterial coats, together Avith the general loss of tone and enfeebled nutrition Avhich accom- pany old age. In certain cases, the exciting cause of the disease is some slight irritation, such as the chafing of a shoe, and, under such circumstances, the gangrene approaches someAvhat to the ordinary inflammatory form of mortification. More often the disease begins, Avithout apparent cause, as a dark purple or blackish spot, surrounded by a dusky red areola, Avhich spreads with the gangrene and is the seat of intense burning pain, the latter, however, subsiding when the gangrene is complete. The seat of the gan- grene is commonly the inner side of the foot, and especially of the great toe, though I have seen a precisely similar condition of affairs in the scrotum, in a patient Avorn out by a Ioav fever; the fact that this form of gangrene occurs, under such circumstances, among comparatively young persons, shoAATs that the term senile gangrene, though significant, is not strictly accurate. Warn- ing is sometimes given of the approach of this form of gangrene, by the existence of signs of defective circulation, such as numbness, coldness, tin- gling, and cramps in the calves of the legs. The course of senile gangrene 400 DISEASES RESULTING FROM INFLAMMATION. is usually chronic, lasting sometimes for more than a year, and recovery occasionally folloAvs after the separation of the affected part. Treatment.—This consists in maintaining the general health of the patient, by the use of tonics and by the judicious administration of food and stimu- lants. Among drugs, opium is particularly useful/and may be given in grain doses three or four times in the tAventy-four hours. Antispasmodics also may be advantageously used in these cases, especially chloroform (internally) and camphor. The local treatment consists chiefly in keeping the part Avarm, by Avrapping it in cotton-Avadding or wool; if there be much fetor, charcoal poultices may be substituted, or cloths wet with a solution of permanganate of potassium. The question of amputation in senile gangrene has already been referred to, at page 92. Bed-sores.—These may occur in any case in which a patient is confined to bed for a considerable period, simply from the long-continued pressure- just as similar excoriations and sloughs may result from the use of a badly padded splint. The worst forms of bed-sore are, hoAvever, seen in patients Avhose general poAvers of nutrition are impaired by previous illness (as in typhoid fever), or who, from spinal injury, are totally unable to vary their position. In such cases, it is not infrequent for the slough to extend so deeply as to involve the sacrum, or any other bone that is exposed to pres- sure, or even, in some instances, to lay open the vertebral canal. The pain attending bed-sores is usually very great, though, in cases of spinal injury, the patient may be unaAvare of their existence. The formation of bed-sores may commonly be prevented by the use of a water-mattress, or of soft pillows, the parts being kept scrupulously clean, frequently bathed with stimulating and astringent lotions, and protected by the application of collodion, soap-plaster, or adhesive plaster; Prof. Brown-Sequard recommends the alternate application of ice and hot poultices. If a bed-sore have actually formed, the separation of the slough may be hastened by the use of yeast or porter poultices, the ulcer which is left being subsequently dressed Avith resin cerate, or some similar application ; the part must be entirely freed from pressure, and the patient's general health improved by the administration of concentrated food, tonics, and stimulants. In obstinate cases, healing may sometimes be promoted by the application of the galvanic current, as suggested by Crus- sel, of St. Petersburg, and recommended by Spencer Wells and by Ham- mond, of New York. Bed-sores may occasionally prove fatal, by involving important structures (as the membranes of the spinal cord), by leading to hemorrhage, by gradually exhausting the patient, or by the induction of pyaemia. Gangrenous Stomatitis, also called Gangrcena Oris, Cancrum Oris, and Noma, is an affection of childhood, coming on after various eruptive fevers, especially measles—a someAvhat similar affection sometimes occurring in adults after typhus. Gangrenous stomatitis has been attributed to the abuse of mercury, and this drug, if improperly exhibited, may of course be one source of depression, in addition to the debilitating effects of illness, depriva- tion of food, etc. That there is, however, any direct causal connection be- tAveen the use of mercury and this disease, is, I think, at least not proved. The first symptom of gangrenous stomatitis is usually a dusky red SAvelling of the cheek, which becomes stiff and shining. Careful examination will now show a sloughing ulcer on the inside of the cheek, extending to the adjacent gum, and discharging fetid, ill-formed pus, which, mingled with saliva, constantly dribbles from the mouth. As the diseases progresses, a gangrenous spot appears on the cheek, the whole thickness of the part being HOSPITAL GANGRENE. 401 finally involved, and perforation of the cheek, with denudation and perhaps necrosis of the alveoli, resulting. The constitutional symptoms are of a typhoid character, coma sometimes supervening before death, which may occur at almost any period of the disease. Dr. Sansom found moving bodies, analogous to bacteria, in the blood of a girl who died from noma, and inocu- lation of the diseased blood in animals produced septicaemia attended Avith the formation of similar bodies. The treatment consists in everting the cheek (the patient being anaesthetized), and thoroughly cauterizing the whole ulcerated surface Avith strong nitric acid. One thorough cauterization is usually sufficient, though the case must be watched, and a second or third application made if necessary. In an aggravated case of noma, occurring in a syphilitic child under my care at the Children's Hospital, cauterization with the acid nitrate of mercury, and the internal administration of iodide of potassium, proved very efficient. The mouth should be frequently syr- inged with detergent and disinfectant washes, such as a solution of the per- manganate or chlorate of potassium, or of borax, and the general health sustained by the frequent administration of concentrated food and stimulus. The application of tincture of iodine is recommended by Dr. Miller, of Kansas City, Avhile Popper, of Pesth, advises that the slough should be scraped aAvay, and the parts dressed Avith creasote. The deformity left after cicatrization may subsequently require a plastic operation for its cure. Noma Pudendi.—This grave affection, which seems to be confined to female children, is very analogous to the preceding, and usually attacks the mucous or submucous tissues of the generative organs, though, according to Holmes, it sometimes begins in the fold of the groin. The treatment consists in early and thorough cauterization, and in the adoption of measures to sus- tain the patient's strength. Parrot speaks favorably of the local use of iodoform. Death sometimes occurs very suddenly, after the apparent estab- lishment of convalesence. Hospital Gangrene.—This affection, which has received a great variety of names, such as Sloughing Phagedozna, Pulpy Gangrene, Putrid Degeneration, Traumatic Typhus, Pourriture d'Hopital, etc., is occasionally met with as a sporadic disease, but has attracted most attention Avhen prevailing epidemi- cally or endemically in hospitals, especially Avhere large numbers of wounded men are croAvded together, as in military hospitals in the neighborhood of a battle-field. It has been studied by a great many Avriters, among Avhom may be particularly mentioned, Pouteau, La Motte, Ollivier, Delpech, Le- gouest, Rollo, Blackadder, Boggie, Hennen, Ballingall, Thomson, Guthrie, and Macleod. It has also been ably investigated by many American sur- geons, Avho had ample opportunities for its study during the late war, and an elaborate monograph on the subject has been contributed by Prof. Joseph Jones, of Noav Orleans, to the Memoirs of the U. S. Sanitary Commission. The characters of hospital gangrene vary in different epidemics. The ma- jority of observers have found the local to precede the constitutional symp- toms, and hence have regarded the disease as a strictly local affection; while in other instances, equally careful observers have found constitutional disturb- ance, headache, furred tongue, etc., to precede the local changes in the wound by an interval of from one to three days. Hospital gangrene is undoubtedly contagious,1 having been developed by indirect inoculation, as well as through 1 Dr. AV. Thomson examined microscopically the discharges in several cases of hospital gangrene which occurred at Douglas Hospital during the late war, with a view of determining the presence or absence of fungi, which it was supposed might be the source of contagion. " No fungi were found. The discharge consisted of fluid, 26 402 DISEASES RESULTING FROM INFLAMMATION. the medium of instruments and sponges; the exceptional cases, in Avhich one of two contiguous Avounds, in the same patient, suffered from the dis- ease, while the other escaped, merely prove that in those instances the affec- tion was not auto-inoculable. While, however, hospital gangrene is usually transmitted by contagion, it may probably originate de novo, as the result of overcrowding, bad ventilation, etc. Two forms of hospital gangrene may be recognized, but the difference be- tween them is one of degree rather than of kind. For the development of either, the presence of a wound is probably necessary, though this Avound may be of the most trivial character, as the sting of an insect, the prick of a lancet, or even the scratch of a finger-nail. A depressed or depraved state of the system does not appear to be at all essential for the development of the disease, though it may very probably aggravate the intensity of the affection Avhen it occurs. The following description, taken from Guthrie, gives a vivid picture of the worst form of hospital gangrene. The Avound thus attacked " presents a horrible aspect after the first forty-eight hours. The whole sur- face has become of a dark-red color, of a ragged appearance, Avith blood partly coagulated, and apparently half putrid, adhering at every point. The edges are everted, the cuticle separating from half to three-quarters of an inch around, Avith a concentric circle of inflammation extending an inch or two beyond it; the limb is usually SAVollen for some distance, of a shining white color, and not peculiarly sensible except in spots, the whole of it being per- haps oedematous or pasty. The pain is burning, and unbearable in the part itself, Avhile the extension of the disease, generally in a circular direction, may be marked from hour to hour; so that, in from another twenty-four to forty-eight hours, nearly the whole of the calf of the leg, or the muscles of the buttock, or even of the wall of the abdomen, may disappear, leaving a deep, great holloAv, or hiatus, of the most destructive character, exhaling a peculiar stench, AA'hich can never be mistaken, and spreading Avith a rapidity quite aAvful to contemplate. The great nerves and arteries appear to resist its influence longer than the muscular structures, but these at last yield ; the largest nerves are destroyed, and the arteries give Avay, frequently closing the scene, after repeated hemorrhages, by one Avhich proves the last solace of the unfortunate sufferer. . . . The extension of this disease is, in the first in- stance, through the medium of the cellular structure of the body. The skin is undermined and falls in; or a painful red, and soon black, patch, or spot, is perceived at some distance from the original mischief, preparatory to the whole becoming one mass of putridity, Avhile the sufferings of the patient are extreme." This worst form of hospital gangrene is, happily, comparatively rare at the present day. In the milder form, the Avhole course of the affec- tion is more chronic, causing less destruction of tissue, and accompanied Avith comparatively little constitutional disturbance. The general characters of granular matter, and debris. The connective tissue seemed to have been broken down into unrecognizable granular material. The fibrous tissue was softened and easily teased out, and in the muscular tissue the striated appearance was lost before the fibrous. No evidence of textural growth was found in the discharges, although the' piled-up ' and thickened margins of the ulcers would probably reveal, on exami- nation, a multiplication of the connective tissue corpuscles, as reported in a similar group of cases at Annapolis, Aid., by Assistant Surgeon Woodward, U. S. A." (Am. Journ. of Med. Sciences, April, 1864, p. 393.) By microscopic examination, Prof. Joseph Jones has discovered numerous animalcules, as well as vegetable organisms, in the gangrenous matter of hospital gangrene, but has been unable to establish any relation betAveen the cause of the disease and the nature and character of these or- ganisms, which have been absent in the most extensive gangrene, when excluded from the atmosphere by sound skin. (See U. S. Sanitary Commission Memoirs, (Surgical), vol. ii. p. 266.) HOSPITAL GANGRENE. 403 the wound are the same, especially the circular shape, and cup-like excaAration or scooped-out appearance of the ulcer. There is less eversion and under- raining of the skin, less oedema and pain, and the surface of the wound is covered Avith a pulpy, ash-colored slough, instead of the putrid clots described in Guthrie's vivid account. The constitutional symptoms of hospital gangrene mav at first present a somewhat sthenic type, but rapidly change into those of a profoundly typhoid and adynamic condition, the patient indeed present- ing much the appearance of one suffering from typhus fever. The mortality from hospital gangrene has varied in different epidemics. During the Peninsular campaign, the death-rate, according to Guthrie, was 20 to 40 per cent., the general aA7erage being about 1 death in 3 cases at- tacked. In the Crimean Avar, the mortality in uncomplicated cases was much less, Avhile in the experience of our OAvn surgeons, during the late war, the number of deaths was comparatively very small. The causes of death, ac- cording to Prof. Jones, may be classified as (1) progressive exhaustion, (2) hemorrhage, (3) entrance of air into veins, (4) opening of large joints, (5) formation of bed-sores Avhich subsequently become gangrenous, (6) diarrhoea, (7) subcutaneous disorganization of tissues around the original Avound, (8) mortification of internal organs, (9) direct implication of vital parts, (10) pyaemia, (11) phlebitis, (12) profuse suppuration, necrosis, etc. In the treatment of hospital gangrene, it is very important to secure good ventilation and to enforce the utmost cleanliness. Affected patients should be at once segregated (if possible) from others, and, if it were practicable, it Avould be better that each person attacked should be placed in a separate apartment or tent. It is, indeed, probable that a certain number of the milder cases would get well under simple hygienic treatment, and the risks of exposure are much less than those of overcrowding; as a German surgeon (Prof. Jiingken) has someAvhat quaintly put it, "It is, after all, better that the patient should shiver a little in a cold but pure air, than that he should die in a Avarm but poisoned atmosphere." As it is certain that the disease may be communicated by means of sponges, etc., the greatest precautions should be taken in Avashing and in dressing wounds. The ward carriage (Fig. 10), or some similar contrivance for using a stream of running water, will, in these cases, be found of great service. The adoption of Lister's anti- septic method is recommended as a prophylactic measure by Nussbaum, of Munich. The Local Treatment of hospital gangrene is noAv, I believe, almost uni- versally regarded as of the highest importance; many different applications have been employed, varying in seATerity from the actual cautery doAvn to simple syrup, or buttermilk, and each remedy has proved occasionally suc- cessful. The oil of turpentine is highly recommended by Prof. Bartholow, and poAvdered camphor by Netter and other French writers. Most surgeons are noAv agreed as to the propriety of thoroughly cauterizing the entire sur- face of the wound once, or oftener if necessary; and to insure thorough cau- terization, it is necessary first to remove all the adherent slough with forceps and scissors, folloAved by rough sponging. The Ararieties of caustic most to be relied upon are, I think, nitric acid, bromine, and a strong solution of the permanganate of potassium. The latter article is that Avhich I have myself employed, in the proportion of 3j to f,5j of Avater, and I have never, as yet, been disappointed in its effect; it is but just, however, to saA' that I have not had occasion to try it in any cases of the Avorst form, such as are described by Guthrie. The permanganate has been favorably reported upon by Prof. Jackson, Dr. Hinkle, Dr. Leavitt, and others. Nitric acid seems to be generally preferred by British surgeons, and is recommended by Prof. Jones, and by the authors of the "Manual of Military Surgery, prepared for the use 404 DISEASES RESULTING FROM INFLAMMATION. of the Confederate States Army," while the hot iron seems to be preferred by the French; the latter application would probably be the best in cases attended with hemorrhage. Heiberg, of Christian!a, from an extended ex- perience during the Franco-German var, gives a preference to the chloride of zinc. Bromine, the merits of Avhich were first announced, during our Avar, by Dr. Goldsmith, has been most favorably reported upon by Drs. Post, Moses, W. Thomson, Herr, and many others, and seems, from the published testimony in its favor, to be, upon the whole, the best caustic which has yet been proposed for these cases. The wound having been previously cleansed, the bromine may be applied undiluted, or in solution Avith bromide of potas- sium, by means of a camel's-hair brush, or a sponge or mop, attached to a stick, or by means of a glass pipette or syringe; as the application is very painful, the patient should be first brought under the influence of ether or chloroform. Bromine has also been used in the form of vapor (the surface to be acted upon being protected Avith dry lint, upon which is placed a cloth dipped in pure bromine, and the whole covered with oiled silk), and by means of hypodermic injection at the circumference of the sore. (See Dr. Brinton's Report to Surgeon-General, in Am. Journ. of Med. Sciences, July, 1863, p. 279.) The bromine acts by producing an eschar, upon the separation of which the Avound Avill usually be found healthy and disposed to heal. Until the slough separates, the wound may be dressed Avith dilute liq. sodae chlori- natis, with the permanganate of potassium (3j-Oj), or simply with Avater dress- ing ; the resulting ulcer is, of course, to be treated on general principles. The Constitutional Treatment, if less important than the local, is still not to be neglected. Almost all surgeons, with the exception of Boggie, ha\Te agreed in recommending a tonic and stimulant, rather than a depletory, course of treatment. The milder cases require scarcely any medication, attention to the state of the secretions being all that is necessary in many instances. When the typhus condition is more marked, the mineral acids may be used Avith advantage; the muriatic acid of the U. S. Pharmacopoeia may be given in five-drop doses, with opium and oil of turpentine, every three or four hours, as is done in cases of typhoid and typhus fever. Opium is, of all single remedies, the most useful in this affection; it may be given quite freely, and a case is reported by Pick, in which gradually increasing quanti- ties of laudanum were administered for fifteen days, the patient taking at the last nearly half an ounce in the twenty-four hours. Quinia and iron (especially in the form of the muriated tincture) are particularly valuable in the later, though they may be required in the earlier, stages of the disease. The diet should consist of nutritious but easily digestible articles of food, such as milk and beef-essence, and on the first manifestation of adynamic symptoms alcoholic stimulants should be freely administered. Amputation may be occasionally rendered necessary by the occurrence of uncontrollable hemorrhage from a wound Avhich has been attacked by hos- pital gangrene, or the same measure may be required at a later period, on account of the extensive destruction of tissue, involving, perhaps, bones and joints, as well as the more superficial structures of the part. It is said that hospital gangrene may occur as an idiopathic affection, upon an unbroken surface, the disease then beginning as a vesicle surrounded by a dusky areola, the vesicle ultimately breaking, and leaving a slough, upon the separation of Avhich the characteristic appearances of the affection are manifested : these idiopathic cases are, however, at least, extremely rare, and in those Avhich have been reported, it may be fairly doubted Avhether some excoriation may not in fact have existed, though so slight as to have escaped observation. ANTHRAX OR CARBUNCLE. 405 Furuncle or Boil.—This very common affection consists of a localized inflammation of the skin and subcutaneous areolar tissue, almost invariably running on to suppuration, and attended by the formation of a small central slough, which is popularly called the core. Boils may occur at any age, and in any part of the body; they are, hoAvever, most common in youth, and are generally seen on the nucha, back, or gluteal region. They are often mul- tiple, frequently come out in successive crops, and occasionally occur epi- demically—those Avho are affected being usually in a depressed state of health. The affection, though very painful and annoying, is not commonly attended Avith danger. The treatment consists in improving the general health by attention to the state of the secretions, and by the administration of tonics, especially quinia, if the patient be debilitated. Yeast is a favorite domestic remedy. Arsenic is sometimes of benefit, given in small doses, and continued for a considerable period. The liq. potassoz has been similarly used Avith advantage, and the celebrated John Hunter, who suffered much from boils, declared that he had cured himself by taking the carbonate of sodium. The local treatment should vary Avith the circumstances of the case. If the boil be not very painful, it should be left to open of itself, being poulticed, or simply protected by means of the ceratum saponis, spread upon a piece of soft buckskin or wash-leather. There is some reason to believe that boils are less apt to recur if left to themselves, than if too actively treated. If, however, the patient be in great pain, with much constitutional disturbance, the sur- geon should not hesitate to make a free single or crucial incision, the case being afterwards treated as one of abscess. It may be sometimes possible to abort a boil by purging, and by the application of tincture of iodine, spirit of camphor (Simon), or mercurial ointment (Roth), or by touching the vesicle which usually marks the point of central slough Avith lunar caustic, a solution of corrosive sublimate, or the strong aqua ammoniae. Planat recommends the use of arnica, both as an internal remedy, and, locally, mixed Avith honey. Anthrax or Carbuncle.—A carbuncle may be regarded as an aggravated form of boil. It usually begins as a vesicle, surrounded by an indurated dusky areola. The subcutaneous tissue sloughs at an early period, giving the part a peculiar boggy feel, before the skin itself gives way.1 The skin may slough merely beneath the central vesicle, but, if the carbuncle be large, numerous apertures will be formed, arranged in a cribriform manner. The carbuncle continues to spread, reaching its height in from three to eight days, and accompanied, while it is extending, with great pain and constitutional disturbance. The average diameter of carbuncles is tAvo or three inches, though in some instances they attain a very much larger size. Mr. Paget mentions a case in a man aged eighty, in Avhich the carbuncle measured four- teen by nine inches. Carbuncles are usually met with on the back of the neck or betAveen the shoulders, but may occur in any portion of the body. They are most frequent in the male sex and in persons in advanced life. The"causes of carbuncle are obscure. The affection is usually nietwith in those Avho are enfeebled by age, or worn doAvn by overwork or privation, and is sometimes associated Avith visceral disease, particularly affections of the kidneys, or diabetes. The prognosis should ahvays be guarded; though the large majority of cases recover, the disease is always serious. Death may 1 Much light has been thrown upon the pathology of carbuncle by Dr. J. Collins Warren, who describes it as a rapidly spreading, phlegmonous inflammation, or purulent infiltration, of the subcutaneous areolar tissue, its characteristic appearance depending on the anatomical peculiarities of the part aflfected. (Columnce Adiposes, etc., p. 25. Cambridge, 1881.) 406 DISEASES RESULTING FROM INFL AM M ATION. occur from the extension of inflammation to an important organ, as the brain or peritoneum, from visceral complication, from simple exhaustion, or from the development of erysipelas or pyaemia. Treatment.—If the surgeon be called at an early stage, it may be possible to abort the disease, by opening the central vesicle and applying some caustic agent, such as the nitrate of silver, the Vienna paste, or a strong solution of the permanganate of potassium; or the plan proposed by Dr. Physick might be resorted to, and a blister applied over the whole inflamed surface. It usually happens, howeArer, that the case is first seen when the bogginess and cribri- form ulceration shoAV that sloughing of the areolar tissue has already occurred. Under these circumstances, it is commonly advised to make crucial or radiat- ing incisions, deep and free, so as to include the healthy tissue beyond the utmost limits of the disease. Other surgeons make subcutaneous incisions; while others again rely upon the use of caustics, applying these either to the surface, to the incision wounds (when these are made), or around the cir- cumference of the carbuncle, in the form of caustic arrows (cauterisation en fleches). It is not proved, hoAvever, that any of these methods are effective, either in limiting the extent of the carbuncle, or in shortening its duration. It is possible that incision may, in the early stage of the disease, give relief from pain, but it does so at the cost of considerable loss of blood; while the healing of the incision wounds themselves, imposes an additional tax upon the already overweighted poAvers of the patient. In most cases it will be found sufficient to cover the carbuncle Avith a piece of leather or thick kid, spread Avith lead plaster or soap cerate, a central aperture being left for the escape of the slough. Another plan, which I have found very useful, is to apply pressure, as suggested by O'Ferral, by means of strips of adhesive plaster, beginning at the circumference and laid on concentrically, until all except the central portion is covered. A poultice may be applied over all if there be much pain, or the ulcerated centre of the carbuncle may be simply dressed with wet lint. The extrusion of the slough is much assisted by the concen- tric pressure (Avhich is not at all painful), and may be further aided by the use of forceps and scissors. Dr. Leitner, of Georgia, accomplishes the same purpose by the application of a cupping-glass. When the slough has come aAvay, the resulting ulcer should be treated upon general principles. The constitutional treatment is equally simple. In the milder cases a little opium may be required as an anodyne, and, if there be constipation, the bowels should be relieved by a mild laxative. Should the tongue be dry and covered Avith a broAvnish fur, muriatic acid, in combination Avith lauda- num and oil of turpentine, may be usefully administered. At a later period, quinia and the tinct. ferri chloridi will come into play, while at any stage, if there be delirium or other nervous complication, camphor and ammonia may be given Avith advantage. The diet should, as a rule, be mild, but nutritious, consisting of such articles as milk, beef-essence, soft-boiled eggs, etc. Alco- holic stimulus, though not necessary in every case, will usually prove a ser- viceable adjunct to treatment, and is often imperatively demanded, especially in the later stages of the affection. Facial Carbuncle.—Under this name is described, by British surgeons, a malignant carbunculous affection, which attacks chiefly the lips, and which presents some analogous features to the disease known in France and in this country as malignant pustule.1 The affection is a very painful one, and fre- 1 M. Reverdin maintains, in an elaborate memoir published in the Archives Gent- rales de Me'decine for June, July, and August, 1870, that the gravity of carbuncles of the face, and particularly of the lips, is solely due to the frequent occurrence of phle- OTHER GANGRENOUS AFFECTIONS. 407 quently proves fatal, through the development of pyaemia. Of 45 cases col- lected by Dr. Lidell, of New York, only five terminated in recovery. The treatment consists in the administration of stimulants, and of large doses of quinia. Local ^measures are of but secondary importance, but an incision may be required to relieve tension and allow the exit of sloughs. Malignant Pustule (Pustule Malig-ne, Charhon).—This affection is usually communicated by inoculation, from direct contact with the blood or other fluids derived from diseased animals, as from horned cattle affected with the murrain, or from septic material conveyed by flies, and is said to have occa- sionally resulted from eating the flesh of such animals, or even to have been transmitted through the medium of the atmosphere. The affection begins a day or tAvo after inoculation, as an itching red spot followed by a A'esicle, Avhich bursting leaves a dry broAvnish eschar. A fresh crop of vesicles next appears around the slough, and the subcutaneous tissue becomes involved, forming a hard SAvelling to Avhich the French give the name of Bouton or Tumeur Charbonneuse. The neighboring lymphatic glands often become secondarily inflamed. There is a good deal of fever and of constitutional disturbance, the patient, in unfavorable cases, rapidly sinking into a typhoid state, and dying Avith the ordinary signs of blood-poisoning.1 The affection is said by Prof. Gross and other American Avriters, to be intensely painful, but Bourgeois (one of the latest French authorities on the subject) speaks of the absence of pain as a prominent characteristic. The disease may be distinguished from carbuncle, by the fact of its beginning in the skin and only involving the subcutaneous tissues at a later period, and by the almost complete absence of suppuration. The treatment consists in thorough cauter- ization Avith caustic potassa, either Avith or Avithout previous scarification, according to the progress wThich the disease has made when first seen; Prof. Gross and Dr. Popper recommend total excision. The constitutional treat- ment consists in the administration of concentrated food and stimulus, with tonics, especially quinia, and the mineral acids. Cezard recommends the use, both internally and externally, of iodine held in solution by means of iodide of potassium, looking upon this drug as a positive antidote to the poison of the disease, Avhile Estradere speaks very favorably of the use of carbolic acid both internally and as a local application. Hypodermic in- jections of iodine are employed by Chipault, and those of carbolic acid by Trelat. Other Gangrenous Affections.—Various forms of gangrene are occasion- ally met with, which cannot be referred to any of the diseases above de- scribed. Under the name of Wide Gangrene of the Skin, is described by Quesnay, Brodie, and others, a form of dry gangrene, in which successive patches in various parts of the body, especially the neck, arms, and back, undergo mortification, preserving at first their white color, but becoming subsequently horny and straw-colored, and shoAving, in the form of red streaks, the "capillaries filled Avith coagulated blood. After the separation of the sloughs, the ulcers heal without difficulty. Quesnay states that this form of gangrene is due either to arterial obstruction, or to compression or paraly- bitis, Avhich may cause death by the inflammation spreading to the sinuses of the dura mater, or by the development of pytemia. He regards the affection as totally distinct from malignant pustule, and recommends early and free incisions. A similar view is held by Dr. Lidell, and has been recently acceded to by Sir James Paget. 1 Dr. Gerald Yeo and some others believe that the disease is identical with that known to European writers as Mycosis Intestinalis, and that the development of an external pustule is not an invariable occurrence. 408 ERYSIPELAS. sis of the nerves of the part. The treatment, according to Brodie, is rather unsatisfactory. In one case, in which the disease was associated Avith irregu- lar menstruation, the sulphate of copper w7as given Avith advantage. Tonics Avould seem to be usually indicated, and Avhen, as in one of Brodie's cases, and in one quoted by Quesnay from De La Peyronie, the disease succeeds an affection of the skin, arsenic might probably be advantageously employed. Cases of symmetrical gangrene are reported by Raynaud, Southey, C. K. Mills, Collins Warren, and other surgeons, and are believed by the last- named Avriter to be due to some irritation of the vaso-motor nerves, causing permanent spasm of the vessels of the affected part. A curious case came under my observation at Cuyler Hospital, in Avhich a soldier, noticing a painful pimple or pustule on the back of his hand, applied to the " medical officer of the day," Avho ordered a flaxseed poultice; the next day the man came to me in great alarm, Avith a black dry slough upon his hand, exactly the size and the shape of the cataplasm ; the eschar, which Avas quite deep, separated in a few days, and the remaining ulcer healed rapidly under the use of the permanganate solution. CHAPTER XXI. ERYSIPELAS. Erysipelas x is an acute febrile disease, attended by a peculiar form of in- flammation, which affects the skin, areolar tissue, and mucous or serous mem- branes. It occurs as an idiopathic affection, or as a complication of a wound, being called in the latter case traumatic erysipelas. External erysipelas, or that which affects the skin and connective tissue, is much more common than the internal variety, or that which attacks the mucous and serous membranes. External erysipelas may be divided into the simple or cutaneous, the phleg- monous or cellulo-cutaneous, and the celhdar or areolar, which is often spoken of as diffuse inflammation of the areolar tissue. Causes of Erysipelas.—These may be divided into the predisposing and the exciting. Of the Predisposing Causes, some relate to the patient's own condition, and others to the circumstances by which he may be surrounded. Among the former may be enumerated a depressed or debilitated state of the system, resulting from any source, such as chronic visceral disease, espe- cially of the kidneys or liver; diabetes; chronic diarrhoea or dysentery; deprivation of food; neglect of hygienic rules; intemperate habits; ovenvork, etc. Any sudden source of depression may act as a predisposing cause of erysipelas; thus, in military hospitals, the disease is often seen to follow in the wake of secondary hemorrhage. Among the surrounding circumstances Avhich predispose to erysipelas may be mentioned overcrowding, bad ventila- tion and seAverage, and the season of the year and the state of the atmo- 1 The usual derivation given for this word is from the Greek kpvu (I draw) and izelac (near) ; others, however, prefer to derive it from kpvdpoQ (red) and Tteldg (livid). (See, upon this subject, a note to Mr. DeMorgan's article in Holm,es's Syst. of Surgery, vol. i. p. 207, and Dr. Stille's article in the International Encyclopaedia of Surgery, vol. i. SYMPTOMS OF ERYSIPELAS. 409 sphere ; it is notorious that erysipelas is most apt to occur during the cold, damp weather Avhich often prevails about and after the vernal and autumnal equinoxes. The principal Exciting Causes of erysipelas are epidemic influ- ence, contagion, and the presence of a wound. Symptoms of Erysipelas.—1. Simple or Cutaneous Erysipelas.—Constitu- tional disturbance, consisting of rigors, headache, nausea, and fever, may precede the local manifestations for one or two days, though in many in- stances the patient is not conscious of any marked indisposition, until the appearance of the rash or cutaneous inflammation. In traumatic erysipelas, the locality of the rash will be determined by the position of the wound; in the idiopathic variety, though the disease may appear on any part of the body, it is most frequently seen upon the face (especially about the nose, ears, and eyelids), next upon the legs, and more rarely upon the trunk. The eruption appears as a red spot, rapidly spreading into a large patch, Avith pretty Avell-defined margins; somewhat eleA^ated; of a bright rosy hue, disappearing under pressure; with a smooth, glazed, shining surface, and attended, with a tingling and burning sensation. Except in the mildest cases, vesicles appear on the affected part, containing serum, which at first is clear, but soon becomes turbid, these vesicles eventually drying into broAvnish scabs. The eruption of simple erysipelas lasts (as a rule) but four days in the same part: it may, however, spread to adjacent parts, or may break out in an entirely different region of the body, the affection in these cases constituting respectively the erysipelas ambulans, and the erysipelas erraticum of the older writers. As the eruption fades, the swelling subsides, the margins lose their definition, and the skin assumes a dry and somewhat wrinkled appearance. The constitutional symptoms are rather aggravated than diminished by the appearance of the eruption, the period of deferves- cence usually coinciding with that of the decline of the local phenomena. 2. Phlegmonous, or Cellulo-cutaneous Erysipelas.—In this form of the affec- tion both the local and general symptoms are more marked. The inflam- mation involves the subcutaneous connectiATe tissue as well as the skin, the swelling being greater, the color darker, the vesications larger, and the pain more intense than in the simple variety. These signs continue gradually increasing up to the sixth or eighth day, Avhen resolution may commence, or, as is very apt to happen, suppuration and extensive sloughing of the areolar tissue take place; the part, from being hard and tense, noAv becomes soft and boggy; the skin, at first deeply congested, becomes pale in spots, and then black, and quickly falls into a state of moist gangrene. The con- stitutional symptoms, which may appear in the beginning to be of a some- what sthenic character, rapidly degenerate into those of a typhoid type, and death may occur from exhaustion, hectic, diarrhoea, or pyaemia. This form of erysipelas is that which most often occurs in connection with wounds, simply because in such cases the deeper planes of fascia are usually opened, and thus exposed to the influence of the disease. Under the name of oedematous erysipelas is described a modification of the phlegmonous form of the disease, which is chiefly met Avith in the legs, and about the genital organs of old or feeble persons. Both the local and gen- eral symptoms are less marked than in ordinary phlegmonous erysipelas, but there is a considerable effusion of lymph and serum, solid oedema some- times persisting, and giving the part the appearance of Scleroderma, or Ele- phantiasis of the Arabs. 3. Cellular Erysipelas (Diffuse Inflammation of the Areolar Tissue).—The former name is preferable, as there may be a diffuse inflammation of the connective tissue unconnected Avith the erysipelatous influence (see page 410 ERYSIPELAS. 394). In this variety of the affection there is great swelling, tension, and pain, but comparatively little redness. The disease extends rapidly and Avidely, sometimes from a wound, but at other times beginning at a distance from the point of injury. Suppuration, sometimes attended with emphyse- matous crackling, occurs about the fourth day, or even earlier, and the skin quickly falls into a state of gangrene. This affection may also attack the deep planes of connective tissue, as in the pelvis or anterior mediastinum. The constitutional symptoms are of a profoundly typhoid type, death some- times occurring on the second or third day of the disease. 4. Traumatic Erysipelas is attended Avith changes in the condition of the wound itself. The edges become flabby, and the neighboring tissues oedem- atous. A thin sanious fluid replaces the ordinary healthy pus, the granu- lations become pale and shining, and the healing process is arrested; recent adhesions may even be broken down and absorbed. A sensation of weight and heat, with great pain, may precede by several hours the development of the characteristic eruption. 5. Erysipelas of Mucous Membranes.—The parts most usually affected are the fauces, pharynx, and larynx. Beginning in the fauces, Avhich are swollen and deeply red, the uvula being markedly oedematous, the disease may spread to the larynx, giving rise to a croupy cough, dyspnoea, aphonia, and some- times death from oedema of the glottis. At a later period fatal consequences may result from extension of the disease to the bronchi or lungs, from sloughing of the part, or from the development of pyaemia. This variety of erysipelas is considered peculiarly contagious. Dr. Goodhart believes cer- tain cases of the affection known as " Surgical Kidney" to be really ex- amples of erysipelas affecting the kidney and urinary tract. 6. Erysipelas of Serous Membranes.—This is chiefly met Avith in the arach- noid and peritoneum, the former being secondarily affected in cases of ery- sipelas of the scalp, or of injuries in the cranial region, and the latter in cases of injury of the abdomen or pelvis, or after various operations, such as herniotomy, ovariotomy, etc. The symptoms are those of inflammation of the affected parts, with the general evidences of a profoundly typhoid condition. Diagnosis of Erysipelas.—Simple erysipelas may be distinguished from erythema, by the fact that the latter occurs in patches of various size, Avhich ha\Te no particular tendency to spread, are not elevated, and are unaccom- panied by the formation of vesicles. The marked constitutional disturbance also is absent in erythema. From scarlet fever the diagnosis may be made by observing the circumscribed character of the erysipelatous eruption, its well-defined margin, the tenseness and glazed appearance of the surface, and the presence of vesicles. There is a peculiar inflammation of the skin Avhich results from contact with the poison sumach (Rhus radicans, Rhus toxico- dendron), which is almost identical in appearance with erysipelas; the diag- nosis can only be made by the history, and by the invariably mild course of the former affection, which, moreover, is not, I believe, contagious. Phleg- monous erysipelas may be distinguished from ordinary inflammation, by the greater extent of surface involved, by the absence of any tendency to point, by the rapidity of its course, and by the asthenic type of the constitutional symptoms. From phlebitis, it may be distinguished by the hard, cord-like condition of the vein, and the absence of general redness in that affection: and from angeiokucitis, by the fact that in that disease the redness and pain are confined to the course of the lymphatics and their neighboring glands. Cellular erysipelas may be distinguished from common diffuse inflammation of the connective tissue, by the eATen greater rapidity of the course of the TREATMENT. 411 former disease, and by the more asthenic type of its general symptoms. Ervsipelas of the fauces or larynx, may be distinguished from ordinary in- flammation of those parts, by the dusky redness exhibited in the former af- fection, and by the generally typhoid condition of the patient. Moreover, the manifestation of erysipelas on the cutaneous surface Avill usually throw light upon the diagnosis. From diphtheria, erysipelas of the throat may be distinguished by the greater degree of constitutional disturbance, and by the absence of exudation. Erysipelas of the arachnoid or peritoneum, can unlv be distinguished from common arachnitis or peritonitis, by the primarily tvphoid character of the constitutional symptoms in the former affections. The presence of delirium is a very frequent accompaniment of erysipelas of any form Avhich affects the scalp, and must not be considered as in itself any evidence of meningeal complication. Prognosis.—The prognosis, in any case of erysipelas, depends chiefly upon the form which the disease assumes, the locality of the part attacked, and the constitutional condition of the patient. Simple erysipelas is usually a mild affection, and, in the large majority of instances, terminates in recov- ery; if, hoAvever, it involve the scalp, or the abdominal wall, there is ahvays a risk of transference to the arachnoid or peritoneum; if the face be affected, it may spread to the fauces or larynx; while, if there be serious visceral dis- ease, especially of the kidney, the slightest attack of erysipelas is likely to prove fatal. Parinaud has collected eight cases, including two observed by himself, in which facial erysipelas has been followed by atrophy of the optic nerve. Phlegmonous and cellular erysipelas are ahvays very serious affections. In the head, abdomen, and lower extremities, they are particu- larly apt to prove fatal, extensive sloughing in the latter situation sometimes laying bare the bones and opening the articulations. Faucial and laryngeal erysipelas sometimes prevail in an epidemic form, and have occasionally, under the name of " black tongue," produced frightful ravages in certain regions of our country. Finally, erysipelas in any form is a serious disease in neAV-born children, in very old persons, and in women in the puerperal state. Treatment.—A great deal may be done to prevent the development and spread of erysipelas. For this purpose, hospital wards, or the apartments occupied by sick or wounded persons, should be well ventilated and scrupu- lously clean. All excreta and soiled clothing should be promptly removed, and particular attention should be given to the sewerage; the presence of a foul drain has not seldom proved the starting-point of a local epidemic of ervsipelas. As the disease can be unquestionably propagated by direct in- oculation, precautions should be taken against the transference of morbid material from one patient to another. The washing of Avounds should, if possible, be effected with a stream of running water; if this be impractica- ble, each patient should, at least, be provided with his OAvn basin and sponge; the dressings should be of such a nature that they can be frequently re- newed ; they should, therefore, be as simple and as inexpensive as possible. Disinfectants, such as the chlorine preparations, the permanganate of po- tassium, carbolic acid, or bromine, may be placed in various portions of the room, or may be employed in the dressings. Personal cleanliness on the part of nurses and dressers should be rigidly enforced, and the latter should not be alloAved to come directly from the post-mortem or dissection- rooms to engage in their Avard duties. The surgeon himself should exercise similar precautions, and, as there is an undoubted connection betAveen ery- sipelas and certain forms of puerperal fever, should, while attending cases of 412 ERYSIPELAS. the former affection, if possible, temporarily decline engaging in obstetric practice. On the first appearance of a case of erysipelas in a surgical Avard, the affected patient should be isolated, and disinfectant measures resorted to, in order to prevent the further spread of the disease. The Curative Treatment of erysipelas may be divided into the constitutional and the local treatment. 1. Constitutional Treatment.—In simple or cutaneous erysipelas, very little medication is, as a rule, required. If the patient, as is usually the case, be constipated, Avith a furred tongue, a mercurial purge may be administered. Emetics are often recommended, but, unless it be known that the stomach contains some irritating material, they are, I believe, as unnecessary as they are disagreeable; their reputation is probably derived from their known effi- ciency in those cases of erythema Avhich result directly from the use of cer- tain articles of food. As a cathartic, tAvo or three grains of blue mass may be given, to be folloAved, in the course of twenty-four hours, by a dose of castor oil or a Seidlitz powder. If there be much heat of skin, neutral mixture may be given, combined with camphor-Avater if the nervous symp- toms are at all prominent. Anorexia will usually indicate the propriety of abandoning solid food, for Avhich milk with lime-Avater, and beef-essence, may be substituted, in small quantities and at frequent intervals. In most cases, at least as met Avith in hospitals, a small quantity of alcoholic stimulus may be serviceably directed, but there is seldom occasion to give large quantities, four or five fluidounces of wine, or two or three of brandy, in the course of the day, being usually quite sufficient. Most cases of cuta- neous erysipelas will run a satisfactory course under the above simple mode of treatment. If, hoAvever, the surgeon wish to do more, there can be no objection to giving the muriated tincture of iron, Avhich is a remedy of un- doubted value in the phlegmonous form of the disease, and which may be conveniently combined with the solution of acetate of ammonium. The sulphites and hyposulphites have been rather extensively used in erysipelas, and have, Avith some surgeons, acquired a reputation, wdiich is, I believe, due more to the natural tendency of this form of the disease to spontaneous recovery, than to any curative virtue of the remedies themselves. In phleg- monous, and in cellular erysipelas, the patient may be put at once, after atten- tion to the state of his bowels, upon the use of the muriated tincture of iron, Avhich must be believed, from published experience, to exercise a controlling influence over the course of the disease. This remedy, which was first brought prominently to the notice of the profession in 1851, by Dr. G. Hamilton Bell, of Edinburgh, may be given in large doses—as much as tAventy or thirty minims—every three or four hours, or even every hour if the urgency of the case require it. Quinia is another drug which may be usefully employed, particularly in the later stages of the disease. Free stimulation may be employed in these cases from the very outset, and as the symptoms assume more and more a typhoid aspect, carbonate of am- monium and oil of turpentine may be properly added to the remedies pre- viously employed. The complications which demand special attention, are the supervention of arachnitis, of peritonitis, or of erysipelatous laryngitis. In the case of arachnitis, benefit may be expected from free purgation and the use of turpentine enemata. If coma occur under these circum- stances, Dr. Copland recommends a full dose of calomel and camphor, followed by an electuary of castor oil and oil of turpentine, placed upon the back of the tongue, and repeated from time to time until purging is begun. Enemata may then be used as adjuvants, and blisters applied to the nucha and thighs, as derivatives. In erysipelatous peritonitis, opium is the remedy most to be relied upon. If the disease attack the air-passages, the greatest TREATMENT. 413 risk is from oedema of the glottis; here (beside the local measures wdiich will be presently alluded to) a cautious trial may be given to antimony in combination with opium, the latter remedy serving to counteract the spasmodic tendency Avhich almost ahvays exists in laryngeal affections. If the dyspnoea, however, should increase, no time should be lost in resorting to laryngotomy; the oedema does not extend beloAV the vocal cords in these cases, and hence this operation is preferable to that of opening the trachea. 2. Local Treatment.—The local treatment of erysipelas is almost as im- portant as the constitutional. Very various applications have been used in these cases, and each, at least in simple erysipelas, often with apparent suc- cess. It must not be forgotten, hoAvever, that, as pointed out by Velpeau, the duration of the eruption in one spot is limited to four days, and that in many instances no other part may become affected. In this, as in many other diseases, a knowledge of the natural history of the affection may tend to shake our faith in the curative power of the remedies employed. With regard to local applications in erysipelas, a good general rule is given by Dr. Reynolds, viz., to avoid anything Avhich shall expose the skin to variations of temperature, or Avhich shall interrupt its natural function. Hence cold ap- plications and oily or unctuous substances should not be employed. In simple or cutaneous erysipelas, if the affected patch be small, it may be sufficient to keep it Avell dusted with rice flour, toilet powder, oxide of zinc, or even com- mon Avheat flour. If the patch be large, particularly if a limb be the part affected, and generally in hospital practice, it will be better to cover the whole seat of eruption with carded cotton, loosely applied; the cotton ex- cludes the atmosphere and keeps the part in a kind of continuous vapor bath. In cases in which the tension of the part is very great, and which approach, in character, to the phlegmonous form of the disease, warm fomentations, such as chamomile or hop poultices, may be substituted for the simpler appli- cations. Various other articles are recommended by surgical writers, par- ticularly collodion, sulphate of iron, tincture of iodine, nitrate of silver, and, recently, nitrate of lead. Bromine in the form of vapor, applied as described in speaking of hospital gangrene, Avas somewhat extensively used during our late war, and with alleged advantage. The nitrate of silver, which was first recommended in this affection by Higginbottom, is used in the form of a very strong solution (one part to three), and is applied, after thoroughly cleansing the part, "two or three times on the inflamed surface and beyond it, on the healthy skin, to the extent of tAvo or three inches." Another plan, if an extremity is affected, is to apply the caustic in a broad band, entirely around the limb, a few inches above the seat of inflammation. The spread of the eruption certainly seems, in some cases, to be arrested by the caustic application thus made, but perhaps not oftener than it would have been spon- taneously arrested at the same point, had the treatment not been employed. In phlegmonous erysipelas more active measures are required. In the early stages benefit may be derived from making numerous punctures with the point of a sharp lancet, as advised by Sir R. Dobson; these may be frequently repeated, and act by relieving tension and promoting resolution. If these fail, or if the case be first seen at a later stage, when the braAvny feeling of the surface indicates impending suppuration of the subcutaneous areolar tissue, incisions, from one to tAvo inches long, and two or three inches apart, should be made over the inflamed surface, in the general direction of the sub- jacent muscular fibres. These incisions, Avhich should extend through the superficial fascia, Avere first popularized by Copland Hutchison. They gape pretty Avidely, OAving to the great distension and SAvelling of the part, their edges presenting a gelatinous appearance from the infiltration of serum and lymph, and soon breaking doAvn into pus mingled Avith shreds of disinte- 414 ERYSIPELAS. grated tissue. If the hemorrhage from these incisions be troublesome, they should be stuffed with scraped lint until the bleeding has ceased. South advises that the incisions should be arranged in the form of a lozenge, thus I . I, the greatest relief from tension being thus obtained Avith the least destruction ot tissue. At a still later stage, Avhen brawniness has given place to bogginess, shoAving that sloughing of the subcutaneous tissues has already occurred, free and deep incisions, three or four inches long, may be required, in order to prevent gangrene of the skin, and to afford an exit for sloughs, the separation of Avhich may be hastened by means of forceps and scissors. Warm fomenta- tions should be constantly applied, and antiseptics may be freely used, not only in the dressings, but injected among the tissues by syringing. When the suppuration is very profuse, the fomentation may be omitted, the part being simply covered Avith lint and charpie, tow, oakum, or carded cotton, the noAv relaxed tissues being supported by the gentle pressure of a bandage. The abscesses, sinuses, and ulcers which are left after phlegmonous erysipelas, are to be treated on the principles laid doAvn in the last chapter. Cellular erysipelas requires the same local treatment as the phlegmonous form of the disease; the incisions should be made even earlier and more freely than in that variety, on account of the greater rapidity Avith which sloughing of the connective tissue occurs under these circumstances. In certain localities, as in the orbit, the scalp, and the scrotum, early incisions are particularly im- perative. In the orbit, the incisions are to be made by everting the lids, and pushing the blade of a lancet or bistoury, held flatAvise, through the conjunc- tiva, between the eyeball and orbital Avails; in the scalp, crucial incisions are the most effective; while in the scrotum, a single free incision on either side of the raphe will usually be all that is necessary. Erysipelatous arachnitis may be met by the application of cold to the scalp—the only form of erysipelas, I believe, in which the use of cold is admissible. In erysipelatous peritonitis, the Avhole abdomen should be covered with a warm hop poultice. If erysipelas attack the fauces, a strong solution of nitrate of silver, or the muriated tincture of iron, may be freely applied Avith a sponge or camel's-hair brush; while in erysipelatous laryngitis, before resorting to laryngotomy, a trial should be given to free scarification of the glottis, and of as much of the larynx as can be reached, followed by the inhalation of steam, and the free application of a solution of nitrate of silver (3j-f^j). The scarification may be effected Avith a probe-pointed curved bistoury wrapped Avith adhesive plaster, or, more conveniently, with an ordinary hernia-knife. Should the patient survive the first risks of the disease, the inevitable sloughing will require the use of detergent gargles (especially such as contain chlorine or bromine), to obviate the fetor and diminish the risk of secondary blood-poisoning. In a case of traumatic erysipelas, if the disease appear to originate directly from the wound, it Avould be proper to apply to the latter some disinfectant, such as a solution of bromine Avith bromide of potassium, in hope that the disease might thereby be, if not arrested, at least favorably modified in its course. Hirschberg, of Berlin, recommends in these cases hypodermic in- jections of a two per cent, solution of carbolic acid. PYEMIA. 415 CHAPTER XXII. PYAEMIA. Pyemia (in the sense in which the term is used in this Avork) is a peculiar morbid condition resulting from the absorption of septic material, and usually accompanied by the formation of puriform collections in various tissues and organs of the body. VirchoAV, to whose labors we are greatly indebted for our knowledge of the pathology of this disease, distinguishes several forms of blood-poisoning, which are usually classed together as pyaemia, and proposes the names Ichorrhccmia, Septicemia, and Septicemia, for that variety which results from the absorption of putrid material from Avounds, and is not accompanied by the development of those puriform collections which the older surgeons called " metastatic abscesses," and the formation of Avhich he believes to be invariably due to plugging of the capillary vessels by fragments of disinte- grated venous coagula. A similar distinction is made by many of the most eminent French surgeons, Avho differentiate betAveen Avhat they call purulent and putrid Infection, and Dr. Lidell, one of the more recent American authors on the subject, is disposed to limit the term Pycemia to those cases Avhich are connected with pre-existing suppuration, and to apply the term Septhozmia to the forms of blood-poisoning which occur in connection with traumatic and hospital gangrene, dissection wounds, etc. Prof. Van Buren, too, teaches that septhaemia is a distinct and Avell-defined malady, due to the absorption of a definite and peculiar poison. While it is quite possible that further experience and more accurate investigation may, at some future time, enable us to separate and classify different varieties of septic poisoning, to recognize their several sources, and to distinguish the courses which they severally pur- sue, I cannot but think, Avith Verneuil, that in the present state of science, it is more practically useful, as it is certainly more convenient, not to aim at these theoretical refinements, but to use the Avord pyaemia (as has been done in the definition given above) as a generic term, embracing one or more morbid systemic conditions—and to study such condition or conditions as parts of one disease, considering successively its pathological, clinical, and therapeutical relations, Avith the light afforded by observation and experience. Nomenclature.—The fact has long been known that patients AA-ho have received injuries (especially of the head, or of the long bones), or Avho have undergone operations, may die from inflammation or suppuration in Avidely different parts of the body ;x and various names have been suggested by sur- geons, expressive of the theories adopted to account for these phenomena. Pywmia or Pyohemla (meaning literally purulent blood) was the name pro- posed by Piorry, in the early part of this century, and has been used by the large majority of surgical Avriters; though a misnomer, as far as any patho- logical significance is concerned, it is perhaps no more objectionable than 1 See Dr. William Thomson's " Historical Notices of the Occurrence of Inflamma- tory Affections of the Internal Organs after External Injuries and Surgical Opera- tions " (reprinted from Edinburgh Med. and Surg. Journal), Philada., 1840; T. Rose;s "Observations, etc.," in Med.-Chir. Transactions, vol. xiv.; Dr. G. W. Norris's edi- tion of Fergusson's Surgery ; Braidwood, " On Pyaemia, etc.," chap, i., London, 1868 ; and Blum's Memoir, in Archives Generates de Midecine, Nov., 1869, pp. 534-554. 416 PYEMIA. any other term, and is adopted in this Avork simply from motives of conveni- ence. Among the other names that have been employed, may be specially mentioned, Phlebitis, Purulent Infection, Purulent Absorption, Purulent or Pyogenic Diathesis, Multiple or Metastatic Abscess, Thrombosis, Surgical Fever, Pyogenic Fever, Suppurative Fever, and Surgical Typhus. These are all more or less objectionable, either as implying an untenable theory, or as referring to some mere incident of the disease. Surgical Fever (the name used by the late Sir James Y. Simpson) is perhaps the least objectionable name—even less so than Pycemia—but is not adopted here because it is usu- ally recognized as a synonym for Inflammatory Fever, which is quite a differ- ent condition. Pathology.—Various pathological theories have been advanced upon the subject of pyaemia, which, though affording an interesting field for study, cannot be entered into within the limits of this wrork. I shall merely refer very briefly to the views Avhich have most advocates at the present day, and which are—1. The theory Avhich makes pyaemia dependent upon the existence of pus in the blood ; 2. That which makes it dependent upon thrombosis (the formation of venous clots or thrombi), and subsequent embolism,1 or plugging of the capillary vessels Avith fragments broken off from these clots and called embola; and 3. That which makes it dependent on the introduction of a septic material into the blood, and which looks upon the processes of throm- bosis and embolism as subsidiary and not absolutely necessary. This seems to me in the present state of our knowledge to be the most plausible theory, and it is that which is here adopted. The theory which accounts for the phe- nomena of pyaemia by assuming the existence of a morbid diathesis, merely puts the difficulty one step further back ; it is as hard to account for the dia- thesis as for the disease which it is supposed to produce. The theory Avhich looks upon the symptoms of pyaemia as reflex phenomena brought about through the agency of the nervous system, is someAvhat plausible, but must be rejected as ignoring the facts Avhich have been obtained by clinical obser- vation and dissection, as well as by experiments upon the loAver animals. 1. Pus in the Blood.—The existence of pus in the blood of pyaemic pa- tients, has been affirmed by a very large number of observers, but strenuously denied by Virchow and others, who declare the supposed pus cells to be merely the white corpuscles of the blood, in increased numbers, and the con- dition of the blood in these cases to be one of kucocytosis, as in the disease called by Virchow, Leukaemia, and by Bennett, Leucocythemia. Sedillot in- deed pointed out certain diagnostic marks as to size, color, etc., by Avhich he believed that the pus cell could be distinguished from the white blood cor- puscle, but it is noAv generally conceded that they are undistinguishable. It may be added that, if Cohnheim's observations are correct—if the Avhite corpuscles and pus cells are really identical, and capable, by means of their amoebiform movements, of wandering through the unbroken capillary walls— the whole question of pus in the blood Avill have lost much of its significance. The entrance of pus into the blood has been accounted for in two Avays, viz., by the previous existence of suppurative phlebitis, and by the occurrence of direct absorption.2 1 From two Greek words, h (in) and /Ja/Mu (I throw or cast). 2 Piorry's idea that the blood itself could become the seat of inflammation and sup- puration, may, in the present state of science, be looked upon as purely chimerical; while the theory which supposes pus to enter the circulation by absorption through the lymphatic system, must be rejected on anatomical grounds, the lymphatic glands acting as filters to prevent the passage of solid particles much smaller than the pus corpuscles. (See Virchow's Cellular Pathology (Chance's edit.), pp. 184-185.) PATHOLOGY. 417 Phlebitis was supposed to be the cause of pyaemia by Hunter, Abernethy, Guthrie, Arnott, Cruveilhier, and Liston, and this view has been and perhaps still is adopted by the majority of practical surgeons. The pus is supposed to be formed from the lining membrane of the vein, and thus to enter the circulation, either directly, or by the breaking doAvn of the limiting clot. The objection to this view is that in many cases of pyaemia the veins are not inflamed at all, and that Avhen inflammation does exist, it is secondary and does not involve the lining membrane of the vessel, being Avhat is called by Virchow a meso-phkbitis or peri-phlebitis. Even Avhen the inner coat is in- volved in phlebitis, the entrance of inflammatory products into the general circulation Avould be prevented by the coagulum which in these cases fills the vein. The theory of absorption of pus has received support from the Avell-attested fact that pyaemia is particularly apt to occur after injuries or operations in parts in Avhich open veins are, from mechanical causes, unable to collapse Avhen cut, or to contract at a subsequent period, as veins ordinarily do, upon the shrinking of their contained clots. On the other hand, it has been repeatedly shown by experiment that (1) the effect of applying healthy pus to blood is simply to induce coagulation; (2) that injection of pus into the blood of healthy animals is not usually followed by fatal results, though repeated injections may produce death; (3) that the injection of the fluid part of pus is of itself followed by no evil result; (4) that injections of small quantities of pus act just as injections of various other substances, such as mercury, oil, powdered oxide of zinc, etc., by producing local obstructions (infarctus) in the first set of capillaries; and that (5) these obstructions may, in healthy animals, spontaneously disappear, the subjects of the experiments eventually recovering. Hence it is shown that if pus be absorbed into the blood, its action can be only mechanical, and it is very reasonably argued that the pus corpuscle, being at least no larger than the Avhite corpuscle of the blood, is no more likely to produce the obstruction Avhich results in the formation of the "pyaemic patch" or "metastatic abscess," than the Avhite corpuscle itself.1 Finally, as already remarked, if Cohnheim's vieAVS be cor- rect, this Avhole question will have lost much of its importance. 2. Thrombosis and Embolism.—Thrombosis, or the coagulation of blood in the vessels during life, may depend upon a variety of causes, as (1) quies- cence or simple retardation of the circulation, (2) the contact of a rough surface, and (3) an alteration of the blood itself, consisting probably in an increase in the proportion of fibrine.2 Thrombi form in the veins in almost every case of injury, or of inflammation of the surrounding tissues, as Avell as in cases of phlebitis. These venous thrombi or clots increase by aggregation, until they reach the points at which the veins in which they are seated anastomose Avith their parent trunk; if the force of the circulation in this be sufficiently strong, it may prevent the further increase of the thrombi, but if not, these will continue to enlarge till they project into the main trunk, as shown in the annexed diagram taken from Callender (Fig. 192). A frag- ment of the projecting part of a thrombus may be broken off and SAvept into the circulation, passing through the heart and plugging an artery, producing 1 It is, however, possible, as remarked by Bristowe, that aggregated masses of pus cells may enter the circulation as pellets or flakes, and prove a mechanical source of embolism. 2 See Moxon, in Guy's Hosp. Reports, 3d s., vol. xiv. p. 101. According to Schmidt, of Dorpat, fibrine (as such) does not exist in the circulating blood, but is produced by the union of two substances, which he calls fibrinogen and fibrinoplastin, and coagu- lation is due to the action of a ferment produced by the disintegration of the white corpuscles. 27 418 PYiEMIA. Fig. 192. embolism, and, if the vessel be of sufficient size, perhaps leading to gangrene; just as Ave have seen in a previous chapter that gangrene may be induced by embolism, from the breaking up of a clot formed in the heart. Under cer- tain circumstances, probably owing to an unhealthy condition of the fibrine, a venous coagulum or thrombus softens and undergoes general disintegration; a large number of small fragments are thus carried into the circulation, and, passing through the heart, plug the first set of capillaries (Avhich, if the seat of thrombosis be in the systemic cir- culation, will of course be the pulmonary), causing thus capillary embolism. A few embola may slip through the first, to plug other sets of capillaries, or each point of obstruction may cause fresh thrombosis, and a repetition of the whole process. In the same Avay capillary em- bolism may be due to disintegration of cardiac coagula, and to cases of this kind Dr. Wilks has applied the name "Arterial pycemia." The secondary effects of capillary embolism consist essentially in the development of congestion and inflammation in the part deprived of its vascular supply, which often, though not always, goes on to the occurrence of suppuration and gangrene —the embola themselves, in the latter case, breaking down and mingling their debris Avith the products re- sulting from the disintegration of surrounding tissue. It is probably to this process of thrombosis and capillary embolism, that is due the formation of the large majority of secondary deposits, or "metastatic abscesses," in cases of pyaemia; but that this process is not necessarily present in every case, is shown by the facts that (1) precisely the same set of changes may result from capillary stag- nation, produced by the introduction into the circulation of putrid fluids,1 (2) that the secondary deposits are sometimes absent from the lungs, though present in other viscera (which would be unaccountable on the supposi- tion that they were due solely to mechanical obstruction by solid particles, as in that case these particles, or embola, would necessarily block the first set of capillaries),2 and (3) that in cases of capillary embolism from cardiac disease (arterial pycemia),3 the course of the affection is very much less acute than is seen in the immense majority of cases of ordinary venous pyaemia, as met with in surgical practice, showing that in the latter there must be something more than the simple processes of thrombosis and embolism. In- deed, Virchow and his followers acknowledge that certain of the phenomena of pyaemia (as ordinarily seen) are not accounted for by these processes, and declare, therefore, that in many cases there is in addition a state of ichor- rhcemia, due to the absorption of septic material. 3. Absorption of Septic Material.—We are thus brought to the conclusion that the only theory Avhich is capable of accounting for all the phenomena of pyaemia is that Avhich supposes the pyaemic condition to be induced by the absorption of septic material (usually in a liquid, but possibly sometimes in a gaseous state), which unfits the blood for the processes of healthy nu- 1 See Savory, in St. Bartholomew's Hosp. Reports, vol. i. pp. 118-126. 2 According to 0. Weber, however, as quoted by Billroth, certain forms of embola, especially flocculi of pus, may pass the pulmonary capillaries and enter the svstemic circulation. Busch explains the occurrence of hepatic embola by the occurrence of retrograde movements of the blood in the vena cava. 3 See Wilks, in Guy's Hosp. Reports, 3d s., vol. xv. pp. 29-35. Diagram illustrating processes of thrombosis and embolism; a, clot projecting into venous trunk and increasing by aggregation ; b, clot un- dergoing disintegration, and allowing fragments to enter the circulation {embola). (Callender.) MORBID ANATOMY. 419 trition, induces capillary stagnation and its consequences, low forms of in- flammation, or serous and synovial effusions, and may, and probably does, in most cases, cause venous thrombosis, giving rise to the occurrence of loose and ill-formed coagula, Avhich, rapidly undergoing disintegration, cause capillary embolism, and thus produce the secondary deposits, or metastatic abscesses, Avhich are so common in this affection. Morbid Anatomy.—Under this head I shall describe very briefly the chief post-mortem appearances observed in fatal cases of pyaemia. In cases which prove very rapidly fatal (the septicemic foudroyante of Verneuil and his folloAvers), time is not afforded for these changes, and, under such circum- stances, the post-mortem appearances are almost negative. The character- istic lesions of this affection consist in local congestion, extravasation, and inflammation, with gangrene, and occasionally true suppuration. Small fibrinous plugs (embola) can sometimes be detected in the smaller vessels leading to the affected part, but more often the microscope reveals only a mass of granular matter, lymph and blood cells, fibrils, oil globules, and debris of tissue. If true pus exist, it is the result of suppuration occurring secondarily around, and not in, the pyaemic patch. Lungs—Pycemic patches, or, as they were formerly called, metastatic ab- scesses, are most often seen in the. lungs, and (according to Callender) in the left, more frequently than in the right. They vary in size from that of a small pea to an inch or more in diameter. They may occupy any portion of the lung, but are most frequent at the posterior part, and are usually present in considerable numbers. They are hard and resisting to the touch, and Avhen cut open present varying appearances, according to the stage which has been reached, their color being reddish-black, brown, pale buff, or yel- lowish-gray. They are always surrounded by a Avell-marked vascular zone. When near the pleural surface, they often cause pleurisy, marked by the formation of lymph, in patches, and by the effusion of turbid serum. Be- side presenting these pyaemic patches, the lungs are often diffusely congested, or even inflamed. Liver—The liver is most often affected, next to the lungs. The progress of pyaemic patches in this organ seems to be more rapid than in the pulmo- nary tissues, so that the puriform appearance is very quickly developed; a circumstance which accounts for the fact that "metastatic abscesses" are often observed in the liver, Avhen the morbid changes in the lungs have escaped attention. Other Viscera.—The Kidneys, Spleen, Heart, Brain, Bowels, Testes, Pros- tate, Eye, etc., may all be similarly affected, and probably in the order named, as regards frequency. Dr. Bristowe, indeed, considers that the kidneys are more often affected in pyaemia than the liver. The splfeen may be much enlarged, even Avhen not the seat of the characteristic pyaemic patches. The Peritoneum is not unfrequently locally inflamed, as the result of pyaemic deposits in the various abdominal viscera. Joints.—The articulations are often SAVollen and inflamed, containing a turbid puriform fluid (sometimes, probably, true pus), the synovial struc- tures being deeply congested, and the cartilages eroded. Bones.—The bones are probably occasionally, but very rarely, the seat of secondary pyaemic changes. On the other hand, pyaemia very often origi- nates in inflammatory affections of bone, especially (as we shall see here- after) in osteo-myelitis. Muscles and Areolar Tissue.—Pyaemic deposits are not unfrequently met with among the muscular layers of the thoracic or abdominal walls, or in the neighborhood of joints, and, according to Bristowe, occasionally in the 420 PYAEMIA. tongue. True suppuration may occur under these circumstances, resulting in the rapid formation of abscesses of large size. External Surface.—The skin presents a yellowish appearance, and is some- times absolutely jaundiced. Open Avounds are found dry, the granulations having often completely disappeared, and the surface being pale and glazed, or occasionally covered with a grayish slough. Lymphatics.—The lymphatics in the neighborhood of a wound are often inflamed, and abscesses form in the adjoining lymphatic glands. It is doubtless to the irritation of the lymphatic system, that is due the increased number of white corpuscles sometimes observed in the blood in pyaemic cases. It was this phenomenon (which Virchow calls leucocytosis) Avhich first suggested to Piorry the name of Pyaemia. Bloodvessels.—Phlebitis is a very frequent accompaniment of pyaemia. The veins are thickened and someAvhat contracted, containing clots, which are usually firm and adherent above, but softened beloAV, and disintegrated into a puriform fluid, which was formerly supposed to be actually pus. The arteries are, I believe, not affected in cases of ordinary pyaemia, except that the smallest branches may be sometimes the seat of embolism. Dr. Wilks believes that in some cases of Avhat he calls arterial pyaemia, the pathologi- cal condition is one of arterial thrombosis in situ, rather than of embolism from softening cardiac clots. The capillaries in various parts of the body are occasionally seen to be plugged by embola; but, as already indicated, this condition is, in most instances, inferred, rather than demonstrated. Blood.—The blood often presents no abnormal appearances, though in other cases it contains an unusually large proportion of Avhite blood corpus- cles (leucocytosis). Its coagulability is usually diminished, and it is com- monly found fluid or imperfectly clotted. This Avant of coagulability is one cause of the liability to capillary oozing or parenchymatous hemorrhage, which is often observed in cases of pyaemia, a tendency Avhich is probably assisted, as pointed out by Stromeyer, by the/ venous obstruction due to thrombosis, and Avhich is still further aided by the complication of leucocy- tosis, when present—capillary bleeding being, as is well knoAvn, a frequent occurrence in cases of leukaemia or leucocythemia. Small organisms (bac- teria) are commonly found in the blood of pyaemic patients, but have not been proved to have causal connection with the occurrence of the disease. Causes of Pyaemia.—As Predisposing Causes of pyaemia may be mentioned previous illness, visceral disease (especially of the kidneys or liver), exhaus- tion, loss of blood, prolonged shock, over-croAvding (especially of suppurating cases), a scorbutic condition, the puerperal state, certain diseases—such as erysipelas, hospital gangrene, carbuncle, osteomyelitis, etc.—and, finally, the presence of an open wound. The Exciting Cause, according to the pathological viewr adopted in this chapter, is the absorption of a septic ma- terial, usually in the form of a liquid, from a Avound or ulcer, but, in some cases, from the alimentary or other mucous membrane; or, possibly, in the form of a gas, by the medium of the lungs. It is asserted by many writers, that pyaemia never occurs except in connection Avith the existence of an open wound. There are, however, cases on record, in Avhich pyaemic symptoms have not appeared until after the cicatrization of a wound, and Savory declares that pyaemia not only occurs without the pre\Tious existence of any Avound, " but sometimes, so far as the most careful and complete examination can show, without any previous suppuration or any other local mischief what- ever."1 Dr. Savreux-Lachappelle2 has collected a number of cases of so- 1 St. Bartholomew's Hosp. Eeports, vol. iii. p. 77. 2 See notice in Archives Gen. de Medecine, October, 1869, pp. 488-491; SYMPTOMS OF PYEMIA. 421 called idiopathic or essential pycemia, and has shown that in most of these instances exposure to cold has been the apparent cause of the affection. There is, moreover, reason to believe that, in some cases, the pyaemic poison is generated in the secretion which lubricates mucous membranes. Hence, Avhile in the immense majority of cases we may safely assume that the mate- ries morbi of pyaemia is developed in the fluids of a wound or ulcer, we are forced to believe it possible that the septic material which gives rise to the disease, may originate de novo in the system, as the result of extraneous in- fluences. With regard to the question of the contagiousness1 of pyaemia, we must speak with a certain degree of hesitation ; in the ordinary sense of the term it is certainly not contagious—not in the same sense, that is, as typhus fever or measles. Pyaemia may, undoubtedly, be inoculated by careless use of sponges, etc., or may possibly be transmitted by proximity alone; but in either case the septic material must be generated in the fluids of the Avound or ulcer of the person about to be affected, before infection can take place. EAren in the rare cases in Avhich the peculiar septic matter of pyaemia is sup- posed to have been absorbed in a gaseous form through the lungs, it is possible that the sole office of the morbid substance derived from without has been to produce a change in the fluids of the part, the true pyaemic poison being there developed, and causing infection as a secondary consequence; just as in other instances it is probable that the pyaemic poison is generated in the secretions of the alimentary or genito-urinary mucous membranes. Symptoms of Pyaemia.—The first symptom of pyaemia, at least in surgical cases, is almost ahvays a sensation of cold, Avith usually a decided rigor or chill. These chills are subsequently repeated, at irregular intervals, and are commonly folloAved by profuse and exhausting diaphoresis, the hot stage Avhich is generally observed after malarial chills being, in cases of pyaemia, absent, or but slightly marked. The greatest elevation of temperature co- incides Avith the period of rigor, the thermometer not often going above 104°, though occasionally, if the chill be very severe, reaching 106° or 107°, or, according to Billroth, even 108°, Fahr. The irregular variations of tem- perature, which range over 10° or 11° Fahr., are considered by Wagstaffe of diagnostic value. During the SAveating stage the temperature rapidly falls. According to Ringer and Le Gros Clark, the elevation of temperature begins before the development of the chill, and the former author believes that the occurrence of the rigor may be predicted by thermometrical observation. The pulse rate is rarely below 90, usually ranging from 100 to 130, and (according to BristoAve) occasionally reaching 200. The respiration is usually hurried and anxious, ranging from 40 to 50 in the minute, and sometimes even more. The breath is said to have a hay-like odor, though I cannot say that I haAre myself observed this symptom. There is commonly cough, with expectora- tion of viscid or of blood-stained sputa, and physical examination reveals the signs of pulmonary congestion, with pneumonia (lobular or lobar) and pleu- risy. Pericarditis may be present, but its signs are often masked by the respiratory sounds. The countenance is flushed, the skin presents a dusky, salloAV, somewhat jaundiced hue, and is often marked with sudamina, which, being surrounded by a zone of congestion, have been mistaken for the spots of typhus, or of typhoid fever. At a later stage, a pustular eruption, resem- bling that of smallpox, has been observed. Petechiae, ecchymoses, and local- ized gangrene, occur in some cases. The tongue is usually furred ; there is commonly complete anorexia; often nausea and vomiting; and usually diar- 1 See in connection with this subject a paper by Dr. J. Burdon Sanderson, in Med.- Chir. Trans., vol. lvi. p. 345. 422 PYEMIA. rhoea. The urine is frequently albuminous. The patient is often delirious, particularly at night, or may be profoundly soporose, though rousing up and answering intelligently when addressed. Intense pain often accompanies the formation of the secondary deposits or inflammations, particularly when these are superficial, as in connection Avith the joints. If there be an open wound, it will probably become dry and glazed, all reparative action ceasing; occa- sionally, however, healthy granulations continue to be formed almost to the end of the case, or, on the other hand, absolute sloughing may occur. Profuse capillary hemorrhage may tend still further to weaken the patient. Before death the symptoms assume a profoundly typhoid character: sordes accumu- late upon the lips and gums; the tongue becomes dry and brown, and some- times cracked and bleeding; subsultus tendinum and carphologia, Avith low, muttering delirium, mark the profound implication of the nervous system, and the patient may die comatose, or apparently from pure exhaustion. Diagnosis.—The diagnosis of pyaemia can usually be made by carefully observing the history and the symptoms of the case. From Inflammatory Fever, from Hectic, and from Typhoid Fever, pyaemia can usually be distin- guished by its greater fluctuations of temperature and higher thermometrical range, and by its repeated rigors, occurring at irregular intervals. From inflammatory fever it further differs, in that the former affection commonly yields on the occurrence of suppuration. The irregularity of the chills, together with the absence, or at least the want of prominence, of the hot stage, will prove of diagnostic value as regards Intermittent and Remittent Fevers. From Rheumatism1 and especially from what is called Rheumatoid Arthritis, the diagnosis is often extremely difficult, particularly if the pyaemia assume a chronic form. Under such circumstances, the surgeon must rely chiefly upon the history of the case, the condition of the wround (if there be one), the de- gree of prostration, and the tendency to suppuration—which occurs as a rule in pyaemic joint affections, and only exceptionally in those of a rheumatic character. The secondary local manifestations of pyaemia may be readily confounded with other diseases. Thus an idiopathic pneumonia, occurring after an amputation, might be mistaken for the lung complication of pyaemia, and a similar error might be made Avith regard to other organs. I was once asked to see a patient in whom marked brain symptoms, Avith general febrile disturbance, had followed traumatic erysipelas supervening upon an excision of the elbow. The case had been supposed to be one of pyaemia, but I diag- nosticated tuberculous meningitis, chiefly from observing the intense head- ache, with screaming, the absence of prostration, and the existence of the tache cerebrate, or red mark produced by lightly draAving the finger-nail over the surface of the chest or abdomen. The correctness of this opinion Avas subsequently demonstrated by an autopsy. Prognosis.—The prognosis of pyaemia is ahvays unfavorable, and in an acute form the disease is almost invariably fatal. The subacute and chronic varieties, however, are less hopeless, and, in any case, the longer the patient can be kept alive, the better is the prospect of ultimate recovery. I have myself seen at least five cases of pyaemia terminate favorably—three after partial excision of the radius or ulna, one after partial amputation of the hand, and one after amputation at the knee—but in none of the five did the affection assume a very acute form. The duration of the disease varies 1 There is reason to believe that the affections known as Gonorrhceal Rheumatism, Urethral Rheumatism, Urethral or Genital Fever, etc., are actually mild forms of pysemia, resulting from the development of septic material in the secretion of the genito-urinary mucous membrane. TREATMENT. 423 greatly in different cases. Occasionally, in what the French call the fou- droyante form of pyaemia, death may occur within a day or two of the first rigor. From four or five days to a week is the usual duration of acute cases, though life may be prolonged for ten days, a fortnight, or even longer. In cases Avhich recover, the patient usually goes through a long illness, and may be left permanently crippled by secondary implication of the articula- tions. The occurrence of abscesses in superficial parts, where they can be evacuated, is looked upon as rather a favorable omen ; and I have sometimes thought that the diarrhoea, in these cases, appeared to act as a derivative in relieving the internal viscera. Treatment.—As Prophylactic Measures, all those precautions should be adopted, Avhich Avere discussed in speaking of operations in general, and of ervsipelas, hospital gangrene, etc., diseases Avhich are often followed by pyaemia. As every patient with a suppurating wound is liable to this affec- tion, the surgeon should use every effort to obtain primary union, or at least cicatrization without any unnecessary delay ; at the same time he must take care to secure free drainage from the wound, lest, in his zeal for early heal- ing, he cause purulent and other fluids to be pent up and confined, thus defeating the very object Avhich he is seeking to promote. The various predisposing causes of pyaemia should as far as possible be obviated, for we know of no way by which the development of the poison can be certainly prevented, nor by which it can be hindered from producing its deleterious effects. The administration of various drugs has been pro- posed, Avith the idea that they would exercise a prophylactic influence: the permanganate of potassium, and more particularly the sulphites and hypo- sulphites (the latter agents on the recommendation of Polli, of Milan), have been somewhat extensively employed, but have not, I believe, fulfilled the expectations of those who have used them, and the same may be said of carbolic acid and the carbolates. Labat, of Bordeaux, has advised the in- ternal exhibition of ergotine, which he believes acts by increasing the plas- ticity of the blood; the evidence adduced in its favor, is, hoAvever, but negative, as is that in favor of the tincture of aconite, recommended as a prophylactic in these cases by Chassaignac. Curative Treatment.—The treatment of this disease must be conducted on those principles Avhich guide the surgeon in the management of other affec- tions of a typhoid character: there is no specific for pycemia. If the patient be at first constipated, Avith a deeply furred tongue, it may be proper to give a small dose of blue mass, folloAved by magnesia or other mild cathartic. Under such treatment the tongue will often clean off, to become, however, again furred in a short time, as the case progresses. Quinia is, I believe, more valuable than any other single drug, in the treatment of pyaemia: it may be given in doses of four or five grains, every three or four hours. Guerin, who has great confidence in this medicine, uses very large doses— giving as much as a drachm in tAventy-four hours. Socin, of Basle, used still larger quantities—90 to 105 grains in the twenty-four hours—Avith suc- cess during the late Franco-Prussian Avar. Legouest and Bouillaud think the cinchona bark itself a preferable agent to quinia. Iron may be combined Avith the quinia in the form of the muriated tincture, or, Avhich BraidAvood prefers, the citrate of iron and quinia may be substituted. The oil of tur- pentine is, I think, a useful stimulant in these cases; it may be given with muriatic acid, in an emulsion, a feAv drops of laudanum being added to each dose, if there be a tendency to undue purging. As diarrhoea, hoAvever, ap- pears in some cases to be a means adopted by nature to eliminate the poison, it should not be hastily checked, unless so profuse as to be in itself a cause 424 PYEMIA. of exhaustion. Opium may be required to relieve pain or restlessness, and in such cases may be given in any form that convenience may indicate. Carbonate of ammonium may often be employed Avith advantage ; if the pul- monary complications be prominent, it may be properly combined Avith syrup of senega, as a stimulating expectorant. Transfusion of blood is recom- mended by Marcacci. In all cases the patient should be supplied Avith abundance of light but nutritious food, given in small quantities and at short intervals, and alcohol, in the form of Avine or spirit, must be likeAvise ad- ministered very freely ; Socin, of Basle, in connection with the huge doses of quinia above referred to, gave his patients three bottles of wine per diem. In the Avorst case of pyaemia in which I haATe ever known recovery to folloAv, the patient got every hour, day and night, a tablespoonful of Avhiskey, Avith six of milk and four of lime-Avater, for more than a Aveek; his anorexia was complete, with constant nausea, and retching at the very idea of food, and it Avas only by his taking this combination regularly, as medicine, that life Avas sustained. With regard to Local Measures, beyond care as to the cleanliness of wrounds, and the use of disinfectants, I do not knoAV of any plan worthy of much confidence. The application of the actual cautery in the course of the super- ficial veins (if these be inflamed), or to the wound itself, has been highly recommended by several writers. Legouest advises that the wound should be washed with the perchloride of iron. Nitric acid and various other caustic agents have been likewise employed, but the evidence is not very satisfactory as to any benefit derived from their use. Ligation of the principal vein of the limb has been employed with alleged benefit in cases recorded by Kraus- sold and others. Probably the most rational plan is to be satisfied with keeping the wound clean and lightly dressed; and diluted alcohol, or weak solutions of the permanganate of potassium, or of carbolic acid, are probably better applications, in these cases, than poultices or other more cumbrous forms of dressing. Free drainage from the wound should be secured by position or otherwise, and if abscesses form in accessible situations, they should be opened at an early period, and their cavities afterwards frequently washed out with disinfectant fluids. Under the course of treatment above described, a certain number of the milder cases of pyaemia may be conducted to a favorable termination, and, occasionally, a patient more severely attacked, may be snatched as it were from the very jaAvs of death; but there is reason to fear that the large ma- jority of pyaemic cases Avill prove fatal in spite of all our care and attention, and that this frightful affection will continue to deserve the name Avhich has been not inaptly bestowed upon it, of the " Bane of Operative Surgery." STKUMA. 425 CHAPTER XXIII. DIATHETIC DISEASES. Struma (including Tubercle and Scrofula); Rickets. Beside the affections to the consideration of which this chapter is devoted, there are two diseases which have claims to be regarded as of a diathetic or constitutional nature, viz., Cancer and Hereditary Syphilis. The former Avill be described when Ave come to speak of malignant tumors, and the latter under the head of Venereal Diseases. Struma. The terms Struma, Scrofula, and Tubercle have been very variously applied by pathologists. Some look upon them as indentical, while others use struma as a general term embracing both the others; some subdivide scrofula into two varieties, the sanguine and phlegmatic, and ignore the independent nature of tubercle, while others recognize the two forms of scrofula, and con- sider tubercle as a distinct affection; some, again, recognize but one form of scrofula (the phlegmatic), and apply the term tubercle to the sanguine variety, while still others are disposed to doubt the existence of any form of scrofula, apart from a syphilitic taint. It will thus be seen that the use of these words is necessarily attended Avith a good deal of confusion, and it would be Avell if Ave could dispense Avith them all, and adopt others which might be universally adopted as having a definite signification. Under the general term of struma, surgeons (whatever be their theoretical vieAvs) practically recognize, as justly remarked by Holmes, three classes of cases, viz., (1) those in which there is evidence of the existence of tubercle, ("2) those in Avhich there is no tubercle, but in which the ordinary processes of inflammation, etc., present modifications Avhich can only be accounted for on the supposition of the antecedent existence of some morbid condition or diathesis, and (3) cases which present, in reality, nothing more than the con- stitutional effects of long-continued local disease. Under the latter head come a large proportion of cases of chronic bone and joint disease, which are commonly though incorrectly called strumous. Rejecting then entirely the third class, Ave have the cases in Avhich tubercle exists, and Avhich may be properly called tuberculous, and those in Avhich there is evidently a morbid diathesis (not tuberculous), to which we may conveniently, if not very scien- tifically, apply the term scrofulous. Tubercle or Tuberculosis.—I shall not enter into any discussion as to the nature and origin of tubercle, a question Avhich belongs more properly to the domain of general pathology than to that of practical surgery, and upon Avhich the leading authorities of the present day are still not agreed.1 It is usually said that tubercle occurs under two forms, the gray or miliary 1 See review of Waldenburg's "Tuberculosis, Pulmonary Consumption, and Scrofula," by Dr. J. C. Keeve, in Am. Journ. Med. Sciences, Jan. 1870, and Mr. Butlin's article in International Encyclopaedia of Surgery, vol. i. pp. 235-239. 426 DIATHETIC DISEASES. tubercle, and the yelloAV tubercle. The latter is probably in many instances not tubercle at all, but the result of caseous or cheesy degeneration (tyrosis) of pus, cancerous deposits, or other pathological formations; in other cases, hoAvever, the yellow is the result of caseous degeneration of the miliary tubercle. Gray or miliary tubercles occur as small granular masses, about the size of millet-seeds, rather hard, semi-translucent, and presenting a glistening cartilaginous appearance. Under the microscope, these masses shoAV a homo- geneous or slightly fibrous stroma, containing cells Avith one or more nuclei, free nuclei, granules, etc. In the so-called yellow tubercle, which usually occurs in larger masses, the cells have a withered appearance, and the granular matter is in larger proportion, and mixed with oil globules. The following scale of the frequency of tubercle, in various textures and organs, is taken from Rokitansky: lungs, intestinal canal, lymphatic glands (particularly the abdominal and bronchial), larynx, serous membranes (espe- cially the peritoneum and pleura), pia mater, brain, spleen, kidneys, liver, bones and periosteum, uterus and tubes, testicles Avith prostate and seminal vesicles, spinal cord, and striated muscles. The favorite primary seats of tubercle, after the lungs and lymphatic glands, are the urinary and sexual organs, and the bones. Tubercles are only met with in vascular parts (hence not in cartilage), and are often deposited in the external coats (adventitia) of the smaller vessels, a circumstance which may account for their frequent appearance in the choroid coat of the eye, Avhere they have been recognized during life by means of the ophthalmoscope (see Waldenburg, and Reeve, loc. cit, p. 148). Tubercle may become indurated and calcified (obsolete), but usually tends to softening, disintegration, and liquefaction ; the fact of its absorption is not established, though its possibility is admitted by both Rokitansky and Virchow. The causes, symptoms, course, and general treatment of tuberculosis are described in every Avork on the Practice of Medicine, and need not there- fore be referred to here: it may be stated, hoAvever, that there are strong grounds for believing that, among the sources of depression Avhich act as predisposing causes of the development of tubercle, long-continued suppura- tion1 is one which must not be ignored. Hence an additional reason in the treatment of surgical cases, for paying attention to the constitutional condition of the patient, and for preventing, if possible, deterioration of the general health. With regard to the question of operative interference in tuberculous cases, no general rule can be given. The prognosis of an amputation or ex- cision for tuberculous disease, is undoubtedly less favorable than that of a similar operation for scrofulous or simple chronic inflammation. If there be evidence of tuberculosis of internal organs, any operation should as a rule be avoided; the only exceptions are—(1) Avhen it appears that the visceral dis- ease is caused by the external affection, and when therefore there would be reason to hope that by removing the latter the progress of the former might be checked, and (2) when the patient's suffering from the external disease is so great, that the operation is called for simply for the relief of pain. Scrofula or Scrofulosis, as the term is here used, denotes a constitutional condition or diathesis, which imparts a peculiar character to the processes of inflammation and ulceration, and which is particularly marked by a tendency to cheesy degeneration in the lymphatic glands, and to a low form of inflammation of the bones and joints. 1 Dr. Burdon Sanderson looks upon tuberculous deposits as closely analogous to the " metastatic abscesses " of pyaemia. The theory of the " inflammatory origin of tubercle " is supported by the results of experiments upon the lower animals. SCROFULA OR SCROFULOSIS. 427 Many writers speak of a scrofulous temperament, and describe certain peculiarities of feature and complexion, as characteristic of the scrofulous diathesis. Mr. Erichsen describes two forms, the fair and the dark, and subdivides each of these into tAvo varieties, the fine and the coarse: Sir Wm. Jenner, on the other hand, regards the fine varieties (Avhich constitute Avhat is usually called the sanguine temperament) as belonging to the tuberculous diathesis, and limits the term scrofulous to the temperament commonly recognized as the phlegmatic. Although, hoAvever, there are doubtless many cases of tuberculosis met Avith among persons of a sanguine temperament, with delicate features, clear complexions, and highly developed nervous systems, there are perhaps almost as many among those whose temperament Avould be unhesitatingly pronounced phlegmatic, so that, as Holmes justly remarks, the exceptions to the rule are almost as numerous as its exemplifi- cations. It is, indeed, questionable Avhether there be any temperament that can be positively declared to predispose to either scrofula or tubercle, or, on the other hand, any temperament in which either or both of these diseases may not under favoring circumstances be developed. The scrofulous diathesis may be inherited, or may be acquired by subjec- tion to various sources of depression, such as bad or insufficient food, intem- perance, bad ventilation, exposure, mental anxiety, etc. Even Avhen not manifesting itself in the form of any particular malady, it is usually charac- terized by weakness and irritability of the digestive system, by a feeble cir- culation, and by a state of general anaemia. Manifestations of Scrofula.—The manifestations of scrofula AAThich chiefly come under the notice of the surgeon, are scrofulous inflammation and ulceration, affecting the skin and mucous membranes, scrofulous disease of the bones Fig. 193. and joints, and cheesy degeneration of the lymphatic glands. 1. Skin.—Various cutaneous eruptions haATe been considered as scrofulous, but upon someAvhat questionable grounds; there can be no doubt, hoAvever, that cutaneous ulcers are modified in their appearance and course by the scrofulous diathesis, the tissues around the ulcers in these cases being greatly thick- ened and infiltrated Avith serum, the granu- lations large and feeble, and the cicatrices, when formed, thin, Aveak, and liable to re- ulcerate ('Fig. 193). 2. Mucous Membranes.—The mucous mem- branes, under the influence of the scrofulous diathesis, become thickened and irritable. Scrofulous ulcer of leg. (Erichsen.) The secretions may be thin and acrid, or sometimes mixed Avith pus. In the eyes there may be granular conjuncti- vitis, Avith perhaps haziness or ulceration of the cornea, and in the Schnei- derian membrane, hypertrophy, giving rise to obstructed breathing and snuffling; the antrum may SAvell, discharging purulent mucus into the nos- trils; the tonsils are not unfrequently enlarged, and the voice rendered husky by relaxation or thickening of the laryngeal mucous membrane; diarrhoea is frequent, and cystitis, urethritis, and leucorrhoea may each in turn be due to the scrofulous diathesis. 3. Bones and Joints.—The scrofulous diathesis seems to render the bones and joints peculiarly disposed to unhealthy and destructive forms of inflam- mation. Thus an accident, Avhich occurring to a healthy person would be 428 DIATHETIC DISEASES. quite trivial, may in one of a scrofulous diathesis be productive of the most serious consequences. I have knoAvn a fall on the ice, Avhich Avould ordinarily have caused a mere bruise, to give rise, in a scrofulous child, to acute osteo- myelitis of the humerus, Avith pyarthrosis of both elboAv and shoulder, ampu- tation at the scapulo-humeral articulation being eventually required. Under the influence of scrofulosis, inflammation of bone is apt to assume the form of caries, or of caries with limited necrosis (caries necrotica), while in the joints are found the various affections popularly called "white swellings," gelatini- form degeneration of the synovial membranes, ulceration of cartilages, etc. 4. Lymphatic Glands.—Perhaps the most unequivocal manifestation of scrofula is the tendency which it induces to cheesy degeneration (tyrosis) of the lymphatic glands. Indeed, Waldenburg, as quoted by Reeve (loc. cit, p. 154), defines scrofula as "a constitutional anomaly in which the lym- phatic glands have an abnormal tendency to disease, and possess a local disposition to undergo cheesy degeneration." Glandular enlargement, par- ticularly in the cervical and submaxillary regions, is very frequently ob- served in cases of scrofulosis, and, under very slight irritation, suppuration is apt to occur in the neighboring areolar tissue, the glands themselves breaking down, and mingling the caseous products of their degeneration with the surrounding pus. The abscesses thus formed are extremely indo- lent, not healing permanently until all the affected glandular structure has been removed, and cicatrizing finally with depressed and disfiguring scars. 5. Other Organs are occasionally though less frequently affected by scrofula. Among those which are most important, from a surgical point of vieAV, may be enumerated the mammary gland and the testis. Treatment of Scrofula.—The treatment of scrofulosis should consist more in attention to hygienic rules than in the use of medicines. Good air, good food, habitual cleanliness, sufficiently warm clothing, and protection from exposure or other sources of depression, are of the highest importance. Special attention should be given to the digestive functions, and either constipation or diarrhoea should be obviated, rather, however, by regulating the diet than by the use of drugs. Among medicines, certain tonics are particularly serviceable. Cod-liver oil probably deserves the first place, the most useful articles after it being iron, quinia, and the preparations of iodine. The syrup of the iodide of iron is a very good combination, particularly for administration to children. These tonics should not, however, be given in- discriminately, and, as a rule, not while there is evidence of marked intestinal derangement. Alcoholic stimulants must be used Avith great moderation, and the lighter wines, or malt liquors, such as lager beer, are commonly preferable to the stronger forms of stimulus. By local treatment, it is doubtful whether much can be accomplished. A most important rule, and one Avhich should be constantly borne in mind, is to take care lest by our treatment we convert this, which is essentially a chronic affection, into one which is acute. Hence in many instances the best thing for the surgeon to do is to let the part alone, merely protecting it from exter- nal injury. In other cases more active measures may be employed, though ahvays with care and Avatchfulness. Scrofulous ulcers may be dressed with slightly stimulating or astringent applications, and the livid, unhealthy-look- ing edges may be touched with the actual cautery, or even removed with the knife. Lymphatic enlargements should be protected by means of soap plas- ters, or, if very indolent, may be submitted to gentle frictions, with moderate pressure, and the use of mildly discutient lotions. Even if abscesses form, it is better, I think, to delay opening them, as long as there is the slightest chance of absorption and spontaneous disappearance. If an opening be inevi- table, it is probably better made with the knife than left to nature, as the RICKETS. 429 resulting scar will be less disfiguring. Any sinuses that are left may be encouraged to heal by stimulating injections, or by means of a seton. Re- peated tappings with the hypodermic syringe, or exploring needle, are recom- mended by LaAVSon Tait and Crocq, in the treatment of suppurating glands in the neck. With regard to operations in scrofulous cases, no rule of universal appli- cation can be laid down. I am decidedly of the opinion that, in the immense majority of instances, enlarged cervical glands should not be interfered Avith ; apart from the fact that the disease in such a case commonly extends much deeper than it appears to, these operations almost always come into the cate- gory of operations of expediency, and, as such, are only exceptionally justi- fiable. With regard to operations for scrofulous bone and joint disease, the question is more doubtful. As a rule, it may be stated that no operation should be performed Avhile a reasonable hope remains that a cure can be effected by expectant treatment; if, however, the powers of nature should be manifestly incompetent for the task, or if (as is often the case among patients of the poorer classes) the time which would probably be required for a natural cure be an important consideration, operate measures may be properly resorted to, and Avill often be followed by the most gratifying results. Ex- cision is of course preferable to amputation, when the circumstances of the case permit a choice. Rickets. Rickets or Rachitis is a constitutional disease, occurring almost exclusively in childhood, and characterized by a peculiar lesion of the osseous system, and by a tendency to the so-called amyloid or albuminoid degeneration of certain viscera, especially the spleen and liver. Causes.—Rickets may possibly in some cases be inherited, but is, at least, much more frequently acquired,1 and usually results from mal-nutrition, or from other sources of constitutional depression to which children may be ex- posed. According to Heitzmann, rickets can be artificially produced by the continued administration of lactic acid. Morbid Anatomy.—The most characteristic manifestation of rickets is seen in the skeleton, and affects the long bones as well as those of the head, chest, and pelvis. The bony changes consist essentially in increased cell- groAvth, Avith deficiency of earthy matter. The epiphyseal cartilages (car- tilages of conjunction) become enlarged, giving Avhat is often called the "double-jointed'* appearance observed in these cases. The periosteum is also greatly thickened, Avhile the osseous shaft itself undergoes softening, its lacumc being much enlarged, and filled with red, pulpy granulations. Under the influence of muscular action, or other mechanical causes, the bones undergo modifications of shape, giving rise sometimes to great deformity; if the child has begun to walk before the development of rickets, these changes will prob- ably be most marked in the loAver extremities. The cranial bones are often much thickened, giving a massive appearance to the head; in other cases they are abnormally thin, or even perforated (craniotabes), the pericranium and dura mater seeming to be in contact; the anterior fontanelle remains open longer than in health. Circumscribed SAvellings may occur in the frontal and parietal bones, as pointed out by R. W. Taylor, and may be mis- taken for syphilitic nodes. These SAvellings may subsequently undergo reso- 1 This subject is well discussed by Parry, in an excellent paper in Amer. Journal of Med. Sciences, for April, 1872. 430 DIATHETIC DISEASES. lution, or may remain as permanent deformities. The ribs bend at their junction with the costal cartilages, allowing the sternum to project, and causing the so-called "pigeon-breasted" deformity. In some cases the enlargement of the sternal extremities of the ribs gives the appearance of a deep gutter on either side of the breast-bone. The spine is occasionally the seat of lateral, but more often of antero-posterior curvature, the backAvard curve being in the dorsal, and the forward in the cervical and lumbar regions. The pelvis often becomes ATery oblique, in consequence of the deformity of the lower extremities, and of the " lordosis " or anterior curva- ture of the lumbar spine ; and serious complications may thus arise in after- life, in the process of parturition, or in operations on the pelvic organs. Symptoms and Course.—In the earliest stages of rickets, there are disorder of the digestive system and other evidences of mal-nutrition, but nothing that can be considered distinctive. Teething is delayed, and often accom- plished with difficulty. The child sleeps badly, and is restless ; sweats pro- fusely about the head, and constantly kicks off the bed-clothes. The muscular system is weak, and the patient, if he has already begun to walk, soon loses both the poAver and the disposition to do so. The urine is abundant, and usually loaded with phosphates. As the disease advances, a curious state of muscular hyperesthesia is often observed, either A'oluntary motion or the touch of another being attended with acute pain, and the child, as a conse- quence, maintaining an almost fixed position, and appearing listless and in- disposed to ev-en the slightest exertion. There is a tendency to bronchial and pulmonary inflammation, laryngismus stridulus, and cerebral irritation with convulsions. Fever is often, but by no means ahvays, present; the appetite is capricious or wanting, and the fecal evacuations (wdiether there be or be not diarrhoea) are ill-formed and offensive. The liver and spleen are often enlarged, and sometimes albuminous or amyloid, in the latter stages of the affection, Avhile the bony deformities, which have been described, frequently persist even after the entire restoration of the general health and strength. Intelligence is diminished during the existence of the disease, but the mental powers are usually completely restored with bodily convalescence. Diagnosis and Prognosis.—There are no symptoms by which, in its earliest stage, rickets can be distinguished from the other diathetic diseases which wTe have considered. In any case in Avhich dentition is much delaved, or in which difficulty in walking is observed, the surgeon may suspect rachitis, and, by careful attention to the symptoms above described, will usually be able to recognize it if present. When the characteristic osseous changes have begun, the nature of the affection can scarcely be mistaken. The prognosis of rickets, if the disease be not too far advanced, is usually favorable; as justly observed by Hillier, however, mortuary records recognize the secondary affec- tions which complicate rickets, Avhile the primary condition Avhich renders those complications fatal, is itself ignored. As a rule, it may be .said that the earlier the disease appears, the less is the chance of recovery, while even in the most favorable cases the affection may last for several years. Treatment.—The hygienic management of rickets is of the greatest im- portance; if the disease occur during the first six or eight months of life, and the mother's milk be found either scanty or of bad qualitv, a healthy Avet-nurse should be procured, or the natural food supplemented or replaced by fresh coav's milk, diluted with lime-water (1 part to 4); dog's milk is pre- ferred by Bernard. After a time, beef-tea may be made to alternate with the milk, and wine or brandy may be given in quantities adapted to the VENEREAL DISEASES. 431 patient's age. The child should be warmly clothed, and kept as much as possible in the open air, and at night in a well-ventilated apartment. Warm or cold >p'-nging, or sea-bathing, will often prove of great service. If the digestive system be much disordered, a feAv doses of mercury with chalk, or s me similar combination, maybe given, but the remedies of greatest impor- tance are tonics, especially cod-liver oil, iron, quinia, and nux-vomica. The cod-liver oil is probably the most valuable, and may be given in graduallv increasing doses as the child is able to assimilate it. Dr. Withers, an Irish surgeon, recommends the sulpho-carbolate of lime. Some difference of opinion exists as to Avhether mechanical appliances should be used to obviate deformity in these cases. In the most acute form of rachitis, when, in the vivid language of Sir William .Tenner, the child " is indeed fighting the battle of life, . . . striving Avith all the energy it has to keep in constant action every one of its muscles of inspiration," the use of splints and bandages would be doubtless an unnecessary annoyance : again, after the stage of bony con- solidation has come on, splints can be of no use, and would do harm by im- peding the natural motions; but, while the bones are yet soft and yielding, a great deal may be often accomplished by the use of light apparatus, to pre- vent if not to remedy deformity. For the lower extremities, simple wooden splints may be used, and may be made to project below the feet, so as to pre- vent the child from standing or walking; while for the spine, various forms of apparatus, such as will be described iu speaking of spinal curvature, may be employed. When excessive deformity of the long bones persists in after- life, it may occasionally be proper to endeavor to remedy it by cutting through the bone Avith saAV or chisel (osteotomy\ or even by removing, subperiosteal^, a wedge-shaped portion. Operations of this kind have been successfully resorted to by Little, Marsh, Billroth, Guerin, Boeckel, Bradley, and other surgeons. CHAPTER XXIV. VENEREAL DISEASES. Gonorrhoea and Chancroid. The term Venereal Disease is applied to certain affections which are usually acquired in sexual intercourse. There are three separate diseases which are properly described a? venereal, which until within a comparatively recent period Avere all confused together, and the distinction between two of which is even at the present time not recognized by a large number of sur- geons. These diseases are Gonorrhoea, Chancroid, and Syphilis. The first two are strictly local, while the latter is a constitutional affection. The non- identity of gonorrhoea with the other A~enereal diseases, though pointed out by Balfour, B. Bell, Hernandez, and others. Avas not clearly established until the publication of Ricord's treatise, in I808, while the diversity of chan- croid and syphilis—first clearly sIioavii by Bassereau, in 1852—is even now denied by a good many surgeons, and is practically ignored by a still larger number. 432 VENEREAL DISEASES. Gonorrhoea. Gonorrhoea, Blennorrhagia, or, as it is vulgarly called, Clap, is a virulent, contagious, muco-purulent inflammation, affecting the mucous membranes. It is chiefly seen in the generative organs, being usually met Avith in the male urethra and in the vulvo-vaginal canal—the glans penis and lining membrane of the prepuce, the uterus, and the female urethra, being less often involved. It also occurs in the conjunctiva, and is said to have been seen in the rectum, nose, mouth, and umbilicus. Causes.—The most frequent cause of gonorrhoea is unquestionably direct contact with the muco-pus derived from a person similarly affected. It may, however, arise from contact Avith the vaginal secretions in cases of leucor- rhoea, from contact Avith the menstrual fluid, or even, possibly, from inter- course between healthy persons, if coitus be violent, prolonged, or attended Avith unusual excitement. In the immense majority of instances gonorrhoea is acquired in sexual congress, and hence is observed in the mucous mem- branes of the urino-genitary apparatus. Ophthalmic gonorrhoea—or, as it is usually called, gonorrhoeal conjunctivitis—is caused by transference of the contagious secretion from the private parts to the eye, by the patient's hand, or possibly by means of dirty towels, etc., wdiile the rarer forms of rectal, nasal, umbilical, and buccal gonorrhoea may be similarly produced, or may be due to practices the nature of which it is not necessary to specify. Gonorrhoea of Male Urethra.—I shall first describe, under this heading, the course, symptoms, and appropriate treatment of an ordinary gonorrhoeal attack, considering subsequently the various complications which may arise, and the modifications of treatment required by each. The first symptoms are usually manifested from one to five days after exposure to contagion, though the disease is occasionally not observed until a Aveek, or even a fort- night, after the infecting coitus. The patient first notices an uncomfortable stinging or tickling sensation (which the French call picotement) at the uri- nary meatus, and, on examining the part, observes the lips of the urethra slightly swollen and reddened, and moistened Avith a small quantity of viscid secretion. This fluid gradually increases in amount, and from being, as at first, colorless, soon becomes milky or yelloAvish-Avhite in appearance, and under the microscope is found to consist of mucus mingled with pus. In this, Avhich is called the first or incubative stage, the inflammation is confined to the anterior portion of the urethra, and especially the part knoAvn as the fossa navicularis, but in the course of two or three days spreads backwards, and becomes much more intense. The discharge is now quite profuse, of a greenish-yelloAV color, somewhat thicker than at first, and occasionally streaked Avith blood; the urethra is tense and painful, and the wThole penis—but par- ticularly the glans—red and turgid. Urination is frequent, and attended Avith a good deal of irritation, or scalding (chaude-pisse), and the stream is lessened in size, on account of the SAvelling of the mucous membrane. If the bulbous portion of the urethra be affected, the perineum is tense and painful; while, if the prostatic portion be involved, the anus feels hot, and as if stuffed with a foreign body. If the inflammation run very high, there may be a good deal of general febrile disturbance. This, the second or acute stage of gonorrhoea, lasts from one to three weeks, and then gradually subsides into the third or chronic stage, which, Avhen long persistent, receives the name of Gleet or Bknnorrhcea. In the third stage, the discharge diminishes in quan- tity and gradually loses its purulent character, Avhile the intensity of all the GONORRHOEA OF MALE URETHRA. 433 symptoms, and especially of the scalding in urination, becomes markedly lessened. The inflammation lasts longest in the posterior portion of the urethra, and matter can be sometimes made to flow by pressure from behind forwards applied to the perineum, when the anterior portion of the canal has apparently quite resumed its normal condition. Gonorrhoea, in most cases, tends to a spontaneous cure, lasting on an average from six to tAvelve weeks ; but occasionally an intractable gleet may persist for many months, or even years. Under the name of Dry Clap have been described cases of gonorrhoea, in which it is said that all the symptoms were Avell marked, with the single ex- ception that at no time was there any discharge. I am disposed to think, Avith Bumstead, that in these cases closer observation, with perhaps exami- nation of the urine, would have shown that some muco-pus Avas actually present. I do not believe that gonorrhoea can exist without discharge, though it is very possible that the amount of discharge may sometimes be so slight as readily to escape detection. Diagnosis.—I do not believe that it is possible to distinguish, Avith absolute certainty, gonorrhoea caused by impure coitus, from other forms of muco- purulent urethritis. It is usually said that the diagnosis can be made by observing the greater virulence of the blennorrhagic affection, and, unques- tionably, ordinary inflammation of the urethra rarely attains the intensity which is common in cases of gonorrhoea. Very intense muco-purulent ure- thritis may, however, be caused by the contact of the acrid vaginal secretions in cases of leucorrhoea, or by the contact of the menstrual fluid; and it is believed by many of the very highest authorities, that genuine gonorrhoea is thus not unfrequently produced. Whether this be admitted or not; whether, that is, we believe in the existence of any special gonorrhoeal virus, or con- sider, as has been done in the preceding pages, that gonorrhoea is merely a peculiarly virulent form of ordinary inflammation, Ave must grant that it is often quite impossible to fix upon the exact source of the disease, in any par- ticular instance; and hence the practical inference, that the surgeon should, in cases the history of which is not clear, exercise great caution in express- ing an opinion, of the correctness of Avhich he cannot be absolutely sure, and which may not only cause great unhappiness, but may perhaps involve some innocent person in unmerited disgrace and blame. Fortunately the question is one of theoretical rather than of practical interest, for the treatment of muco-purulent urethritis is the same, no matter Avhence its origin. In its chronic stage, the diagnosis of gonorrhoea presents still greater difficulty, for a thin, gleety, urethral discharge may come from very various sources of irri- tation—being indeed a not unfrequent attendant upon the gouty, strumous, and scorbutic diatheses, or a mere secondary affection resulting from diseases of neighboring parts, such as the rectum or prostate gland. The form of urethral discharge Avhich, as will be seen hereafter, is a manifestation of sec- ondary syphilis, can usually be recognized by its grayish-Avhite color, and by the absence of inflammatory symptoms. Prognosis.—Though in the large majority of instances, gonorrhoea proves a perfectly tractable affection, and passes off without any disagreeable con- sequences, cases are occasionally met Avith in which a troublesome gleet proves utterly rebellious to treatment, remaining as the starting-point for an acute attack of the disease, which may be provoked by any sexual excess, indulgence in intoxicating beverages, or even imprudence of diet; in other cases gonorrhoeal inflammation gives rise to organic stricture of the urethra, or may cause serious and even fatal disease of the bladder and kidneys. Treatment.—The treatment of gonorrhoea is principally of a local charac- ter. If the patient be seen in the first stage, before the inflammation has 28 434 VENEREAL DISEASES. reached its point of greatest intensity, Avhat is called the abortive treatment may be properly employed. The plan which I am in the habit of folloAving is to direct urethral injections of a solution of nitrate of silver (gr. i-f'^j). Of this preparation from two to four fluidrachms should be carefully injected into the urethra, three, four, or five times a day, the patient taking the pre- caution to wash out his urethra by urination ten or fifteen minutes before each injection. The injections are best made with a small hard-rubber syringe, which is in every way preferable to the common glass syringe usually sold for the purpose. In using the syringe, the patient should gently intro- duce its beak as far as it will go into the urethra, the lips of which are then closely pressed against the instrument with the thumb and fingers of the left hand, while the piston is slowly driven dowrn by the forefinger of the right hand, which holds the syringe. By this method the escape of fluid is pre- vented, and the whole amount is introduced into the canal; there is no risk of the injection entering the bladder, and even should it do so, no harm would result, for it Avould be instantly decomposed by the salts of the urine. Tavo syringefuls may be used on each occasion of injection, as the effect of the first is always to some extent neutralized by the mucus Avhich lines the ure- thra. The first effect of these injections is apparently to aggravate the dis- ease, the discharge becoming purulent and profuse; in the course of a day or two, however, it again becomes thin and Avatery, and perhaps streaked with blood, while the concomitant symptoms lessen in intensity; the injections may now be used less frequently, or altogether discontinued, and very often no further treatment will be required. If, however, the discharge do not cease in a few days, mildly astringent injections may be used to complete the cure. No constitutional treatment is required during this stage, except a saline cathartic if there be constipation. The patient should be kept as quiet as possible, and upon rather low diet. The recumbent position should be maintained (confinement to bed is desirable, but often impracticable), and all sources of excitement, particularly of the sexual organs, carefully avoided. Some surgeons use, in this stage, very strong injections of nitrate of silver (gr. x to xx-f gj), and a very rapid cure may thus occasionally be obtained. The treatment should in such a case be conducted by the surgeon himself, one injection being all that is usually employed. The plan which I have recommended is, I think, safer, and equally satisfactory. In the second or acute stage of gonorrhoea, the precautions already referred to, as to rest and quiet, are of the highest importance. After the boAvels have been freely moved, the patient should be put at once upon the use of alkaline and diluent diuretics—the following combination being perhaps as suitable as any other: R. Sodii bicarbonat. 3j ; Spt. seth. nitr. f |ss; Infus. lini comp. Oj. M. A wineglassful of this mixture, which is not disagreeable to the taste, may be taken every two or three hours—the Avhole pint being consumed during the day. The glans penis and prepuce should be gently freed from the discharge as often as it accumulates, and much comfort may be derived from the local application of water as hot as can be borne. In- jections are not usually available during the first twenty-four hours of the acute stage, but if the meatus be not so much inflamed as to render the use of the syringe painful, anodynes1 may be thus employed with advantage— or even simple demulcents, such as thin starch—or local sedative's, such as the subnitrate of bismuth. Kiichenmeister, of Dresden, employs diluted lime-water. As soon as the first intensity of this stage has passed by, injec- tions become again the most important remedies, the best articles being 1 The following formula is given by Bumstead: R. Extract, opii 7}j; Glycerinse f|j; Aquae f|iij. M. gonorrhoea of male urethra. 435 probably the sulphate or acetate of zinc, the acetate of lead, and, as the disease becomes chronic, the sulphate of copper, or tannic acid. The follow- ing formula? will usually be found satisfactory: R. Zinci sulphat., Plumbi acetat., aa 9ij; Morphise sulphat. gr. i-ij; Aquae f^viij. M.—R. Cupri sulphat. gr. xij ; Yin. opii f 3j; Aqua? rosae f Jvj. M.—R. Ac. tannici 3j; Glycerinae f f$j; Aquae f 3v. M. Dr. See, of Paris, speaks very favorably of injections of silicate of sodium (gr. v to xv-f^j), Avhile Dr. Boyland, of Baltimore, recommends salicylic acid (gr. v-f^j), and Radha Xauth Roy, an East Indian surgeon, the sulphate of quinia (gr. ij-f gj). Dr. S. Eldridge advises the local use of ergotin. During this stage the patient should keep the testes constantly supported Avith a well-fitting suspensory bandage, a precaution which seems to lessen the risk of the inflammation spreading to the epididymis. During the third stage, injections should be continued, and advantage may be sometimes derived from the use of deep injections, applied through a double catheter, or simply by using a syringe with a long nozzle. Special forms of apparatus for this purpose have been devised by various surgeons, among others by Reliquet, Morgan, Dick, Durham, Windsor, Bumstead, Bigelow, and Hcavsoii. Harrison advises irrigation or douching of the urethra with a solution of sulpho-carbolate of zinc. In some cases, a slight discharge will persist long after the subsidence of all inflammatory symp- toms ; for these chronic gleets, a very strong solution of tannin (3j-f.?j) Avill sometimes be found useful; it may be used as an injection, or the prepara- tion described in the last edition of the U. S. Dispensatory as the glycerate of tannic acid may be applied on a sponge, through the tube of an endoscope. This instrument, Avhich will be again referred to, is occasionally useful in obstinate cases of gleet, by enabling the surgeon to ascertain the exact point to Avhich local medication should be applied. It Avill usually be found that the continuance of the discharge is due to persistence of inflammation in some of the mucous crypts or follicles which line the urethra, or to the existence of a slight stricture ; in the latter case, the occasional passage of a full-sized bougie will be found of service. During the later stages of gonorrhoea, the general condition of the patient often requires the use of tonics, Avith good food, and malt liquors, or other forms of alcoholic stimulus. The plan of treatment sketched in the preceding pages is that which seems to me best adapted to ordinary cases of urethral gonorrhoea, and I have seldom found it necessary to resort to any other. Many surgeons place great reliance upon the internal administration of certain stimulating diuretics, especially copaiba and cubebs, Avhich they employ to the partial or complete exclusion of the various injections which have been described. These remedies are, hoAvever, both inconvenient and disagreeable, and I believe in the large majority of cases quite unnecessary, though they may occasionally prove useful in the chronic stage of the affection. They may be administered sepa- rately or together, and may be combined with alkalies, and given either in pill or as an emulsion. When copaiba alone is to be prescribed, a convenient form is the gelatine capsule, containing twenty drops. On account of the disagreeable taste and nauseating quality of copaiba, Avhen sAvalloAved, it has been proposed to use it by enema, or as an injection for the urethra. I have employed the latter plan, but Avithout benefit, and indeed it appears that the effect of the drug can only be obtained by allowing it to pass through the kidney, and thus medicate the urine. Other modes of treatment have been used, and may occasionally be tried with advantage: such are the application of blisters to the thigh, or even 436 VENEREAL DISEASES. to the penis itself, painting the latter Avith tincture of iodine, the use of medicated bougies,1 etc. Complications of Gonorrhoea.—The complications of gonorrhoea which require special notice, are chordee, inflammatory bubo, strangury, retention of urine, hemorrhage from the urethra, perineal abscess, and epididymitis. 1. Chordee consists of a painful erection, in which the inflamed state of the urethra prevents the spongy portion from becoming elongated to the same extent as the cavernous portions of the penis. Hence the organ often presents a twisted appearance, and laceration of the lining membrane of the urethra, or of its submucous tissue, may take place, giving rise to hemor- rhage, or laying the foundation for the development of stricture. The treatment consists in the use of camphor and opium by the mouth, or as a suppository, in the application of an ice-bag to the perineum, in inunction of that part with belladonna ointment, or, as suggested by Otis, of New York, in the application of dry cold to the penis by Petitgand's method of "mediate irrigation" (p. 55). Inhalations of amyl nitrite have afforded relief in some cases. 2. Bubo.—The inguinal lymphatic glands occasionally become inflamed in cases of gonorrhoea, constituting the sympathetic or inflammatory bubo. The treatment consists in endeavoring to promote resolution by the application of blisters or the tincture of iodine; if suppuration occur, the pus should be evacuated through a small incision made in the direction of the long axis of the body, and the after-treatment conducted as in a case of ordinary abscess. 3. Strangury and Vesical Irritation may arise from inflammation of the prostate, or of the neck of the bladder; or, at a late stage, apparently from an atonic state of the part; the treatment consists in the use of warm fomen- tations and hip-baths, with anodynes, such as Dover's powder, or the tincture of hyoscyamus. The introduction of lumps of ice into the rectum is highly commended by Horand. When of the atonic form, advantage may be derived from the use of the mineral tonics. 4. Retention of Urine, if dependent upon spasm or inflammatory swelling, should be treated by the use of the warm bath, Avith full doses of opium, and perhaps leeches to the perineum, catheterization being avoided if possible. If an instrument be required, a large flexible catheter should be used without the stylet. If the retention arise from prostatic or perineal abscess, or from stricture, other measures may be required, which will be described in the proper place. 5. Urethral Hemorrhage may occur in the form of capillary oozing, or may result from rupture or laceration of large vessels, as a consequence of chordee, or of attempts at catheterization. The treatment consists in the local use of cold, or in pressure, applied by introducing a full-sized catheter and strapping the penis to the instrument. 6. Perineal Abscess may occur as a complication of gonorrhoea, and, beside causing great suffering, may give rise to retention of urine; the treatment consists in the use of poultices or Avarm fomentations, Avith an early incision in the median line, so as to prevent, if possible, the abscess from opening into the urethra—an occurrence which would almost certainly be followed by the formation of a perineal fistula. An early incision is also required in the rare case of an Urethral Abscess appearing in front of the scrotum. 7. Epididymitis, Hernia Humoralis, or Swelled Testicle, is one of the most important complications of gonorrhoea, rarely occurring before the third, 1 Bougies, or urethral suppositories, containing iodoform and the oil of eucalyptus, are recommended by Cheyne, of King's College Hospital, London. COMPLICATIONS OF GONORRHOEA. 437 and usually as late as the sixth, week of the disease. From the fact that it commonly appears as the discharge from the urethra is diminishing, it was formerly considered a sympathetic or metastatic affection, but it is now pretty well established that it is merely the result of the .extension of inflammation from the prostatic portion of the urethra, through the ejaculatory ducts and vas deferens, to the epididymis, and more rarely to the testis itself. The left side is more often affected than the right, probably because, as usually hang- ing loAver in the scrotum, the left testicle is naturally less well supported by that structure ; both testes are occasionally involved, rarely at the same time, but more often in succession or alternately. The symptoms are those of acute inflammation in any tense structure, great pain and tenderness, especially over the region of the globus minor, and marked swelling, which is, hoAvever, chiefly due to effusion into the tunica vaginalis (acute hydrocele). The diagnosis from orchitis, or inflammation of the testis proper, can only be made by noting the history of the case, and by observing the localization of the symptoms to the region of the epididymis. Epididymitis affecting an undescended testicle, or one retained in the inguinal canal, may be mistaken for Fig. 194. inflammation of a lymphatic gland, or for strangulated hernia, but the true nature of the case, under such circumstances, Avill be at once suspected, if, on examining the scrotum, the testis be found absent from its place. The prognosis of swelled testicle is always favorable, but the globus minor may become permanently obliterated by the inflammation, and, if this should occur on both sides, the patient would, of course, be rendered impotent. The treatment which I have for some years employed for this affection, when seen in the acute stage, is that Avhich was suggested by Petit and recommended by Yidal (de Cassis), and which has been more recently revived by H. Smith, of London. It Consists in making a punc- Gonorrhoeal epididymitis. (Liston.) ture or limited incision into the inflamed organ at its most tender part, with a sharp and narroAv straight bistoury; a feAv drops of blood follow the withdraAval of the knife, and the pain is almost instantaneously relieved, the tenderness quite or almost disappearing Avithin twenty-four or forty-eight hours. The patient is confined to bed for a few days, with the scrotum supported on a pilloAV, and covered with a cloth dipped in cold water, or in lead-water and laudanum. The use of urethral injections should be temporarily discontinued, and may be resumed, if neces- sary, when the acute symptom's have subsided. Iodine ointment, or some similar sorbefacient, may be used to remove the induration of the globus minor, which often remains after all tenderness has disappeared. This mode of treatment has proved in my hands perfectly satisfactory, the pain being at once relieved, and resolution following without any unfavorable occur- rence. Several cases have, however, been recorded by Demarquay and Salleron, in Avhich hernia and complete extrusion of the seminiferous tubules followed the incision, the patient being thus effectually castrated on the affected side; the incision is said, in Salleron's case (Arch. Gen. de Med., Fev. 1870), not to have exceeded one centimetre in length—about four-tenths of an inch. On the other hand may be placed the remarkable success obtained 438 VENEREAL DISEASES. by Vidal and Smith, the former surgeon having punctured 400 testes, Avith- out one bad result, while the latter declares that the method has served him well in 500 cases. To guard against the accident which occurred to Demar- quay and Salleron, it would be prudent, however, to limit the incision to one not exceeding a quarter of an inch in length. This little operation appears to act by relieving the tension due to the want of expansibility of the tunica albuginea; it is therapeutically analogous to the incisions practised in cases of paronychia, and, in the words of Mr. Hutchinson, "appears to relieve pain much Avith the same certainty that iridectomy does in acute glaucoma." Other modes of treatment have been recommended for epididymitis, among which may be mentioned Velpeau's plan of making numerous punctures of the tunica vaginalis with the point of a lancet, Fricke's method of strapping the testicle with adhesh-e plaster (very painful during the acute stage), the application of ice, as advised by Borgioni, or of iodoform ointment, as prac- tised by Alvares, Langlebert's method of surrounding the scrotum Avith Avadding and India-rubber cloth and applying a suspensory bandage, and the plan recommended by Mr. Rouse, of St. George's Hospital, Avho relies chiefly upon the administration of opium, in doses of a grain, night and morning (St. George's Hosp. Rep., vol. iv. pp. 251-258). The plan formerly advised in most text-books, and still favored by many surgeons, consists essentially in local bleeding and the free use of tartar emetic and calomel— in the adoption, in fact, of a decidedly " antiphlogistic " course of treatment. Among the rarer complications of gonorrhoea must be mentioned peritonitis and subperitoneal abscess, due, according to Faucon, to irritation transmitted from the vas deferens, seminal vesicles, prostate, bladder, ureters, or kidneys. Balano-posthitis, or External Gonorrhoea, is the name given to inflamma- tion of the prepuce and glans penis. When confined to the former, it is called balanitis, and Avhen limited to the latter, posthitis. This affection is usually due to exposure in coitus, but may result from the irritation caused by the accumulation of smegma, in cases of phimosis, or in persons Avho neglect ablution. It is chiefly seen in those Avhose prepuce is elongated, and may be very generally prevented by the practice of circumcision, the co\Ter- ing of the glans losing the character of mucous membrane after this opera- tion, and becoming assimilated to skin. The symptoms are those of ordinary muco-purulent inflammation, and the affection is often accompanied Avith a temporary phimosis. The treatment consists in the application to the inflamed surfaces of the solid stick of nitrate of silver, or in packing the preputial fold with lint dipped in a solution of the same salt Oj-i^j), the whole penis being then surrounded with an evaporating lotion. If phimosis exist, it may be necessary to relieve this by an operation which will be described in another portion of the volume. Gonorrhoea of the Female Generative Organs is usually limited to the vulvo-vaginal canal, though the urethra is occasionally affected, as are likeAvise the lining membranes of the uterus and Fallopian tubes. The ovaries may be secondarily inflamed (furnishing a pathological analogy to the swelled testicle of the male), or peritonitis may ensue from the escape of gonorrhoeal matter into the cavity of the abdomen. The symptoms are those of acute inflammation, attended Avith profuse muco-purulent discharge. The diagnosis from leucorrhoea and from ordinary vulvo-vaginitis, is often difficult, and occasionally impossible. . Leucorrhoea usually proceeds chiefly from the womb, while gonorrhoea affects principally the exterior parts, but these posi- tions may be occasionally reversed. Muco-purulent vulvo-vaginitis may, as OPHTHALMIC GONORRHOEA. 439 is Avell knoAvn, result from various causes independently of contagion, such as exposure to cold and moisture, the presence of ascarides, external violence, masturbation, or immoderate coitus. Hence, the surgeon should be very cautious in pronouncing an opinion as to the nature of a suspicious discharge in a woman, and particularly in a female child, as vaginal discharges in chil- dren are not unfrequently made the ground of criminal accusations against totally innocent persons. Even the implication of the urethra is not positive, though it is certainly prima facie evidence of the inflammation being the result of impure contact. The treatment of gonorrhoea, in the female, should, during the acute stage, be limited to the use of laxatives and diaphoretics, with warm hip-baths and emollient fomentations to the external parts. In the subacute stage, astrin- gent injections (especially of alum or sulphate of zinc) may be used, the patient applying them herself by means of a self-injecting enema apparatus (in quantities of not less than a pint), or the surgeon making the application through a speculum. In either case the patient should be recumbent, with the hips somewhat elevated. After the use of an injection, it is well to keep the inflamed surfaces apart by introducing a strip of lint, or a small tam- pon, dipped in the astringent solution. Another plan, proposed by the late Sir J. Y. Simpson, is to introduce medicated pessaries, or vaginal supposi- tories. This method has, according to Dr. Black, been successfully em- ployed in the women's venereal wards of the Philadelphia Hospital. Vaginal poultices are employed by Fournier. When the urethra is affected, injec- tions may, if thought proper, be employed as in the male, or copaiba and cubebs may be administered internally. The inflammation may persist in the vulvo-vaginal ducts and CoAvper's glands long after apparent recovery. Bubo rarely follows gonorrhoea in the female, but, when met Avith, should be treated as in the male. Ophthalmic Gonorrhoea, or, as it is usually called, Gonorrhoeal Ophthal- mia or Conjunctivitis, is produced by direct inoculation of the palpebral or conjunctival mucous membrane with gonorrhoeal matter, and must not be confounded with a form of ophthalmia principally affecting the sclerotic, which is dependent upon what will be presently described as gonorrhoeal rheumatism. Ophthalmic gonorrhoea usually affects but one eye, and runs a very rapid course, ending, if not checked, in destruction of the organ. It is more fre- quent in men than in Avomen, and is believed by some Avriters only to accom- pany cases of urethral gonorrhoea. The symptoms are first manifested in from six to eighteen hours after inoculation. The discharge, at first thin, soon becomes thick, purulent, and profuse. The conjunctiva is the seat of great chemosis, rising above and partially overlapping the cornea, while the eyelids SAvell and often completely close the eye. The cornea soon becomes hazy, ulceration occurs (usually near the margin), perforation folloAvs, with perhaps prolapse of the iris and consequent staphyloma, or the Avhole cornea may slough, in Avhich case the eye is of course irretrievably lost. the treatment must be both constitutional and local: the practice of de- pletion, Avhich Avas formerly common in these cases, is now generally aban- doned, it being recognized that the disease is invariably one of depression. The bowels having been relieved by a laxative, the patient should be at once put upon the use of quinia, with or without the mineral acids, and should take concentrated food in the form of beef-essence, Avith alcoholic stimulus if required. The local treatment is of the highest importance. The sound eye should be protected by the application of a compress of charpie, held in place by a disk of adhesive plaster covered with collodion, or by the 440 VENEREAL DISEASES. use of an ingenious bandange devised by Mr. Buller, of London, which consists of a square piece of Mackintosh fitted with a Avatch-glass, and fast- ened by adhesive plaster. If there be much chemosis, radiating incisions through the SAVollen conjunctiva should be practised, as recommended by Tyrrell, and, in any case, a strong solution of nitrate of silver (9j or ij-f^j) should be freely painted Avith a camel's-hair brush over the inflamed sur- faces, and allowed to remain a few seconds until the part is Avhitened, when the surplus should be Avashed off Avith a gentle stream of tepid or cool Avater. This application may be repeated once or twice a day, according to the severity of the case, Avhile a weaker solution (gr. v or x-f§j) should be instilled every three or four hours, and the accumulating discharge very frequently washed away Avith a weak solution of alum, applied with a syringe, or squeezed from a piece of lint. Bader employs an ointment of the red oxide of mercury, gr. j to "§,], Avith \ gr. of daturia. Free and, if Fig. 195. Fig. 196. Ophthalmic gonorrhoea. (Dalrymple.) necessary, repeated division of the external canthus, so as to relieve the eye from pressure, is recommended by Van Buren and Keyes, while Critchett goes further, dividing the upper lid as far as the margin of the eyebrow, and separating the flaps thus made, and keeping them apart with sutures attached to the broAV during the whole course of treatment, the lid being subsequently restored by a plastic operation. If perforation of the cornea be threatened, instillations of atropia should be resorted to, so as to prevent, if possible, prolapse of the iris. Cold applications may be employed throughout the duration of the disease, if agreeable to the patient, while opium may be given in full doses to relieve pain. As the severity of the inflammation subsides, the application of the strong solution of nitrate of silver may be stopped, the use of the weaker solution being continued until convalescence is established. A granular condition of the lids is sometimes left, requiring the occasional application of the sulphate of copper in sub- stance. Counter-irritation, by blisters or tincture of iodine, applied in the form of a horseshoe to the brow and temple, has recently been highly recommended in cases of ophthalmic gonorrhoea by Furneaux Jordan. GONORRHEAL RHEUMATISM. 441 Gonorrhoea affecting the Nose, Mouth, Rectum, or Umbilicus, presents no features of special interest; in each locality it requires the use of emol- lient applications during the acute stage, and of stimulating astringents at a later period. Rectal gonorrhoea may prove an occasional cause of organic stricture of that portion of the alimentary canal. Gonorrhoeal Rheumatism is a sequence of gonorrhoea Avhich is almost ex- clusively confined to the male sex, and Avhich, in the rare instances in Avhich it is seen in Avomen, seems to be dependent upon implication of the urethra in the gonorrhoeal affection, never occurring, according to Cullerier, in cases of simple vaginal gonorrhoea. It is, in fact, a variety ot urethral fever, and is probably due to the absorption of septic material generated in the muco- purulent secretion of urethritis, being thus (as has already been remarked) a mild form of pysemia. It has been objected, by some, to this explanation, that, if pyemic, the disease should arise equally from vaginal as from urethral gonorrhoea, and it has been maintained that its invariable urethral origin indicates a peculiar sympathetic connection between the urinary canal and the articulations, and that the affection must therefore be consid- ered metastatic. Other Avriters have regarded the connection as accidental, and taught that a rheumatic diathesis was a necessary antecedent; while others, again, have looked upon the rheumatic manifestations as indicating the essential identity of gonorrhoea and syphilis. It is well established, how- ever, that, in very many cases, no antecedent rheumatic diathesis can be traced; Avhile, apart from the total want of resemblance betAveen this affec- tion and constitutional syphilis, and the fact that the latter does, and that this does not, arise from vaginal infection, the absolute diversity of the dis- eases has been so clearly established by the unerring test of inoculation, as to render the suggestion of their identity scarcely worthy of consideration. The notion of metastasis is disproved by the fact that the urethral discharge does not usually disappear, but is rather increased, upon the development of the rheumatic symptoms, Avhile the anatomical differences in the structure of the urethral and vaginal mucous and submucous tissues, are quite sufficient to account for the occurrence of septic absorption from one and not from the other. Gonorrhoeal rheumatism affects principally the joints (particularly the knee and ankle), the synovial bursse, the muscles and tendons, and the scle- rotic coat of the eye, from Avhich, hoAvever, it may extend to the conjunctiva, or to the iris and cornea. The articular symptoms resemble those of rheu- matoid arthritis, rather than those of acute rheumatism, the disease not tending to attack many joints in succession, and being very rarely accom- panied Avith cardiac complications, though blenorrhagic endocarditis is de- scribed by Lacassagne, Desnos, Marty, Baudin, and Cianciosi. The joints are painful and SAVollen, and occasionally reddened ; the inflammation rarely ends in suppuration, but not unfrequently in false anchylosis. The muscular affection is principally manifested in the fleshy parts of the thigh and arm, and in the soles of the feet. Gonorrhoeal Rheumatic Ophthalmia is attended with pain, dimness of vision, photophobia, and lachrymation; if the con- junctiva be much involved, there may be a muco-purulent discharge, but there is not much chemosis, and the cornea very rarely ulcerates. Iritis may result in adhesion to the capsule of the lens, and permanent impairment of vision. Pericarditis and Endocarditis are occasional complications of gonorrhoeal rheumatism, and sometimes folloAv gonorrhoea Avithout the occur- rence of other rheumatic symptoms. According to Marty, the aortic are more often affected than the mitral valves. The treatment of the articular affection is best conducted by the use of repeated blisters, and by the internal administration of anodynes, Avith or 442 VENEREAL DISEASES. without quinia, according to the constitutional condition of the patient; in the later stages, compression by means of adhesive strips may be employed Avith advantage. If suppuration be imminent, the intra-articular fluid may be AvithdraAvn by means of a capillary trocar and aspirator, as advised by Laboulbene. The iodide of potassium is particularly adapted to those cases in Avhich the muscular and fibrous structures are affected, and may be given in large doses. The same remedy may be employed in the ophthalmic variety of the disease, and may be supplemented by the oil of turpentine, in drachm doses, if the iris be involved ; in the latter case instillations of atropia should also be practised, Avhile astringent collyria may be required if there be much conjunctivitis. Counter-irritation, by blisters or iodine, may be applied to the temples, if thought necessary, or a more permanent effect may be pro- duced, as suggested by Dr. W. Thomson, of this city, by applying the mouth of a bottle containing a small quantity of bromine—a brief contact Avith the vapor of this powerful agent sufficing to produce an eschar which will con- tinue for several weeks. Chancroid. The Chancroid, or Simple Venereal Ulcer (often called Soft, or Non-in- fecting Chancre), is a strictly local affection, resulting from contact with the secretion from a similar sore in the same or another person.1 It is usually acquired in impure coitus, but may be mediately transmitted by means of towels, etc. Surgeons, or accoucheurs, are occasionally infected in the dis- charge of their professional duties, particularly if they happen to have abrasions on the fingers at the moment of exposure. Locality.—Any part of the body may be the seat of chancroid, though the most usual position is, of course, the generative organs—in the male about the preputial fold, corona glandis, framum, and urinary meatus, and, in the female, about the nymphae, or os uteri. It was formerly supposed that the cephalic region was insusceptible to this affection, but it is now known that the chancroid can be readily artificially inoculated upon the face, and at least seven cases (Puche, Rofeta, Diday, Labarthe, R. W. Taylor, Venot—tAvo cases), are on record, in which a cephalic chancroid resulted from the ordi- nary mode of contagion. Course.—The chancroid has no period of incubation, the varying intervals betAveen exposure and the appearance of the sore, depending upon Avhether the contagious matter is deposited upon an abraded, a delicate and soft, or a thick and callous surface. When artificially inoculated, the first symptoms appear Avithin a few hours, the inoculated point becoming ele\Tated and sur- rounded with a red areola, in the course of the second or third day. The papule thus formed, in another day becomes a vesicle, and subsequently a pustule, which either bursts, exposing the chancroidal ulcer, or dries into a scab beneath which the ulceration progresses. If the chancroidal matter be deposited in an abrasion, the ulcerative stage may begin at once. The fully- formed chancroid is thus usually developed from four to six days after expo- sure,2 and appears as a round ulcer, from a line to half an inch in diameter, 1 Kaposi, Bumstead, and some other writers, believe that chancroid results from the inoculation of pus from any source, as from acne, the pustules of scabies, etc. This view seems to me to lack confirmation, and is certainly contrary to anything that I have observed in my own practice. 2 F. N. Otis, however, records a case in which the chancroid did not appear until the tenth, and was not fully formed until the thirteenth, day. CHANCROID. 443 unadherent to the subjacent tissues, with sharp-cut edges, as if punched out of the skin, covered Avith an adherent gray slough, furnishing pus which is auto-inoculuble,* and at first surrounded with a reddish areola. It is com- monly multiple, eighty per cent, of affected persons having, according to Fournier's observations, from two to six sores each. The chancroid may present, at its base, a slight degree of hardness, Avhich is the result of inflam- matory action, but which must not be mistaken for the induration commonly observed in the true chancre, or initial lesion of syphilis. Bubo.—The chancroid is not unfrequently folloAved by SAArelling of the inguinal glands, or bubo, Avhich may come on at an early period, but from the risk of Avhich the patient is never free as long as the chancroidal ulcera- tion continues: Puche met Avith it three years after infection.2 The bubo which folloAvs chancroid may be of the simple inflammatory variety, such as is seen in cases of gonorrhoea, or after injury—or may be the result of direct absorption of chancroidal pus, in Avhich case it receives the name of virulent or chancroidal bubo. The chancroidal bubo is usually monolateral, and com- monly on the same side as the sore from Avhich it originates, though it is occasionally seen on the opposite side, as the result of the interlacement of the lymphatics on the dorsum of the penis. It affects only the superficial glands, and only one at a time; hence, it is said to be monoganglionic. The chancroidal bubo invariably tends to suppuration, the resulting ulcer being precisely analogous to the original chancroid, and furnishing a contagious and auto-inoculable pus. Sometimes suppuration occurs first in the areolar tissue around the affected lymphatic gland, Avhen the abscess will not assume the chancroidal character until disintegration of the gland itself has begun. The chancroid and chancroidal bubo have little or no tendency to a spon- taneous cure. While one ulcer is healing, others may be produced by auto- inoculation and fresh glands involved by absorption, the disease, perhaps, being thus prolonged until the patient is carried off by some intercurrent affection, or dies utterly worn out by suppuration and long-continued suffering. Complications.—A chancroid may be complicated by the existence of warts or vegetations (Avhich are by no means necessarily of a venereal ori- gin) ; by inflammation of the penis and prepuce, Avhich may lead to phimosis or paraphimosis, or to gangrene of the prepuce; by the coexistence of gon- orrhoea or of syphilis; and by phagedenic or serpiginous ulceration. Phagedccnle Ulcered! on is a \rery serious complication, and is apparently due more to the constitutional condition of the patient than to any peculiar virulence of the source of contagion; it is, in other Avords, not a distinct variety of chancroid, but a complication which may affect any simple venereal sore. Its occurrence is sometimes traceable to distinct sources of depression, such as intemperate habits, the previous existence of syphilis, or the abuse of mercury. The phagedsenic chancroid is attended with Avide and deep erosion of tissue, a considerable portion of the head of the penis being occasionally eaten aAvay in the course of a feAv hours, and the disease sometimes not being arrested until almost the Avhole organ has perished. The ulcer is usually covered Avith a yellowish-gray, pultaceous slough, the appearance of which is compared by Barton to that of melted tallow, though the slough may in other cases be blackened by exposure. Phagedsenic ulceration may attack a chancroidal bubo, and death may result under such 1 That is, which can, by inoculation, produce in the same person a sore of the same nature as that from which it was derived. 2 According to Horteloup, chancroidal pus may be absorbed and remain latent in a lymphatic gland for many months, finally causing a true chancroidal bubo long after the original chancroid has been completely healed. 444 VENEREAL DISEASES. circumstances either from exhaustion or from hemorrhage—by the giving way of the femoral artery—as happened in a case recorded by Sir A. Cooper. Serpiginous Chancroid.—The serpiginous or creeping chancroid differs from the preceding, chiefly in pursuing an extremely chronic course. This com- plication, which is fortunately rare, is exceedingly intractable, occasionally persisting for many years. It usually occurs in the groin, attacking perhaps an open chancroidal bubo, and sloAvly creeps onAvards, eroding the adjoining skin at one part, Avhile a thin blue or violet cicatrix forms at the opposite side of the ulcer. It is chiefly seen in persons whose constitutions have been undermined by long-continued Avant and neglect. Diagnosis.—From herpetic or aphthous eruptions on the prepuce or glans penis, and from excoriations from mechanical causes, the chancroid may be ordinarily distinguished by the fact that the former make their appearance almost immediately after the suspicious connection, while the latter is not usually fully developed before the fourth day. In some instances, however, the diagnosis is extremely difficult, though it may be determined by observ- ing the further progress of the affection, or by inoculation, which, in the case of herpes, etc., will give a purely negative result. If the chancroid be situ- ated within the urethra, it may simulate gonorrhoea; if within the cervix uteri, leucorrhoea; and if on the glans, and complicated with phimosis, bala- nitis. Here, again, to ascertain the nature of the affection, it may sometimes be necessary to resort to inoculation, which proceeding, if the affection be chancroidal, will result in the formation of a chancroid, but in the case of gonorrhoea, etc., will result merely negatively. The diagnosis from chancre, or the initial lesion of syphilis, will be considered when we come to speak of that affection. All of these diseases may exist together, and it thus some- times happens that the same woman may infect three persons differently, according to their several susceptibilities, giving to one gonorrhoea, to another chancroid, and to a third syphilis. Prognosis.—The prognosis of a case of uncomplicated chancroid, if this be properly treated, is always favorable; the phagedsenic chancroid is a more serious affection, frequently entailing considerable loss of substance, though rarely endangering life, unless neglected; the serpiginous chancroid is the most intractable form of the affection, and the surgeon should be very guarded in his prognosis of a case of this kind, as, though not in itself attended by any particular risk to life, it often persists for years, in spite of the most judicious treatment. Treatment.—I shall first describe the treatment of the ordinary chancroid, or simple venereal ulcer, indicating subsequently the modifications required by the various complications of the disease. In the first place, it is to be observed that, as the chancroid is a strictly local affection, it requires, in itself, merely topical treatment. If any constitutional remedies are to be employed in a case of chancroid, they are only such as are indicated by the patient's general condition, without regard to the particular disease with which he is affected. The first object to be accomplished, as soon as the surgeon has made up his mind that he has to deal with a chancroid, is to apply some agent which will entirely destroy the whole surface of the ulcer, thus removing at once the tendency of the disease to spread, and converting the sore into a healthy granulating surface. To do this, various forms of caustic may be employed, the best, in my judgment, being the strong nitric acid. The surface of the sore having been carefully dried Avith lint, the acid is applied on the end of a piece of soft wood, well rounded and smoothed TREATMENT OF CHANCROID. 445 (this is better than a camel's-hair brush), in such a Avay as to reach every portion of the ulcer. Every cranny and crack should be permeated, as any portion of the chancroidal surface which escapes will reinoculate the whole ulcer. After the acid has remained a few moments, it may be washed off with a stream of cool water. The effect of the application is to convert the whole surface into a slough, upon the detachment of which a healthy ulcer is left, which rapidly fills up and becomes cicatrized, the pus, hoAvever, retaining its contagious character until the ulcer is almost, if not until it is quite, healed. If there be a number of chancroids, or if the surface to be cauterized be very extensive, it may be necessary to resort to anaesthesia before applying the acid, or, as has been recently suggested, a preliminary application of carbolic acid may be made, so as to utilize the local anaesthetic power of this agent. One application of nitric acid, if thorough, is sufficient, but it occasionally happens that, in spite of the surgeon's care, some portion of the ulcer escapes, Avhen the cauterization must be subsequently repeated once or oftener. After the cauterization, water-dressing or lime-wrater may be applied until after the separation of the sloughs, when the remaining ulcer should be treated upon general principles. Black-Avash (calomel 3j, lime-water ()j) answers a very good purpose as a stimulating astringent, but has no specific virtue. A solution of salicylic acid is recommended by Boy- land, of Baltimore. Iodoform, in powder, in the form of ointment (gr. xv to xxx-gj), or in solution Avith glycerin and alcohol (iodoform ^iss, glycerin f^vj, alcohol f^ij), is an excellent application which has been particularly recommended by Izard, and by Damon, of Boston. The solution may be employed as long as there is profuse suppuration, while the poAvder and ointment are particularly useful in a later stage of the affection. Autier recommends a two-per-cent. solution of salicylic acid in glycerin. Chancroid in the Female should be treated in the same Avay, the acid being carefully applied in these cases through a suitable speculum; black-wash may be used as an after-dressing, or the aromatic wine,1 which is a more elegant though somewhat expensive preparation. If the chancroid be seated in the male urethra, at such a point that it cannot be seen by separating the lips of the meatus, it may be touched through the tube of an endoscope with a strong solution of nitrate of silver (3ss-f'3j) ; the use of nitric acid in this situation is undesirable, on account of the risk of a stricture following its caustic action. Chancroids on surfaces Avhich are ordinarily in contact, as the glans and lining membrane of the prepuce, or the inner surfaces of the nymphae, should after cauterization be kept apart by the interposition of a fold of lint, dipped in black-wash or other astringent lotion. Treatment of Bubo.—In the treatment of a bubo occurring after a chan- croid, as it is impossible in the first instance to determine whether it be really a chancroidal, or merely an inflammatory, bubo, an effort should be made to promote resolution by the use of blisters, iodine, or iodoform, which may be conveniently applied in the form of an ointment (gr. xxx-|j). If, hoAvever, suppuration have evidently occurred, and particularly if the in- tegument be thin and discolored, it is better to make a free opening (by an incision in the direction of the long axis of the patient's body), so as to evactuate the contents of the abscess, and the ulcer Avhich remains, if it assume the chancroidal character, must then be treated as the original sore. Some surgeons prefer to open a chancroidal bubo with caustic potassa, but I do not see that this agent is in any way preferable to the knife, while it is certainly more painful. It sometimes happens that, when the pus is evacu- 1 The following formula is taken from Bumstead : Claret wine, Compound spirit of lavender, of each f$v; Tincture of opium fSjss ; Water fgiijss; Tannin 3J-^j. Mix. To be diluted if necessary. 446 VENEREAL DISEASES. ated from a chancroidal bubo, an enlarged lymphatic gland is found, more or less dissected from the surrounding tissue, and projecting through the lips of the incision: this gland is filled Avith chancroidal matter, and as long as it remains Avill keep up the specific nature of the sore; and though it "will in time undergo spontaneous disintegration, other glands will by that time have been infected, and the disease will thus be perpetuated. Such a chan- croidal lymphatic gland should be therefore removed; this may be accom- plished by repeated applications of caustic, but is much more conveniently effected by enucleation, which consists simply in seizing the gland with forceps, and dissecting it from its attachments. Before proceeding to cauterize an opened chancroidal bubo, the patient should be thoroughly anaesthetized, as the operation is usually both tedious and painful. The first step consists in tracing out and slitting up every sinus that can be detected, Avith a grooved director and probe-pointed bis- toury ; the flaps of undermined and unhealthy-looking integument are next to be clipped aAvay Avith scissors; enlarged glands to be carefully enucleated; and finally the strong nitric acid to be thoroughly applied to every portion of the surface, and even a short distance beyond the incisions, Avith the same precautions as in the cauterization of the original chancroid. A large slough is thus formed, the detachment of which is the work of some time; water-dressing may be applied after the cauterization, the subsequent treat- ment being conducted on general principles. The management of a chan- croidal bubo is thus seen to be a much more serious affair than that of the chancroid itself; hence the importance of prompt and effectual treatment of the original sore, that absorption may, if possible, be prevented. Warts.—The treatment of venereal wrarts does not differ from that of vege- tations on the generative organs arising from other causes, and Avill be de- scribed in a subsequent chapter. Phimosis.—A troublesome complication of chancroid on the prepuce or glans penis, is phimosis, Avhich may be congenital, or the result of inflamma- tory action. A great objection to any cutting operation, in these cases, is that the cut edges themselves Avill almost certainly be inoculated with the chancroidal virus; hence, if the phimosis be the result of inflammation, it is better to attempt to subdue this by the use of cold Avashes, and by the injection of detergent lotions beneath the prepuce, when it will often be possible to draw back the latter and make the necessary applications to the glans. Another plan, Avhich may be occasionally useful, is to pack the pre- putial fold with lint saturated with a solution of nitrate of silver, as recom- mended in cases of balanitis. If the phimosis do not yield, or if it be congenital, it will probably be necessary to slit up the prepuce, or, if the chancroid be seated near the orifice of the latter, to perform circumcision; if the cut edges in either case become inoculated, they must be freely cau- terized Avith nitric acid. Paraphimosis occurs as the consequence of the patient drawing back the prepuce and then being unable to return it; the necessary applications having been made to the chancroid, the prepuce may be restored to its place by the manipulation Avhich will be described in the chapter on Dis- eases of the Generative Organs: the after-treatment consists in the use of cooling applications to relieve inflammation of the part. Gangrene of the Prepuce is an occasional result of inflammatory phimosis, and is a very serious complication of chancroid. If, in any case of phimosis, the foreskin become much swollen, and of a dark red or purple hue, the surgeon may fear the occurrence of gangrene, and should lose no time in relieving the tension of the part by freely slitting up the constricting pre- puce. If gangrene, however, have actually occurred, the surgeon's efforts PRIMARY BUBO OR BUBON D'EMBLEE. 447 must be chiefly directed to limiting its extension by the use of fermenting poultices and detergent injections, and by the internal administration of opium. Hemorrhage, occurring during the separation of the slough, may be checked by the use of the actual cautery. The patient may escape Avith the loss of a small portion of the prepuce, but occasionally the Avhole ex- tent of this structure will perish, when it may be detached en masse, and leave the patient as effectually circumcised as by an operation. After the separation of the mortified part, the chancroids, Avhich will noAv be fairly exposed, must be treated in the manner already described. Phagedazuic Chancroid.—In this serious affection, no time should be lost in detaching the slough, and in applying the strong nitric acid to the Avhole ulcerated surface in the manner already directed, the patient having been previously etherized if necessary. The subsequent dressings may be made with a solution of the potassio-tartrate of iron (a favorite remedy Avith Ricord), with one of chlorinated lime, Avith iodoform, or Avith an opium wash, if the part be inflamed and very painful. The application of a con- stant current of electricity is recommended by Schwanda, of Vienna, and the use of the continuous Avarm bath by Simmons, of Yokohama. Opium should be administered internally in such doses as to relieve pain Avith- out disordering the digestion, and alcoholic stimulus may be given in quan- tities proportioned to the age and strength of the patient. Tonics are usually required, the best being, probably, the potassio-tartrate or muriated tincture of iron, either of which may be given pretty freely. The diet should be nutritious but unirritating. The nitric acid should be reapplied as often as any tendency to a recurrence of phagedena is manifested. Serpiginous Chancroid.—In the treatment of this most intractable affec- tion, free and repeated cauterization of the whole ulcerated surface and sur- rounding integument is the only remedy Avorthy of much confidence. The actual cautery is probably the best application in these cases, the subsequent dressings being made Avith chlorinated Avashes. The strength of the patient must be maintained by the use of tonics and the administration of suitable nutriment: opium may be given as often as required to relieve pain. Cases have been reported in which both phagedsenic and serpiginous chancroids have been cured by the use of mercury or iodide of potassium, but there is every reason to believe that in these instances the affection was really syphilitic, phagedenic and serpiginous ulceration being occasionally, though rarely, met with as complications of both primary and tertiary syphilitic sores. Primary Bubo or Bubon d'Emblee.—Under this name has been described an acute or subacute inflammation of an inguinal lymphatic gland, occasion- ally met Avith after coitus, and not connected with either gonorrhoea, chan- croid, or syphilis. It is, in fact, a simple adenitis, resulting from mechanical irritation, usually in a patient of strumous constitution; and its symptoms and treatment differ in no respect from those of ordinary adenitis, an affec- tion Avhich Avill be considered in its proper place. 448 VENEREAL DISEASES. CHAPTER XXV. VENEKEAL DISEASES.—Continued. Syphilis. Syphilis1 is a constitutional disease, resembling in many respects the specific fevers, such as variola, etc., but differing from them in its much slower course, in its communicability only by direct or indirect inoculation, and in the possibility of its being inherited as well as acquired. History. The origin of syphilis has not been positively determined. The limits of this volume will not permit any discussion of the evidence which has been adduced by various authors as bearing upon the history of this disease (although the subject is one of very great interest), and I will therefore invite the reader to refer, for information upon this matter, to the various excellent monographs upon Venereal Diseases Avhich have been published from the days of Astruc doAvn to our own time. It may, hoAvever, be stated that (1) the disease does not appear to have been known to the ancients, though both the simple venereal ulcer (or chancroid) and gonorrhoea were unquestionably familiar to them; (2) there is no sufficient proof that syphilis originated in this country and was hence imported to Europe; and (3) although the disease certainly first attracted public attention in the latter part of the fifteenth century, during the campaigns of Charles VIII. of France, it is impossible, in view of existing evidence, to fix any particular date as the precise period at which syphilis originated. Causes. Syphilis may be inherited or acquired. Hereditary syphilis, in the great majority of cases, depends upon previous infection of the mother, though it is believed by Diday and others that the disease may be transmitted from a father to his offspring, the mother being only secondarily affected. Examples of hereditary syphilis are unfortunately not rare, and it is even believed, by Hutchinson, that the disease may be transmitted to the third generation. Acquired syphilis can only arise from contagion, which may be either imme- diate or mediate. Immediate or Direct Contagion results from contact with a chancre (the primary lesion of syphilis), or with certain secondary lesions—particularly that which is known as the mucous patch—or from inoculation with the blood of a syphilitic person. It Avas formerly believed that syphilis Avas transmissible through the various secretions, especially the saliva, milk, and 1 I have described in this chapter the pathology and treatment of syphilis, accord- ing to my own views (which are essentially those of the so-called "dualistic" school of syphilographers), believing that I should thus better subserve the purposes of the student than by entering, in the brief space at my command, upon a discussion of controverted points which are, after all, chiefly of theoretical interest. COURSE OR NATURAL HISTORY OF SYPHILIS. 449 seminal fluid; through contact Avith cutaneous surfaces of Avhich the skin happened to be thin, as the lips; or even through the medium of the atmos- phere. It soon became evident, however, that the assertions of patients upon these points Avere, for obvious reasons, not trustworthy, and a natural reaction ensued in medical opinion, AAThich finally culminated in the axiom of Hunter, which, until lately, Avas generally received as correct, that the primary sore alone was contagious, and that hence syphilis could only be acquired by contact with a chancre. It has now been repeatedly established, by both clinical observation and direct experiment, that certain secondary manifestations of syphilis are contagious, Avhile it has, on the other hand, been rendered almost equally clear, that the supposed instances of contagion through secretions are really examples of contagion from secondary lesions; thus where the saliva has been supposed to convey the disease, there have been mucous patches in the mouth of the infecting person, and Cullerier has shown, at the Lourcine Hospital, that it is not the milk of a syphilitic Avoman that infects her nursling, but the secondary lesions Avhich are found upon her breast. The only possible exception is in the case of the semen, and even here there is no positive evidence that a Avoman can receive syphilis from the seminal fluid, unmixed Avith the product of urethral sores or Avith blood, while negative evidence has been furnished by experimental inocula- tions practised by Mireur, of Marseilles. That the blood of a syphilitic person may prove the source of contagion, has been demonstrated by both experiment and clinical experience, as well as by observation of the fact that syphilis may be transmitted by vaccination, when blood is mixed with the lymph obtained from a syphilitic child, while vaccine matter does not appear to be capable of conveying syphilitic infection, if care be taken to exclude the admixture of blood.1 The menstrual discharges of syphilitic Avomen are, as pointed out by Hyde, of Chicago, probably not unfrequently a source of contagion. Mediate or Indirect Contagion.—The contagious matter from a syphilitic sore may be transmitted to a previously healthy person by means of spoons, drinking-cups, sponges, catheters, etc. Rollet has recorded a number of cases of this nature, and similar cases have since been published by Cullerier, Barton, and others. Hence, though surgeons may justly look with suspicion upon the statements often made by syphilitic patients, that their disease has been acquired in water-closets, etc., it should ahvays be remembered that such an occurrence is at least possible, and care should be taken not to wound the feelings of others, and perhaps cause domestic unhappiness, by express- ing an unguarded opinion, Avhich, after all, may be erroneous. Tardieu, Hutin, Simonet, Maury, and Robert have observed cases in which syphilis had been transmitted by tattooing, the coloring matter having been mixed Avith saliva from the mouth of a person affected Avith mucous patches. Course or Natural History of Syphilis. (Including its Morbid Anatomy?) The course of syphilis varies according as the disease is hereditary or acquired. The latter form of the affection will be first considered. The 1 Vaccination with pure vaccine matter may, however, hasten the development of latent syphilis. It has been recently suggested that syphilis may be conveyed in vaccination by the admixture with the vaccine lymph of epidermic scales, or of pus, as well as of blood. 29 450 VENEREAL DISEASES. natural history of a typical case of acquired syphilis is usually described as going through three stages, known respectively as primary, secondary, and tertiary syphilis; and this convenient and time-honored division is that which I shall adopt. Ricord's classification subdivides the second period, by mak- ing a late-secondary stage, while Lancereaux adds a preliminary stage, or that of incubation. A recent writer, Dr. Barton, of Dublin, modifies Ricord's division by omitting the late-secondary stage, and subdividing the tertiary into the period of sthenic or lymphy deposits, and that of asthenic or gummy deposits — a subdivision which seems unnecessary, as both these forms of deposit frequently coexist in the same case. The classification of Virchow and other German writers, based strictly upon the pathological changes pro- duced by syphilis, though scientifically correct, is less convenient than that which is founded on its clinical characters. Syphilis is then to be studied in its first stage, or that of primary symptoms—chancre and syphilitic bubo; second stage, or that of secondary symptoms—early eruptions and sore throat, the period of general superficial lesions; and third stage, or that of tertiary symptoms—the period of late eruption, ulceration, and deposit. Primary Syphilis. Incubation.—A variable period of incubation intervenes betAveen exposure to contagion and the appearance of a chancre. This period has been esti- mated by different observers at from one to seven weeks, and it is probably safe to say that the average is from two to three weeks. Cases have been recorded by Hammond, R. W. Taylor, and others, in which the period of incubation has been but one or two days, while in other instances a much longer period than the average—as much as ten or eleven weeks—has inter- vened between exposure and the development of the chancre. The period of incubation is, according to F. N. Otis, directly proportional to the dis- tance between the point of inoculation and the proximal lymphatic vessels. Whatever be the source of acquired syphilis, whether from a primary or secondary lesion, the first symptom is invariably a chancre.1 This fact is of great importance, and may be considered as an axiomatic truth. Varieties of Chancre.—The chancre assumes various forms, and there appears to be some relation betAveen these and the severity of the subsequent symptoms; thus Avhat is knoAvn as the " Hunterian" or " deep chancre " is commonly the precursor of a severer case of syphilis than a " superficial erosion." We may recognize tAvo principal forms of chancre, the superficial and the deep, and either of these may assume a phagedsenic form, constituting a third variety, the phagedcenic chancre. 1. The Superficial Chancre, Chancrous Erosion, or Superficial Erosion, is by far the most common form of chancre, and is that which usually results from contact with secondary lesions. Of 170 cases tabulated by Bassereau, no less than 146 were of this variety. It has a long period of incubation— from three to five Aveeks—and appears as a reddish-broAvn papule (rarely, if ever, as a pustule), usually with an ulcerated spot in the centre, but some- times (particularly if seated on an exposed surface) covered with a dry, brownish scab. The ulcer is commonly circular or irregularly elliptical in shape, slightly if at all excavated, red in color, and furnishes a thin serous 1 This remark, of course, applies to syphilis acquired in the ordinary way; it is possible that were the syphilitic poison carefully introduced directly into a lymphatic vessel, or into a vein, a chancre might not result, but that in the former case a syphi- litic bubo, and in the latter constitutional syphilis, might occur as the primary lesion, as it does in the case of the hereditary form of the disease. CHARACTERISTICS OF CHANCRE. 451 exudation, without pus, unless as the result of extraneous irritation. When taken betAveen the thumb and finger, the margin and base of the ulcer present a cartilaginous or membranous hardness, knoAvn as parchment-like induration. This induration is of variable persistence, and sometimes disappears before the ulcer has healed. It is much less evident when the chancre is situated in mucous, than Avhen in cutaneous, tissue, and hence in certain situations, as in the male urethra or upper part of the vagina, this form of chancre may readily escape detection. 2. The Deep Chancre (commonly known as the Hunterian Chancre) has a comparatively short period of incubation—from a week to ten days—and is apparently of rarer occurrence at the present day than formerly. It presents a deep excavated ulcer, with elevated, sloping margins and a foul surface, furnishing a serous exudation often tinged Avith blood. The base of this chancre is deeply indurated, the sensation communicated to the fingers being frequently compared to that given by a split pea, a term originally used by Benjamin Bell, in illustration of the size of the chancre itself. The indura- tion of this form of chancre is very persistent, sometimes remaining long after the cicatrization of the ulcer. This form of chancre usually though not necessarily arises from a primary lesion of the same variety. 3. The Phagedenic Chancre is nothing more than either the superficial or deep chancre, attacked by phagedenic ulceration. If this extend so far as to pass the limit of induration, the case may be mistaken for one of phagedenic chancroid. Characteristics of Chancre.—Induration is a characteristic feature of all forms of chancre, but I am hardly prepared to say that it is universally present. In the case of deep chancre it is very evident, and in the parchment-like form could probably be detected at some period in almost every case of superficial chancre, if the patient Avere constantly under observation. It may, however, in this form of chancre, be quite evanescent, and may, in either variety, disappear under the influence of phagedsenic action. It must be distinguished from the inflammatory thickening and hardness Avhich occa- sionally surround the chancroid, and this can usually be done by observing the sharply defined limitation of the true syphilitic induration (which gives exactly the sensation of the presence of a foreign body), and by obseiwing the absence of the ordinary signs of inflammation. The microscopic char- acters of syphilitic induration are not very distinctive. Robin found fibres of areolar and elastic tissue, with fusiform cells, free nuclei, and amorphous granules, A\hil6 Ordonez observed hypertrophy of the normal structures, Avith inflammatory lymph, hemorrhagic effusions, round or oval nuclei, fusi- form cells, and bundles of fibres in different stages of development. Accord- ing to Auspitz and Unna, the epidermis undergoes a peculiar development, groAving doAvnwards in processes which send out lateral projections, these being subsequently isolated by the growing connective tissue. Induration is usually developed Avithin a very few days after, and, occasionally, even before, the appearance of a chancre; it is rarely if ever manifested for the first time after three weeks. Sigmund, of Vienna, found that in 231 out of 2(il cases, induration appeared from the 9th to the 14th day after contagion. The period during which induration persists is ordinarily from two to three months, and in some instances it lasts for many years. A chancre is in most cases solitary, thus differing in a marked manner from the chancroid, Avhich is commonly multiple. AYhen two or more chancres coexist in the same patient, it will be found that they have arisen from multiple but simultaneous inoculation, and usually by contagion from secondary lesions. 452 VENEREAL DISEASES. The chancre is, under ordinary circumstances, not auto-inocutable; if, however, as is done by the advocates of syphilization, the chancre be irritated by savine ointment, etc., until its secretion becomes purulent, an ulcer may be indeed produced by auto-inoculation—but it is not proved that this ulcer is a chancre.1 This fact (the non-auto-inoculability of chancre) appears to be owing to a property which syphilis shares with smallpox and many other affections, viz., that one attack of the disease protects a patient, for a time at least, from any subsequent infection. This protective influence extends through all the stages of syphilis, so that a second attack of syphilis, though possible, is very rare. Cases have been, indeed, recorded in Avhich a chancre has apparently arisen after impure coitus, in a person at the time actually suffering from general syphilis; but, as shown by Fournier, the suspected chancre in these cases is really but a reulceration in the seat of the original primary lesion, which may be caused by any irritation, either constitutional or local—sexual intercourse being but one form of local irritation, though one which may easily give rise to confusion, particularly if the patient's partner in the venereal act should happen to be affected with any disease of the generative organs, whether syphilitic or otherwise.2 The duration of the chancre is self-limited ; it heals Avithout treatment in a period varying from a few weeks to several months, the only exception being probably in the case of the phagedenic variety. The primary and secondary periods of syphilis usually overlap each other, syphilitic erythema occurring, according to Bassereau, in about three out of four cases, before the chancre has completely healed. The cicatrix of a chancre is more or less depressed, according to the depth to which ulceration has extended. It is at first discolored, but subsequently becomes whiter than the surrounding skin. It is usually very persistent, and can often, though not always, be distinguished from the scar of a chancroid. Ricord first pointed out that a chancre, instead of undergoing cicatrization, might become converted into a mucous patch. This change may occur in any situation, but is most often seen Avhere mucous tissues are habitually in contact, as the inside of the lips, the tongue, the inner surfaces of the labia, the folds of the anus, or the lining surface of the prepuce. The change occurs Avhen the repair of the chancre has been nearly completed by granulation, and consists in the formation of a white membranous pellicle, which gradually spreads from the circumference of the sore to its centre. It is from inattention to this fact that a mucous patch has been in some cases supposed to be really the initial lesion of syphilis, the patient not being seen until the transformation has occurred, and the previous existence of a chancre thus escaping recognition. 1 It has been recently suggested that the ulcer which results from the auto-inocu- lation of a chancre is a chancroid, and that this tends to confirm the view of Clerc, that the latter lesion is a derivative of the chancre, or, in other words, the result of chancrous contagion in a person already syphilitic, just as varioloid is the result of the variolous poison acting upon a person already protected against smallpox; but the analogy fails, because varioloid is just as much a constitutional disease as variola itself, while the chancroid is a purely local lesion, and because the contagion of varioloid will communicate to an unprotected person not varioloid but smallpox, while the chancroid can only reproduce itself. Moreover, if the chancroid be a derivative of the chancre, the latter (and of course syphilis generally) must have existed before the affection which is its mere modification—an hypothesis which is contradicted by all that is known of the histories of the two affections. As a matter of observation, the ulcer derived from auto-inoculation of a chancre appears to be precisely such a sore as can be produced by inoculating a syphilitic subject with non-venereal matter. 2 See Fournier, Archives Gen. de 3Iedecine, Juin et Juillet, 1868. SYPHILITIC BUBO. 453 Mixed Chancre.—It has already been stated that chancroid and syphilis may exist in the same patient. They may likeAvise be acquired at the same moment. Hence a patient, a few days after impure coitus, may present several venereal ulcers, not indurated and evidently not syphilitic—and yet in a feAv Aveeks, Avithout further exposure, one of these may become indu- rated and be followed by secondary symptoms. The syphilitic has been inoculated simultaneously Avith the chancroidal poison, just as it may be inoculated Avith the poison of coAvpox, the vaccine disease disappearing at the usual time, and syphilis folloAving after its OAvn proper period of incuba- tion. Again, syphilis may be inoculated upon a previously existing chan- croid, a chancre being the result; or conversely, if a person Avith chancre have sexual intercourse Avith a woman affected Avith chancroid, he may acquire the latter disease, his chancre serving as a point of inoculation. The term mixed chancre is, perhaps, an unfortunate one, as seeming to imply that the venereal ulcer to which it refers is intermediate betAveen chancre and chancroid; the fact being that it is not in any degree intermediate, but a result of the accidental coexistence of two separate diseases. Syphilitic Bubo.—Induration and chronic enlargement of the neighboring lymphatic glands are almost, if not absolutely, constant sequels of chancre. As in the large majority of cases the latter is situated on the genital organs, it is the inguinal glands that are usually affected, constituting the ordinary syphilitic bubo; but induration will attack the facial and submaxillary glands if the chancre be cephalic, and those of the elbow and axilla if the initial lesion occupy the finger. Cases have been recorded by H. Lee, and others, in Avhich a chancre is said to have been folloAved by secondary symptoms, Avithout the intercurrence of a bubo, and the possibility of such an event must therefore probably be acknoAvledged: such cases must, hoAv- ever, be extremely rare, and in no instance can it be fairly claimed that this has happened, unless the patient has been continuously under the notice of a skilled observer, as syphilitic bubo is often unperceived by the patient him- self, and may, like the induration of a chancre, pass off in a comparatively short time. The development of a syphilitic bubo coincides pretty closely Avith that of induration in the chancre Avhich precedes it; it is poly ganglionic and usually bilateral, or, in other words, involves the whole chain of superficial glands, and commonly invades both groins at once. The glands are hard, movable upon each other and beneath the skin, usually painless, and about the size of almonds (amygdaloid enlargement); one is frequently larger than those Avhich surround it, the group being fancifully designated by French Avriters as the "pleiade ganglionnaire." The syphilitic bubo has in itself no tendency to suppurate, and Avhen suppuration occurs it is due to the influence of some external irritant, to the patient's being of a scrofulous diathesis, or to the coexistence of a chancroid. In the latter case, the suppurating bubo will be chancroidal, and its pus, of course, auto-inoculable. The duration of a syphilitic bubo is variable, lasting usually longer than the induration of the chancre, and being in many cases quite distinct for six months or a year after infection. Cases have even been recorded, by Venning and others, in which the amygdaloid condition of the inguinal glands persisted tAventy years or longer; and it is believed by the above-named Avriter that the dis- appearance of this condition may be considered an evidence that the disease has worn itself out, and that the patient is susceptible of re-infection. The syphilitic bubo is often attended by induration of the lymphatics running from the chancre to the affected glands; resolution usually occurs about the time 454 VENEREAL DISEASES. that induration disappears from the chancre, but, occasionally, suppuration has been observed, a number of fistulous openings being formed in the course of the vessel. It is believed by some surgeons that a syphilitic bubo may occur Avithout any pre-existing chancre, and this has been spoken of as a form of the Bu- bon d'Emblee. Such cases are, however, really instances of defective obser- vation, or of voluntary deception upon the part of the patient. A superficial chancre may readily be unnoticed by a patient, or even by a surgeon, par- ticularly if situated in the urethra, or neck of the uterus, or if unaccompanied by induration: there is no sufficient evidence to throw doubt upon the truth of the axiom, that the initial lesion of syphilis is invariably a chancre. Secondary Syphilis. BetAveen the time of appearance of a chancre and the period at which secondary symptoms are developed, there is an interval which is sometimes called the period of incubation or latency. The former term is better applied to the interval between the date of contagion and that of the appearance of the chancre, while in many cases the disease cannot properly be said to be latent, as the chancre and attendant bubo frequently continue after the ap- pearance of general syphilis, the primary and secondary stages often, as already remarked, overlapping each other. The shortest period in which an untreated chancre is known to have been followed by secondary symptoms is twenty-five days, while the average period, as shown by an analysis of nearly 500 cases, is about six weeks. Secondary syphilis rarely appears after the first three months, and almost never later than six months, unless the natural evolution of the disease has been interfered with by treatment. Secondary syphilis cannot occur without primary syphilis having preceded it:1 the apparent exceptions are due to the primary symptoms having escaped detection, an event Avhich, as already seen, may readily occur under various circumstances. Premonitory Signs.—Certain premonitory symptoms usually precede the development of secondary syphilis, lasting from a few days to a week or more, and consisting in febrile disturbance, with languor and general discom- fort, vague pains of a neuralgic character, headache, sometimes apparently neuralgic, but sometimes due to inflammation of the pericranium,2 and (par- ticularly in women) anaemia. With the exception of the pericranial head- ache, these symptoms usually disappear upon the occurrence of the eruption and other secondary symptoms. The most characteristic and usual manifes- tations of secondary syphilis, are cutaneous eruptions, sore throat, mucous patches, and general enlargement of the lymphatic glands. More rarely we find falling of the hair, certain affections of the eyes and ears, paralysis, and other symptoms referable to the implication of the nervous system. Cutaneous Eruptions.—There is no definite syphilitic eruption. On the contrary, a large number of skin diseases may occur as manifestations of syphilis, and several of them are not unfrequently found coexisting in the 1 This remark does not, of course, apply to hereditary syphilis. 2 According to Mauriac, periostitis, whether of the cranium or other parts, is much more common as an early manifestation of syphilis among the Arabs in Africa, and the inhabitants of South America, than among the residents of other countries. MUCOUS PATCHES. 455 same case. The limits of this work will not permit any extended description of the various syphilitic eruptions, or, as they are often called, Syphilo-der- mata or Syphilides, for a full account of Avhich I would respectfully refer the reader to the numerous excellent works on Venereal Diseases which have re- cently been published, and more especially to those of Cullerier, Lancereaux, and Belhomme and Martin, in France, of H. Lee and W. J. Coulson in England, and of Bumstead and Van Buren and Keyes in this country. Cazenave's classification is that usually adopted, those eruptions which belong to the secondary stage of syphilis being the exanthematous (erythema and roseola), the papular (syphilitic lichen), the vesicular (herpes, eczema, syphi- litic varicella, etc.), the bullous (pemphigus and superficial rupia), and the pustular (ecthyma, acne, and impetigo). Syphilitic erythema is usually the earliest of the eruptions, and is frequently so slight as to escape the attention of the patient. Ecthyma is likewise an early manifestation of secondary syphilis, and is very often met with in the scalp. There are certain features which habitually mark all forms of syphilitic eruption, and which have a certain diagnostic value. These are (1) the so-called protean character of the eruption, or the appearance simultaneously, or in quick succession, of more than one variety; (2) the peculiar reddish-brown or copper-colored hue of the eruption in its declining stage ; and (3) the absence of itching. Four- nier has lately pointed out a peculiarity of the skin in syphilis, which he considers quite significant. This is cutaneous anesthesia, of which he de- scribes three varieties, viz., anesthesia as regards pain, or analgesia (by far the most common), anesthesia of general sensibility, and anesthesia as regards changes of temperature. Sore Throat.—The sore throat of secondary syphilis may consist merely in erythematous efflorescence of the part, or in a superficial aphthous ulcera- tion. This may affect the fauces, tonsils, palate, cheeks, or tongue. Occa- sionally, in this stage, the tonsil may present an excavated ulcer, with sharp- cut edges and sloughy surface, which someAvhat resembles a chancroid, and has been incorrectly called an amygdaline chancre. The severer forms of syphilitic sore throat, with the concomitant affections of the larynx and esophagus, belong to the tertiary period of the disease. Mucous Patches.—These, which are also called Condylomata, Moist Papules, and Mucous Tubercles, are particularly interesting as being the manifestation of secondary syphilis which is chiefly concerned in the trans- mission of the disease, though it is probable that any of the moist forms of eruption may occasionally prove the source of contagion. Mucous patches occur on mucous membranes, or where the skin is thin, and particularly Avhere tAvo surfaces are habitually in contact. They are thus chiefly seen on the vulva, or around the anus, between the buttocks, on the scrotum, or on the penis; in the mouth, on the tonsils, lips, and tongue; and more rarely betAveen the toes, on the inside of the thighs, and on other parts of the body. On the skin they appear as flat, slightly elevated papules, about half an inch in diameter, and covered with a slimy, fetid exudation. This appears as a kind of false membrane or pellicle, which covers a raw surface from which the cuticle has been previously removed. On the mucous membranes they are less elevated, and, in the mouth at least, the exudation takes the form of a Avhitish pellicle, constituting the so-called " opaline patch." Condylomata usually first appear as reddish spots, effusion taking place beneath the cuticle, Avhich drops or is rubbed off, the surface being then soon covered with the characteristic exudation. Occasionally a chancre is directly transformed 456 VENEREAL DISEASES. into a mucous patch, in the manner already described. Mucous patches produce a great deal of local irritation, and give much annoyance by their offensive odor. They often become ulcerated, and are occasionally confluent. At the angles of the mouth, on the tongue, and at the margin of the anus, Fig. 197. Mucous patches. (Miller.) they are apt to be fissured, in the latter situation constituting a form of what are known as rhagades. Mucous patches are very frequently met with in either sex, but probably most often in women. They run a very chronic course, and are apt to recur at irregular intervals. Urethral, Vaginal, and Uterine Discharges, without the existence of any recognizable ulceration, are, as pointed out by Hammond, Morgan, and H. Lee, occasionally met with as symptoms of secondary syphilis, and are prob- ably more often the source of contagion than is commonly supposed. Enlargement of Lymphatic Glands. — This is a very constant and sig- nificant manifestation of secondary syphilis. The glands most commonly affected are the posterior cervical, though others are occasionally involved. The cervical engorgement is most marked when a pustular eruption exists upon the scalp; this form of glandular enlargement is very different from the glandular induration observed in the primary stage, though, like that, it usually ends in resolution. The period of development of this character- istic symptom is, according to Bumstead, from six to eight weeks after the anpearance of the chancre. Alopecia, or Falling of the Hair, is an early symptom of secondary syphilis. It is sometimes so slight as to be scarcely recognizable, and is most marked when the scalp is the seat of an abundant eruption. Beside the hair of the head the eyebrows may be affected, and more rarely the eyelashes and beard. Ihis form of alopecia is amenable to treatment, and, according to Bumstead, AFFECTIONS OF JOINTS AND BURSA 457 is often absent when mercury has been taken in the primary stage. There is another form met with in connection Avith tertiary syphilis, which is usually incurable. Affections of the Eye. — Iritis is not unfrequently met with during the secondary stage of syphilis, though the worst form of the affection is that which occurs in the tertiary stage. The latter, according to Gascoyen, is really due to syphilitic contamination, Avhile the variety met with during the secondary stage, and to which VirchoAv gives the name of serous iritis or peri-iritis, results from accidental causes, beginning with congestion or in- flammation of the conjunctiva, and involving the iris only secondarily. The vascular sclerotic zone around the margin of the cornea is not very well marked in this form of the disease, nor is pain a constant symptom. Nodules of lymph soon appear upon the iris, especially around the pupil, and the aqueous humor often becomes turbid; the cornea is occasionally involved. The pupil is sluggish and contracted (occasionally dilated), but there is little photophobia. Both eyes are often attacked, though usually not simultane- ously. This form of iritis is much less intractable than the parenchymatous variety Avhich occurs in tertiary syphilis. Retinitis and Choroiditis are occa- sionally met Avith in syphilis, usually as a concomitant or sequel of iritis; the symptoms consist of mistiness of vision, micropsia, and diminution of the visual field, with a feeling of fulness in the eye and some circumorbital pain, but Avithout photophobia. It is sometimes possible, according to Wells, to distinguish these affections from those which are not syphilitic, by their oph- thalmoscopic appearances, even if no other symptoms of syphilis are present. Syphilis is, according to Cowell, by far the most frequent cause of diffuse neuro-retinitis and exudative retinitis, Avhich are the ordinary forms of the disease. The former is quite amenable to treatment, and is fortunately much commoner than the exudative variety. Syphilitic affections of the lachrymal apparatus have been recently described by R. W. Taylor, of NeAV York. Affections of the Ear.—Acute myringitis, or inflammation of the membrana tympani, sometimes occurs in secondary syphilis, and may cause permanent deafness from inflammatory thickening of the part. Dr. F. R. Sturgis has reported tAvo cases of inflammation of the middle ear due to secondary syphilis, and syphilitic disease of the internal ear has been observed by Roosa and by Moos. Affections of the Nervous System.—Hemiplegia, with or Avithout loss of consciousness, often preceded by persistent headache, mydriasis, and perhaps ptosis, is occasionally observed in connection Avith the secondary stage of syphilis. The explanation of these cases (in Avhich no appreciable lesion may be found after death) is, according to Dr. E. L. Keyes, of NeAV York, who has paid particular attention to the subject, that the paralysis is due to general or partial congestion of the brain, analogous to the congestions of the skin and mucous membranes which occur in secondary syphilis. Affections of Joints and Bursae.—These may, according to Keyes, be affected in secondary syphilis, becoming congested and sometimes painful, though in other cases the congestion is painless and followed by effusion. The various manifestations of syphilis Avhich belong to the secondary stage occur with a certain degree of regularity (the exanthematous, for instance, usually preceding the papular eruptions), and last, with occasional intermis- sions, for a period varying from one to six months. They are general symp- 458 VENEREAL DISEASES. toms, that is, are met with in various parts of the body simultaneously, and tend to a spontaneous cure, leaving, as a rule, no traces to mark their course. In mild cases of syphilis, the disease appears to wear itself out in this stage, and tertiary symptoms are therefore by no means of invariable occurrence. Tertiary Syphilis. After the subsidence of the secondary stage of syphilis, there is usually an interval before the development of tertiary symptoms. This interval is of no definite length, being in some cases of several years' duration, and the patient meanwhile being apparently quite well, while in other cases the third stage begins before the second is concluded, so that they absolutely overlap each other. Tertiary syphilis may affect almost any tissue or organ of the body, and the symptoms of this stage are developed with such irregularity as to render it impossible to classify them chronologically. The third stage of syphilis is called the stage of deposit, as it is marked by the deposit, in various parts of the body, of new material, which may take the form of a contractile lymph, leaving depressed cicatrices, or of a soft gummy substance, constituting the so-called gummatous syphilitic tumors. We may consider successively the manifestations of tertiary syphilis, in the skin, mucous membranes, eyes, solid viscera, nervous system, areolar tissue, muscular and fibrous tissues, and bones and periosteum. Skin.—The chief cutaneous manifestations of tertiary syphilis are the tubercular and squamous eruptions, together with a destructive form of rupia. Syphilitic Tubercles, which may be either dry or ulcerated, occur most often on the face, especially about the lips and nose, where they occasionally pro- duce great disfiguration. They begin as small, solid, cutaneous tumors, of a dusky-red color, and with a firm base, and are frequently developed in connection with the hair-follicles. They are often aggregated in a circular form, and, if resolution occurs, leave depressions in the skin, which, though at first copper-colored, ultimately become white and scar-like. The ulcerated Fig. 198. Syphilitic rupia. (Druitt.) syphilitic tubercle occasionally produces great ravages, and may be mistaken for lupus, rodent ulcer, or serpiginous chancroid. It heals with a charac- teristic Avhite and depressed cicatrix, if the ulceration have extended deeply, or Avith a thin and shining scar, if superficial. The squamous eruption assumes the form of Psoriasis, Pityriasis, or Lepra. Syphilitic psoriasis often attacks the palmar and plantar surfaces, and the eruption is in these situations very characteristic of the nature of the disease; palmar or plantar psoriasis may be attended with cracks and fissures, which cause a good deal of irritation and interfere with the functions of the part. The late form of Rupia, Avhich occurs in connection with tertiary syphilis, differs from that seen in the secondary stage merely in the greater depth to Avhich ulceration SYPHILIS OF THE EYE. 459 extends. In this stage a severe form of Alopecia is occasionally seen, in which the hair-follicles all over the body may be destroyed, the affection being, of course, incurable; this variety of alopecia usually occurs in con- nection with the tubercular eruption already described. Syphilitic Onychia, or ulceration in the matrix of the nails, which become dry and distorted, and are finally thrown off, is a concomitant of the squamous eruptions, and affects the hands more often than the feet. Mucous Membranes.—The tongue is often affected in tertiary syphilis; it may present white patches upon its surface, apparently due to lymphy deposit and opacity of the epithelium, upon the detachment of which a smooth and slightly depressed spot remains—or there may be a tubercular condition of the tongue, analogous to that described as affecting the skin, which may end in ulceration, or may assume the form of a deep-seated lymphy deposit, causing stiffness, contraction, and distortion of the organ. The ulcerated form of lingual syphilis may cause great destruction of the part, and has been mistaken for epithelioma: the latter affection attacks particularly the side of the tongue, is solitary, and involves the submaxillary ganglia; while the lingual syphilitic tubercle is commonly multiple, occupies the dorsum and base of the tongue, and is not attended by enlargement of the lymphatic glands. The tonsils, fauces, and palate suffer in tertiary syphilis from ulceration, Avhich may be circumscribed or phagedenic. The latter variety usually results from the ulceration of syphilitic tubercle, and may produce very Avide destruction of parts, involving the soft palate and uvula, pillars of the fauces, and orifices of the Eustachian tubes, and causing difficulty of swal- loAving, Avith perhaps regurgitation through the nostrils, deafness, and diffi- culty of articulation. The discharge is very offensive, and the ulceration may extend to the nose, larynx, or oesophagus, or may even involve the cervical vertebre. The larynx and trachea may be affected Avith a deposit of syphilitic tuber- cle, which may undergo ulceration, causing dyspnoea, often of a paroxysmal character, and perhaps requiring tracheotomy for its relief. Contraction of the Avindpipe may occur, constituting tracheal stricture, or the voice may be permanently impaired by alterations of the vocal cords. The pharynx and oesophagus may be the seat of syphilitic ulceration, and esophageal stricture may result after cicatrization. The colon may be, accord- ing to Paget, affected in tertiary syphilis with a form of ulceration analogous to the ulcerated tubercle of the skin. Cullerier has described a syphilitic enteritis, which he considers analogous to the erythema of the skin, and as therefore belonging to the secondary period; his vieAvs upon this point, however, are not generally accepted. The rectum may become ulcerated in tertiary syphilis, giving rise to a troublesome form of stricture in that part. The urethra may be involved in tertiary syphilis, and H. Lee believes that many cases of stricture are of syphilitic origin. Eye.—The Avorst form of syphilitic iritis is that Avhich occurs during the tertiary stage. In this variety of the disease the iris is primarily attacked, but in an insidious and almost painless manner, becoming the seat of a de- posit of yellow tubercles, AAdiich are shown by the microscope to be identical in structure Avith the gummatous tumors found in other parts of the body. The deeper-seated structures are occasionally involved, permanent disorgan- ization being then apt to occur, though Dr. Rankin, of New York, has re- ported a remarkable case of syphilitic atrophy of both optic nerves, cured by large doses of mercury, strychnia, and iodide of potassium. R. W. Taylor 460 VENEREAL DISEASES. reports cases of tertiary, as Avell as of secondary, syphilitic disease of the lachrymal apparatus, Avhile C. S. Bull has observed optic neuritis and paralysis of the ocular muscles as a result of syphilis. Solid Viscera.—Visceral syphilis has, until recently, not attracted as much attention as it deserves. Among the organs (apart from those of the nervous system) in which syphilitic lesions have been observed, may be par- ticularly mentioned the testis, liver, spleen, kidneys, mesenteric glands, lungs, and heart. The limits of this Avork Avill not permit a description of the changes produced by syphilis in any of these viscera, except the testis; and, indeed, syphilis of the internal organs is habitually treated by the physician rather than by the surgeon. For a full account of these affections I would refer the reader to the work of Lancereaux, which has been trans- lated for the New Sydenham Society, and which gives a very complete ac- count of visceral syphilis. Syphilitic Sarcocele, or Syphilitic Orchitis, appears under two forms, the interstitial and the circumscribed or gummy. Interstitial Orchitis occurs in the early part of the tertiary stage, and is attended with the formation of a contractile lymph, Avhich occupies the trabecule of the testis, rendering the organ hard and dense, and sometimes eventually leading to its atrophy. One testis only is usually affected, becoming somewhat enlarged, but pain- less, and giving annoyance only by its weight. Hydrocele often accom- panies this form of the disease, which is very chronic, and rarely followed by suppuration. The Circumscribed or Gummy Orchitis was first described by Hamilton, of Dublin, as Tubercular Syphilitic Sarcocele. In this variety, numerous masses of a yellowish-gray color are deposited in various parts of the testes, both of which are usually affected. These masses, at first firm, undergo softening, Avith fatty or cretaceous degeneration, and not unfre- quently lead to suppuration, with the formation of fistulous openings, and occasionally a fungous protrusion of the testicle itself. Under the micro- scope, these yellowish masses are found to differ from ordinary lymph, in containing a large amount of cells and fat globules, Avith crystals of mar- garine. The ovary is occasionally affected in tertiary syphilis in a similar manner to the testicle. Nervous System.—The brain and spinal cord suffer in tertiary syphilis, deposits of a lymphy or gummy nature taking place in the substance of those organs, or in their membranes, and giving rise to various nervous dis- turbances, such as Epilepsy, Paralysis (which may be local or general), Chorea (a rare manifestation of syphilis of which Dr. R. H. Alison has col- lected four cases), Mental Perturbation, or, as pointed out by M. H. Henry, absolute Dementia. Diabetes is said to have resulted from syphilitic disease of the base of the brain. The credit of first distinctly recognizing the ex- istence of syphilitic lesions of the central nervous system is due, I believe, to Reade, of Belfast, Ireland, Avhose first paper was written in 1847, though not published till some years subsequently. The subject has since then received a good deal of attention, and elaborate memoirs have been written on syphilitic affections of the nervous system by several authors, especially by Lagneau, the younger, and Zambaco, to whose Avorks the reader is re- spectfully referred. A few cases are on record in Avhich syphilitic deposits have been found in the nerves, as well as in the nerve-centres. Arteries.—The occurrence of arterial degeneration as a result of syphilis has long been recognized, but the change has been supposed to be identical with atheroma. According to Heubner and Ewald, however, it differs from MUSCULAR AND FIBROUS TISSUES; BDR8A 461 that condition in affecting exclusively the smaller arteries, and in having no tendency to gelatinoid or cartilaginoid change, or to fatty or calcareous de- generation. The syphilitic change, according to these authors, consists in the formation of a new growth of the connective tissue type, occupying the inner coat of the vessel, and formed by nuclear proliferation of the cells of the epithelial lining. If so large as to occlude the artery, thrombosis occurs and is folloAved by atrophy of the vessel. Areolar Tissue.—The subcutaneous and submucous areolar tissues are the favorite seats of the so-called gummy or gummatous deposits of tertiary syphilis. These usually occur as hard, round, indolent, subcutaneous nod- ules, Avhich gradually undergo softening and become adherent to the skin ; ulceration finally takes place, and, after the extrusion of a slough, the part heals, leaving a depressed scar which is at first purple, but subsequently becomes white. When cut open, these nodules or gummatous tumors pre- sent a tolerably firm cystic investment, containing a semi-solid gelatinous or gummy substance, whence their name. Their size varies from a half inch to tAvo or more inches in diameter, and they are usually solitary, occurring at successive intervals, though occasionally multiple. They are chiefly seen upon the extremities and upper part of the trunk. Under the microscope, they are found to consist principally of fibres, granules, and nucleated cells, with a few' elastic fibres, free nuclei, and capillary bloodvessels. When situated in the submucous tissue, gummata give rise to troublesome ulcera- tions, and cause some of the most intractable forms of syphilitic sore throat. They are also met with in the submucous tissue of the genito-urinary organs in both sexes. Muscular and Fibrous Tissues; Bursae.— Gummatous Tumors occur in the voluntary muscles, tendons, and fascie, interfering with the functions Fig. 199. Syphilitic panaris. (From a patient at the Children's Hospital.) of the parts, and sometimes causing deep and painful ulcers. They may also, according to Keyes, affect the burse, either primarily or by extension from other tissues. In the fingers and toes, in which situations they may involve either the superficial tissues, or the periosteum and bone (Avhen disorganiza- tion of the joints may follow), they give rise to the troublesome condition known as Syphilitic 'Panaris or Whitlow, or Syphilitic Dactylitis, the latter name being preferred by Taylor, of New York, Avho has given an excellent account of the affection. (See Fig. 199.) Ricord and others state that syphilis may cause rigid muscular contraction (as of the biceps), without 462 VENEREAL DISEASES. organic change. The so-called congenital tumor of the sterno-mastoid muscle appears in some cases to be a syphilitic lesion. Bones and Periosteum.—Periostitis is of frequent occurrence in tertiary syphilis, and the periosteum of those bones Avhich are subcutaneous is most often affected, as of the tibia, cranial bones, clavicle, sternum, radius, and ulna. Osteocopic (literally, bone-tiring) pain is often observed long before any other symptom, and, in a large majority of cases, has the peculiarity of being aggravated by the warmth of bed. Syphilitic periostitis is usually circumscribed, and gives rise to the formation of oblong SAvellings, called nodes, Avhich are commonly hard and indolent, being due to lymphy deposit in and beneath the periosteum, but which in other cases are fluctuating and tender, and apparently due to the deposit of gummatous material. They may often be dispersed by treatment, but occasionally persist, becoming con- verted into exostoses. Suppuration rarely occurs, unless the bone itself be involved. Syphilis affects the bones by producing chronic osteitis, leading to hypertrophy and induration, or to caries and necrosis. These may affect any bones, but are most frequent in the jaws and skull—either the vault or base, but, according to H. Allen, rarely both together—and sometimes lead to destruction of the hard palate, falling in of the nose, or grave cerebral disturbance. Syphilitic necrosis may, according to Virchow, be recognized by observing that the sequestrum has a perforated and worm-eaten appear- ance, Avhich he attributes to the previous existence of gummy matter in the part. A peculiar form of dry caries is described by the same writer, as due to the pressure of a gummy tumor, leading to inflammatory atrophy without suppuration. Two such cases are referred to by Erichsen, both occurring in the head of the tibia. Hereditary Syphilis. The natural history of this form of syphilis differs from that of the acquired variety, chiefly in having no primary stage. A foetus may be infected in several ways : (1) the mother may be the subject of secondary or tertiary syphilis, the father being healthy ; (2) both parents may be syphilitic, when the disease will probably be inherited in a worse form than if one alone be affected ; (3) the mother may be healthy at the time of conception, but may acquire syphilis during pregnancy, and transmit it to her offspring; and (4) the father may transmit the disease to the fetus, without directly infecting the mother, Avho, however, may in turn be infected by the embryo. The latter mode of transmission is denied by many authors, and is certainly of rarer occurrence than the others. The syphilitic embryo very often dies before the full term of intra-uterine life is accomplished, and abortion then follows. Occasionally, though rarely, a child presents mucous patches and other unmistakable evidences of syphilis at the moment of birth, and the disease is then properly called congenital. More often, hoAvever, the child is apparently healthy when born, or, if cachectic, presents no definite morbid lesions. Hereditary syphilis is usually developed from a fortnight to two months after birth, but may appear at any time within the first year. It is very doubtful Avhether the first manifestation of hereditary syphilis ever occurs at a later period, the apparent exceptions which have been reported being probably cases of acquired syphilis, or, if of the hereditary form of the disease, cases in Avhich the early symptoms have been overlooked. The early manifestations of hereditary syphilis belong to the secondary period of the disease, those which are most characteristic being mucous DIAGNOSIS OF SYPHILIS. 463 patches, syphilitic pemphigus, and coryza—the snuffles of the popular vocab- ulary. Laryngitis may also occur in this stage, with inflammation of the buccal mucous membrane, or syphilitic stomatitis. If the latter exist, the temporary teeth are apt to be ill-formed and carious, and often drop before the usual time. The child becomes salloAv and Avithered, and seems prema- turely old. If death do not occur from malnutrition during this stage of the disease, there is usually a lull in the symptoms, the later manifestations (which belong to the tertiary period) not being developed until after the fifth year, and usually about the age of puberty. The most characteristic signs of hereditary syphilis, in this stage, are interstitial keratitis, linear cica- trices at the corners of the mouth, and a peculiar notched condition of the permanent teeth (Fig. 200), particularly of the upper central incisors, first pointed out by J. Hutchinson. Interstitial keratitis usually affects both eyes, and is attended with a formation of lymph between the lamine of the cornee, which often remain permanently opaque in spots. Iritis is much rarer in the heredi- Fig. 200. tary, than in the acquired, form of the disease. Inflammation of the choroid1 and optic nerve, and deafness, are also sometimes observed as a result of hereditary syphilis. The viscera affected in these cases are Syphilitic permanent teeth. (Hutchin- chiefly the liA'er and lungs, the brain and son.) thymus gland being more rarely involved. The bones may be affected in hereditary syphilis, the lesions particularly deserving attention being the syphilitic panaris or dactylitis (p. 461), and a peculiar inflammatory condition of the epiphyseal extremities of the bones, sometimes attended Avith suppuration and caries, and, from the loss of func- tion Avhich attends the disease, called by Parrot the pseudo-paralysis of inherited syphilis. A person aaIio is the subject of hereditary syphilis is in a great degree, if not altogether, protected from syphilitic contagion in after-life, this being another proof of the essentially constitutional nature of the disease. Acquired infantile syphilis does not present any marked difference from the same dis- ease as observed in the adult. Diagnosis of Syphilis. I have dwelt at length upon the natural history and morbid anatomy of syphilis, because it is only by means of a thorough comprehension of these that the surgeon is able to recognize and attach due significance to the various symptoms of the affection—these symptoms being often developed with ap- parent irregularity, and being constantly modified by previous treatment, or by various extraneous circumstances. In the diagnosis of most diseases, great assistance can often be obtained from the patient, Avho, if ordinarily intelli- gent, can usually give a more or less complete history of his own case; but in syphilis, very little reliance can be placed upon the statements of the patient. Apart from Avilful deception, or concealment, to Avhich there is of course unusual temptation in many cases of syphilis, there is another difficulty, Avhich is that, the symptoms being spread over a term of years, and often in themselves trivial, the patient either does not notice them, or subsequently forgets their existence, and thus, with every intention of honesty, is con- 1 Dr. C. S. Bull has seen syphilitic iritis and irido-choroiditis within a few hours of birth, the affection then being properly called congenital. 464 VENEREAL DISEASES. stantly apt to mislead the surgeon by giving erroneous ansAvers to such ques- tions as are propounded. The most important point for consideration Avith reference to the diagnosis of primary syphilis, is the mode of distinguishing the chancre from the chancroid. It is by no means always easy, or even possible, to make this diagnosis without careful and repeated observation: the surgeon must in fact rely more upon the natural history of the disease, than upon the symptoms presented at any one period. The diagnostic marks between chancre and chancroid may be conveniently presented in parallel columns:— Chancroid. No period of incubation ; the sore is fully developed from four to six days after ex- posure. Usually multiple, if not at first, becoming so subsequently by auto-inocu- lation. An excavated ulcer, with sharply-cut, punched-out edges, a gray sloughy surface, and furnishing a copious auto-inoculable pus. Not adherent to subjacent tissue. No induration unless from extraneous causes, and then merely temporary inflam- matory engorgement. Little or no tendency to heal; often spreads, and liable to become phagedenic. Bubo not usual, and, when present, com- monly monolateral and monoganglionic; apt to suppurate, and, if it do so, the re- sulting ulcer usually chancroidal. A strictly local disease, never producing systemic infection, and one attack afford- ing no protection against subsequent con- tagion. Chancre. A distinct period of incubation; sore appears from one to seven (usually three) weeks after exposure. Usually solitary, and, when multiple, is so from the first; very rarely, if ever, by auto-inoculation. A superficial erosion, or an ulcer with hard, elevated, sloping edges, scooped out surface, and furnishing a scanty, serous, usually non-purulent secretion. If an ulcer, adherent to subjacent tissue. Peculiar, persistent, non-inflammatory induration, often parchment-like in char- acter. Tends to heal spontaneously, and rarely becomes phagedenic. Bubo almost in- variable, bilateral, polyganglionic, indu- rated, and indolent; rarely suppurates, and does not furnish auto-inoculable pus. A strictly constitutional disease, sys- temic infection being present from the first, and manifesting itself by definite symptoms, usually from six weeks to three months after the appearance of the chan- cre. One attack usually protects from subsequent contagion. Beside the information derived from observation of the patient, valuable aid in forming a diagnosis may be sometimes derived from confrontation and inoculation. Confrontation consists in examining the person from whom the disease has been contracted, and its value depends upon the fact that chan- croid, can only produce chancroid, while syphilis can only be imparted by a syphilitic lesion. It is in many cases, from obvious reasons, impossible to make use of confrontation, but, when available, it is a diagnostic means of great value. Inoculation of either chancroid or chancre, should never be practised ex- cept upon the patient's own person; if the suspicious sore be a chancroid, inoculation will produce another chancroid, while if it be a chancre, the result will almost invariably be negative—unless the original sore have been first irritated by treatment, when inoculation may indeed produce an ulcer, though not, probably, one of a chancrous nature (see p. 452). ^ Microscopic examination has been employed by Biesiadecki as a means of distinguishing chancroid from chancre. Sections of a chancroid present appearances identical with those of simple ulceration, while in chancre the interior of the bloodvessels and lymphatics is packed Avith Avhite cells, thus accounting in some degree for the characteristic induration. It is often possible to declare a sore to be a chancroid, when yet it Avould not be safe to assert positively that symptoms of syphilis will not follow, for (1) the patient may have acquired both diseases simultaneously—in which PROGNOSIS OF SYPHILIS. 465 case he may have what is called a mixed chancre, or may have a genuine chancroid on the genital organs, and a chancre (derived perhaps from a secondary lesion) elsewhere, as, for instance, in the mouth; or (2) he may have acquired syphilis in some previous exposure — the disease remaining latent until excited to activity by the fresh irritation produced by the chan- croid, Avhich, in such a case, would naturally appear to the patient to be the actual cause of syphilitic infection. Chancre may occasionally have to be diagnosticated from cancer, epithe- lioma, or similar affections. This is particularly the case when chancre occurs in unusual situations, as on the fingers, lips, or tongue. The syphilitic nature of the disease may usually be recognized by observing the early im- plication of the neighboring lymphatic glands, and the effect of anti-syphilitic treatment, which should always be tried before resorting to operative meas- ures in any doubtful case. Syphilitic Bubo is not likely to be mistaken for any affection except chronic scrofulous adenitis. If there be no concomitant signs by Avhich the nature of the case may be revealed, the surgeon should avoid giving mercury until the development of secondary symptoms. Diagnosis of Secondary and Tertiary Syphilis.—Here the surgeon must rely not upon any one or two symptoms, but upon the coexistence of a num- ber, and especially upon their course and order of development; in other words, he must rely upon careful clinical observation and his general knoAvl- edge of the natural history of the disease. A surgeon meeting with a case of iritis, or of cutaneous eruption, or of periosteal rheumatism, in a person of notoriously lax morality, should not at once jump to the conclusion that the disease is probably syphilitic; for to do so Avould be as unphilosophical as it might be unjust. If, on the other hand, a patient should suffer from frequent attacks of recurrent iritis, copper-colored eruptions of various forms, post-cervical engorgement, alopecia, and occasional development of mucous patches; or from osteocopic pains, indolent nodes, and gummatous tumors of the areolar tissue—even though such a patient should appear as virtuous as Joseph, or as wise as Penelope—the surgeon might reasonably conclude that he had to deal with a case of syphilis, and should direct his remedies accordingly. The diagnosis may often be assisted by observing the traces of past manifestations of the disease, such as induration of the genital organs, or of the inguinal glands, or the depressed white cicatrices of syphilitic ulcera- tion. The seat of ulceration is often in itself significant. Leg ulcers which are not syphilitic, are almost always found below the middle of the calf, and any ulcer of obscure origin, situated at a higher point, may accordingly be looked upon with suspicion. Finally, the diagnosis of syphilitic affections of the viscera, or nervous system, in the absence of external manifestations, can often be merely con- jectural. Light may, however, often be thrown upon such cases, by noting the effect of anti-syphilitic treatment. Prognosis. Syphilis, as seen at the present day, is certainly a milder affection than formerly. ' This is apparently due chiefly to the tendency Avhich it shares with other diseases,1 to become less virulent by frequent transmission. A 1 A familiar example is the vaccine disease, which is more violent when produced by matter fresh from the cow, than when transmitted from arm to arm in the ordi- nary way. 30 466 VENEREAL DISEASES. considerable number of persons—more than is commonly supposed—are, besides, at least partially protected by inheritance. Moreover, as surgeons more generally understand the natural history of the affection, their treat- ment has become more judicious; and the reckless use, or abuse, of mercury, which Avas formerly so common in cases of syphilis, and which undoubtedly exercised an untoAvard influence on the course of the disease, has now given Avay to a more moderate and philosophical employment of this poAverful remedy. In any individual case, the prognosis Avill depend upon several circum- stances. Infection from a deep (Hunterian) or from a phagedenic chancre, will probably give rise to a worse form of the disease than would be acquired from contact Avith secondary lesions. A deep chancre usually indicates a graver infection than a superficial erosion. If a patient be of a strumous constitution, or broken down by previous illness, or of dissipated habits, the prognosis will, other things being equal, be less favorable than in the case of one who is robust, and Avho will probably take due care of his health during the course of treatment. According to Sigmund, syphilis acquired in advanced life runs a milder course than in younger persons. Secondary symptoms will almost invariably occur in every case of syphilis, but in a mild case will probably declare themselves at a later period, will be less intense, and will be more evanescent, than in one which is severe. Again, the form of the first eruption is of prognostic value, an erythema, or roseola, indicating a milder form of syphilis than one of the other varieties. When the tertiary stage has once appeared, the chances of complete recovery be- come very doubtful; though the disease, however, can rarely, under these circumstances, be entirely eradicated, its manifestations may, in most in- stances, be, by judicious treatment, held more or less in check, and life prolonged Avith considerable comfort to the patient. Death from acquired syphilis is rare. The prognosis of hereditary syphilis, if properly treated, is usually favor- able as regards life, unless the disease be manifested at the time of, or very soon after, birth, when a fatal result may be feared. Treatment of Syphilis. Treatment in Primary Stage.—As syphilis is a constitutional disease, it is to be met principally by constitutional treatment. The most valuable anti-syphilitic remedy is unquestionably mercury, the next in value being probably the iodide of potassium.1 It is believed by most authorities that not only do the primary manifestations of syphilis disappear more quickly when mercury is given, than when it is withheld, but that the development or evolution of secondary symptoms is, if not prevented, at least retarded and favorably modified by the administration of the remedy during the pri- mary stage. Prof. Bumstead and others believe, however, that, upon the whole, those cases do better in which mercury is withheld until the onset of the secondary stage, and hence only use this drug for primary syphilis in exceptional cases. My own opinion is that, while there can be no doubt that a chancre will heal under local applications alone, yet that, if the nature of the sore be well marked, and particularly if it be accompanied by the characteristic syphilitic bubo, it is, on the whole, safer to give mercury, 1 The modus operandi of these drugs is still a matter of dispute ; perhaps we may come nearest the truth in saying that they probably act by promoting elimination and absorption—elimination of the syphilitic virus, whatever that may be, and absorption of the lymphy and gummy deposits which characterize the later manifes- tations of the disease. TREATMENT OF SYPHILIS. 467 taking care, of course, to guard against salivation, and discontinuing the remedy if it appear to irritate the patient's system. If, however, there be the slightest doubt as to the nature of the sore, or if the general condition of the patient be such as to contra-indicate the use of mercury, it is much better to rely upon local measures, giving only tonics or such other medicinal agents as may be required by the particular exigencies of the case. For primary syphilis, mercury is, perhaps, best given by the mouth, and the preparation which I prefer is the protiodide (hydrargyri iodidum viride of the U. S. Pharmacopeia), Avhich may be conveniently combined with opium, as in the following formula: R. Hydrarg. iodid. virid. gr. iij-iv; Ext. opii gr. ij; Confect. opii £j. M. Div. in pilul. No. xij. Sig. One three times a day. This combination may often be used for many weeks, or even a longer time, without salivating, purging, or producing any other disagreeable effect. It should be discontinued as soon as any tenderness of the gums is perceived. AVith regard to the Local Treatment of chancre, all that can be done is to keep the part clean and free from sources of irritation, hastening cicatriza- tion, when healing has begun, by occasional light touches Avith nitrate of silver. There is no advantage to be gained by attempting to destroy the indurated base of the sore by cauterization, for there is every reason to be- lieve that systemic infection has taken place at or before the first appearance of the chancre. Excision is recommended by some authors, and may be resorted to under exceptional circumstances: thus if, in a case of phimosis, a chancre Avere situated at the extremity of the prepuce, circumcision would be justifiable, though it could hardly be expected to exercise any curative influence over the course of the disease. If a chancre be attacked Avith phagedcena, advantage may be derived from the use of opium, and of the potassio-tartrate of iron, both locally and generally, with free stimulation, if the condition of the patient require it. Mercury may be given cautiously, and, as it Avere, tentatively, being discontinued if the phagedenic action continue to spread under its employment. Cauterization with nitric acid, which, it will be remembered, is the great remedy for phagedenic chancroid, is rarely needed in the treatment of phagedenic chancre. If the surgeon suspect the existence of a mixed chancre, he should treat the case as one of simple chancroid, until the syphilitic nature of the affection becomes evident. Cauterization with nitric acid will, in such a case, be required under any circumstances, and little or no harm will result from delaying the use of mercury until the diagnosis has been rendered positive. But little can be done for the treatment of Syphilitic Bubo: attempts may be made to promote resolution by pressure, or by the employment of discu- tient applications, though the latter should be used with great caution, lest they induce suppuration. Pressure may be conveniently applied by means of a compressed sponge and spica bandage, or by means of a suitable truss. If the patient remain in bed, a weight, or bag of shot, may be simply laid upon the groin. Inunction Avith mercurial or iodine ointment, combined with the ointment of hyoscyamus, or of stramonium, may sometimes be ad- vantageously employed; or the part may be simply covered with mercurial plaster, or even with the ordinary soap plaster. I have sometimes observed benefit from the application of tincture of iodine, around, but not over, the enlarged glands, in the Avay recommended by F. Jordan. An Austrian surgeon, Dr. Jakubowitz, recommends injections with a hypodermic syringe of a solution of iodide of potassium (R. Potass, iodid. gr. xv, Tine, iodin. gtt. v, Aque f|j. M.). If suppuration occur, troublesome sinuses will proba- bly be left, Avhich must be treated on the general principles laid down at page :>94; while if, as is often the case, the patient give evidence of struma, mercury must be abandoned, and iodine and cod-liver oil substituted. 468 VENEREAL DISEASES. Secondary Stage.—By the course of treatment above described, it is possible, though not probable, that the development of secondary symptoms may be prevented. In Secondary Syphilis the use of mercury is generally acknowledged to be proper, though, even here, its employment will occasion- ally be forbidden by the constitutional condition of the patient, or by inju- rious consequences having resulted from its incautious or too prolonged administration during the primary stage of the disease. An important rule to be remembered in the use of mercury, in all stages of syphilis, is that the drug should be very gradually introduced into the system, and that salivation should be carefully avoided.1 In the secondary stage, mercurial inunction is, I think, preferable to the internal administration of the remedy; half a drachm of mercurial ointment, or, which Berkeley Hill prefers, an ointment containing twenty per cent, of the oleate of mercury, may be slowly rubbed into the inner part of the thighs, once a day (the hand being covered with a soft leather glove, soaked in fat to prevent absorption, if the treatment be carried out by an attendant), or into the soles of the feet, as recommended by Coulson, in which case woollen socks should be constantly worn. In in- fantile cases, a few grains of the ointment may be smeared upon a strip of flannel, Avhich is then applied as a belly-band. In many cases the use of inunction is objected to by the patient, and, under such circumstances, various preparations of mercury may be given by the mouth, the best probably being the corrosive chloride, in doses of from one-sixteenth to one-eighth of a grain, three times a day, after meals. It is best given in solution, much diluted, and may be conveniently combined with the bitter tonics, with the muriated tincture of iron, or (dissolved in ether) with cod-liver oil. The following formule, the second and third of which are imitated from Bumstead, will usually prove satisfactory :— R. Hydrarg. chlorid. corrosiv. gr. j ; Tinct. gentian, comp. fgij ; Syr. zingiberis f?j ; Aquse fgv. M. Sig. Tablespoonful three times a day. R. Hydrarg. chlorid. corrosiv. gr. vj-viij ; Tinct. ferri chlorid. fgj. M. Sig. Ten drops for a dose, in water. R. Hydrarg. chlorid. corrosiv. gr. i-ij ; Etheris fgj ; 01. morrhue ffviij. M. Sig. Tablespoonful for a dose, in the froth of porter. The red iodide of mercury is also a good preparation, in cases of second- ary syphilis, and may be given in combination with the iodide of potassium, in doses of one-sixteenth of a grain of the former to eight or ten grains of the latter remedy. Mercurial fumigation may be employed in obstinate cases of cutaneous syphilis, and is the method preferred by Langston Parker and H. Lee. The patient being enclosed in a suitable framework, covered with oil-cloth, steam is introduced, together with the fumes derived from the slow volatilization of a drachm or two of calomel, or of the red oxide of mercury, by means of a tin plate heated with a spirit-lamp, or, which is perhaps better, by means of the ingenious apparatus devised by the late Dr. Maury, of this city (Fig. 201). y y The use of mercury by hypodermic injection has been of late successfully resorted to, in cases of syphilis, by Lewin, of Berlin, R. W. Taylor, of New York, and others, and this mode of exhibiting the drug may be employed Avhen other methods are for any reason contra-indicated. From one-twelfth to three-eighthsof a grain of the corrosive chloride, dissolved in 15 minims of water, or, which Staub prefers, in a chlor-albuminous solution, made Avith 1 Dr. Keyes, of New York, has shown, by actual counting, that small doses of mer- cury absolutely increase the number of red corpuscles both in healthy persons and in the subjects of syphilis. TREATMENT OF SECONDARY SYPHILIS. 469 muriate of ammonium, common salt, and white of egg,1 may be injected once or twice daily; or Bamberger's peptonized solution, which contains the bichloride and common salt; or, which is preferred by Ragazzoni, half a grain of the biniodide, dissolved Avith a little iodide of potassium in half a fluidrachm of distilled Avater. Pick and Streitz employ a preparation known as "iodo-pepton," which is a peptonized solution of the corrosive chloride with iodide of potassium. Either of these methods I should consider upon Fig. 201. Maury's fumigating apparatus. the Avhole better than the injection of calomel, suspended in a mucilage of acacia, as recommended by the Italian surgeons Pirochi and Porlezza. Should Salivation occur during the administration of mercury, the remedy must be stopped, and astringent and detergent mouth-washes freely employed. The treatment may be subsequently cautiously resumed, or the iodide of potassium may be used instead. The occurrence of Mercurial Eczema, which, hoAvever, is rarely produced by the doses of mercury employed at the present day, would, also, of course, require the discontinuance of the remedy. The Local Treatment of secondary syphilis is sufficiently simple. The irritation produced by Mucous Patches, may be relieved by the application of nitrate of silver, or, which I prefer, the solution of nitrate of mercury, with black-wash as an after-dressing. Conradi and Charon recommend the use of nitrate of silver, folloAved instantly by the application of metallic zinc. Syphilitic Sore Throat may be treated with chlorate of potassium gargles, 1 Staub's solution may be made according to the following formula:— R. Hydrarg. chlorid. corrosiv., Ammonii muriat., aii ^j ; Sodii chlorid. 5jj ; Aq. dest. f^iv. Misce et cola, deinde adde Ovi alb. no. j, Aq. dest. q. s. pro f§iv. Of this solution 15 minims, containing about Taj grain of the sublimate, may be injected twice daily. 470 VENEREAL DISEASES. or Avith caustic applications, if there be any phagedenic tendency. The use of dilute muriatic acid, by means of the atomizer, may occasionally be advantageously resorted to. Iritis demands the unsparing instillation of atropia. The great risk is from occlusion of the pupil, and, in this affection, the local is even more im- portant than the general treatment. With regard to the use of mercury for syphilitic iritis, I do not, in ordinary cases, recommend it, unless it be required for other syphilitic manifestations. The plan of treatment Avhich I prefer is that recommended by Carmichael, which consists in the administration of drachm doses of the oil of turpentine, in addition to Avhich may be given (in the iritis of the tertiary stage) the iodide of potassium. The following formula will be found satisfactory, in most cases:— R. 01. terebinth, f^jss ; Tinct. opii fgss; Acaciae, Sacch. alb., aa^ij; 01. gaul- theriae gtt. iv ; Aquae f^iv. M. Sig. Tablespoonful three times a day. If, hoAvever, a very rapid effect be needed, or if the patient cannot take the turpentine, it may be necessary to resort to mercury. Alopecia is sometimes the source of a good deal of annoyance, and may be treated with Avashes containing the tincture of cantharides. The course of treatment briefly sketched in the preceding paragraphs is that adapted to a case of secondary syphilis occurring in a healthy person. If the patient be debilitated, tonics, and especially iron and quinia, should be given at the same time as mercury, if it be deemed safe to give the latter drug at all. The diet should be plain but abundant, and a moderate amount of alcoholic stimulus should be given if the patient is used to its employ- ment. The clothing should be sufficiently warm, and preferably of wool, and great care should be taken to avoid all exposure to wet or cold. The mercurial course should, as a rule, not be begun until the disappearance of the premonitory signs, but should then be continued regularly, and Avith as few intermissions as possible, until all secondary symptoms have passed by. By careful and judicious treatment, and by strict attention to hygienic rules, there is reason to hope that the disease, if of ordinary mildness, will exhaust its virulence in this stage, and that the patient may thus escape the tertiary manifestations of syphilis, which are at the same time the most distressing and the most hopeless. To remove the pigmentary stains left by syphilitic eruptions, Langlebert applies small blisters kept open for a few days, so as to substitute white for copper-colored cicatrices. Tertiary Stage.—In tertiary syphilis, mercury may be employed (prefer- ably by inunction) for the dry tubercular and squamous eruptions, and for the interstitial form of syphilitic orchitis; but for the other manifestations of the tertiary stage the iodide of potassium is usually a better remedy. It may be given in doses of from five to fifteen grains, three times a day, either alone or in combination with the bitter tonics, mineral acids, or cod-liver oil. As a Local Application to syphilitic ulcers, black-wash, or iodoform, either in powder or in solution with glycerin and alcohol, may be commonly em- ployed ; or if the ulceration be widely diffused, as in bad cases of rupia, calomel fumigation may be substituted. For the tertiary affections of the throat, chlorinated gargles, with caustic applications, or atomization of dilute muriatic acid, may be suitably resorted to. The use of iodide of potassium must often be persisted in, more or less continuously, for many years, and it is therefore a good plan to ascertain by experiment the minimum dose Avhich will keep the symptoms in check, and let that be constantly employed. The same hygienic rules should be ob- served in the tertiary as in the secondary stage of the disease. TUMORS. 471 Hereditary Syphilis, in its early manifestations, is best treated by mercurial inunction, in the way already described. In the later stages, iodide of potassium, with tonics, and especially iron and quinia, Avill be found of ser- vice. The saccharated iodide of iron is particularly recommended by Monti. A syphilitic infant need not be Aveaned if its mother be able to nurse it. It should not, hoAvever, be put to the breast of a healthy woman, lest the latter should be infected by contact with secondary lesions in the child's mouth. If a pregnant Avoman be syphilitic, she should take mercury, in order, if possible, to prevent abortion, and to save her offspring from inheriting her disease. Syphilization.—Syphilization, or inoculation with the pus obtained by artificial irritation of a chancre, or with that from a chancroid, Avas first rec- ommended by Auzias de Turenne, of Paris, both as a prophylactic and as a remedy for syphilis, and has been extensively used in the treatment of the disease by Prof. Boeck, of Christiania. This mode of treatment has been thoroughly tested by a number of surgeons in different parts of the Avorld, and the opinion of the profession is almost unanimously opposed to its em- ployment. Its use as a means of prophylaxis is clearly unjustifiable, for there is no evidence that the artificially inoculated disease is more tractable than that which is acquired in the ordinary way; and as to the curative effect of syphilization, the testimony of most unprejudiced observers tends to show that (1) it is very doubtful whether it exercises any beneficial in- fluence, and that (2) if it do any good, it is probably merely as a means of producing a depurative effect, just as has been done by vaccination, or by the use of blisters. Inoculation Avith chancroidal pus (which is sometimes practised under the impression that the chancroid is a syphilitic lesion) is quite unjustifiable, as merely adding another disease to that from which the patient is already suffering. I do not recommend a resort to syphilization under any circum- stances, and haATe mentioned it simply as a matter of historical interest. CHAPTER XXVI. TUMORS. The word tumor, in its etymological sense, signifies a swelling. In the writings of surgeons and pathologists, however, it is used Avith a more re- stricted meaning, and may be defined as a circumscribed enlargement of a part, due to the presence of a morbid growth. Tumors occur in both sexes, and at every age, and may be occasionally found in almost every region of the body. Though originating in and deriving their nourishment from the tissues in Avhich they occur, they have, in a certain sense, an independent organic life, groAving or withering Avithout regard to the state of nutrition of the rest of the body. They may be more or less strictly limited by an in- vesting membrane, or may be Avidely diffused, or infiltrated, among the sur- rounding tissues. Their anatomical elements may be the same as those of the tissue in Avhich they grow (homologous, homomorphous), as in the case of a fatty tumor groAving amid fat, or may be quite different (heterologous, heteromorphous), always, hoAvever, preserving a certain analogy to normal 472 TUMORS. tissue elements, from which, though in character they may deviate, they never entirely depart. Tumors may be either solitary or multiple; if the latter, they may be of the same or of different kinds. When tAvo or more tumors of the same nature coexist, they may have been developed simulta- neously or consecutively; and in the latter case it is occasionally, though (except in the case of cancer) rarely, possible to trace a direct anatomical connection, through the vascular system (as in the process of embolism1), or otherwise, between the first, which is then called primary, and the secondary tumors, or those which are subsequently formed. The origin of secondary cancerous tumors is, in the large majority of cases, traceable to absorption from the primary tumor, through the medium of the lymphatic system. Causes.—The causes of the development of tumors are sometimes suffi- ciently obvious; as where a cystic tumor results from obstruction of an excretory duct, or where the occurrence of a fatty tumor, or of an adven- titious bursa, is directly traceable to the effect of pressure. In most instances, however, no direct cause of the occurrence of a tumor can be detected, Avhile the indirect or predisposing causes are usually matters of conjecture, rather than of demonstration. Inheritance is sometimes a cause of the development of tumors, especially of the cancerous variety. Age, and the degree of func- tional activity of any particular organ, sometimes exercise a causative influ- ence upon the development of tumors: thus morbid growths are more frequent in adults than in children, and occur more often in an organ the functional activity of which is decreasing, than in one Avhich is undergoing development, or in one which, though completed, is still active. Sex exerts a certain causative influence, women being, upon the whole, more liable to tumors than men. Finally, as direct irritation has been seen to give rise to a tumor, it is occasionally possible to trace the origin of a morbid growth to indirect irritation transmitted through the nervous system; mammary tumors thus sometimes appear to be caused by uterine disturbance. V Classification of Tumors.—It is a matter of common observation that certain tumors occasion inconvenience merely by their bulk or position, and by their interference Avith the functions of adjacent parts, having no ten- dency in themselves to cause death: while other tumors inevitably prove fatal if left to themselves, and have an almost invariable tendency to recur in the same or another part if removed: hence the ordinary division of tumors into those which are benign, innocent, or non-malignant, and those which are malignant Certain tumors, again, are fatal if neglected, but if removed are not certain, though apt, to recur: these have been looked upon as occupying an intermediate position, and have been called semi-malignant This general division, founded upon the clinical characters of morbid growths, has many advantages, but is obviously not as accurate or scientific as would be a classi- fication of tumors founded strictly upon their anatomical peculiarities. Such a classification has been proposed by VirchoAv and other authors, and would doubtless have been generally adopted by surgical writers as well as by path- ologists, but for the fact that a knowledge of the microscopical characters of a tumor does not always give definite information as to its clinical history, which is of course (from the surgeon's point of view) the most important matter for consideration. The classification adopted in the following pages, 1 A remarkable case has, however, been recorded by Hayem and Graux, in which a fibro-plastic tumor of the ligamentum patellae was followed by a similar growth in the lung, directly traceable to embolism. Other examples of transference of non- cancerous tumors have been recorded by Virchow, Moore, Bryant, and Heitzmann, of New York. CLASSIFICATION OF TUMORS. 473 aims to combine, in a manner convenient to the student, a reference to both the clinical histories and the anatomical peculiarities of the various morbid groAvths. CLASSIFICATION OF TUMORS. Non-Malignant Tumors. B. Compound, or Proliferous. (8.) Complex. (9.) With intra-cystic growths (10.) Cutaneous. (11.) Dentigerous. 1. Cystic Tumors; Cysts. A. Simple, or Barren. (1.) Serous; hygromata. (2.) Synovial. (3.) Mucous. (4.) Sanguineous. (5.) Oily. (6.) Colloid. (7.) Seminal. 2. Solid Tumors and Outgrowths. (1.) Fatty or adipose. (2.) Fibro-cellular or connective-tissue. (3.) Mucous or myxomatous. (4.) Fibrous, fibro-muscular, fibro-cystic, etc. (5.) Cartilaginous, fibro-cartilaginous, and mixed. (6.) Osseous. (11.) Neuralgic. (7.) Glandular. (12.) Pulsating. (8.) Lymphoid. (13.) Floating. (9.) Vascular. (14.) Phantom. (10.) Papillary. Semi-Malignant or Recurrent Tumors. (1.) Recurrent fibroid. (2.) Myeloid. (3.) Sarcomata. Malignant Tumors. 1. Carcinoma. (Cancer.) (1.) Scirrhous or hard cancer (Scirrhus). (2.) Medullary or soft cancer (Encephaloid) (a) Melanoid. (b) Haematoid. (c) Osteoid. 2. Epithelioma. (Epithelial or skin-cancer.) (d) Villous. (e) Colloid. (/) Fibrous. Non-Malignant Tumors, as a rule, displace, without involving, surround- ing tissues; they possess considerable vitality, and hence may persist for a long period Avithout undergoing either ulceration or interstitial degeneration; they are homogeneous, or at least do not commonly exhibit, in the same mass, any great diversity of structural elements; and if removed, they do not usually recur. Malignant Tumors, on the other hand, are commonly infiltrated among the surrounding tissues, Avhich they gradually replace or appropriate to them- selves; they possess comparatively little vitality, and hence tend to ulceration and destructive degeneration; they exhibit, in the same mass, a considerable number of diverse structural elements; and though removed with the greatest care, almost invariably recur. The Sem i-Malignant or Recurrent Tumors occupy an intermediate position; they often groAV rapidly and cause ulceration of the o\Ter-lying integument; they frequently contain, in the same tumor, a great variety of structural elements; and, though they do not commonly spread to distant organs, they mostly have a strong tendency to recur after even apparently complete removal. 474 TUMORS. These remarks, though generally, are not universally, applicable. It oc- casionally happens that a tumor, Avhich is undoubtedly cancerous, does not recur after removal, Avhile, on the other hand, a growth Avhich, structurally, is such as Avould be placed among the non-malignant tumors, may recur indefinitely, and eventually cause death. The special characters and appropriate treatment of each variety of tumor AArhich comes under the observation of the surgeon, will now be briefly described. Cystic Tumors, or Cysts. Cysts may originate in several ways. The most common is from the dis- tention and enlargement of ducts, or sacs, as is usually the case Avith the mucous and ordinary cutaneous cysts (Retention cysts). Another mode of origin is from the enlargement and coalition of the natural interspaces of the areolar and other tissues; these interspaces being distended with fluid, the surrounding structures undergo condensation, until a cyst wall is formed. It is in this way that adventitious bursa? are formed, as well as cystic de- velopments in solid tumors. A third mode of origin is from the direct groAvth of neAvly-formed elementary structures, cells, or nuclei—the cysts thus formed being sometimes called primary or autogenous, as distinguished from the other, or secondary, cysts. Finally, a cyst may be formed by the protrusion and subsequent separation of a portion of a serous membrane, as happens in some cases of so-called " false spina bifida," and probably, as pointed out by Michel, of Charleston, in certain examples of serous cyst of the inguino-femoral region. A. Simple or Barren Cysts. Serous Cysts, or Hygromata, may occur in any part of the body, but are most usual in or near glandular structures. These cysts contain a liquid of variable consistency, and of a yellowish, reddish-broAvn, or olive hue; this liquid sometimes contains crystals of cholestearine, and in other cases is fibrinous and coagulates when removed. The cyst walls are of connective tissue, adherent to surrounding structures, not \Tery vascular, and lined with a tessellated epithelium. These cysts may be single or multiple, and, in the latter case, may intercommunicate, or may be merely aggregated. When found in external parts, they may commonly be diagnosticated by observing that they have a smooth and rounded outline, are movable with, though adherent to, the neighboring healthy structures, are painless, covered with normal skin, and sometimes translucent,1 and fluctuate, or, if very tense, are at least found to be elastic and resilient on pressure. The treatment may consist in puncture (Avhich may also be used as an exploratory measure), the application of tincture of iodine, the injection of the same substance after tapping, the use of a seton, incision with or Avithout cauterization, or partial or complete excision. Iodine injections, or the seton, are particularly adapted for cysts found in the cervical and axillary region, as in the cases described by T. Smith under the name of " congenital cystic hygroma;" and incision, with cauterization or simply stuffing the cavity Avith lint, for those met with in the gums or bones. Partial incision is usually sufficient if the cyst be solitary, any portion that is left subsequently granulating and undergoing cicatrization. For multiple cysts, however, total excision may be required, and, if seated in the mammary gland, it may be necessary to remove the whole breast, in order to prevent any portion of the diseased structure from remaining. Serous cysts are occasionally connected Avith vascular naevi, in 1 When occurring in the neck, they constitute the so-called hydroceles of that part. COLLOID CYSTS. 475 which case the operation for removal may be attended with profuse bleeding. In the breast, it sometimes happens that a serous cyst coexists with a cancer. Synovial Cysts may consist simply in enlargement and distention of the normal synovial bursa1; or maybe adventitiously developed in abnormal situations, as the result of pressure; or may occur in the sheaths of tendons, constituting ganglia. The fluid of these cysts varies in consistency from that of serum to that of honey, and they not unfrequently contain small bodies, about the size and shape of melon-seeds, which may be loose, or attached to the cyst Avails, and which are composed of a dense connective-tissue sub- stance. The treatment of synovial cysts consists in the use of external irri- tation, in tapping, followed by stimulating injections, in the formation of a seton, in subcutaneous division and scarification, or, finally, in excision. Mucous Cysts are chiefly seen in mucous membranes and in connection with the mucous glands, where they result from distention of obstructed ducts or follicles. They are met with in connection Avith Cowper's or Duverney's glands, in the antrum, and beneath the tongue, where they con- stitute a form of ranula. Their general characters are those of the serous cysts, from which they differ chiefly in the nature of their contained fluid (Avhich resembles mucus), and in their locality. The treatment consists in free incision, or in cutting aAvay a portion of the cyst Avail, the cavity being alloAved to heal by granulation. Sanguineous Cysts, or Haematomata, may result from accidental hemor- rhage into the cavity of a serous cyst (just as hematocele from hemorrhage into the sac of a hydrocele), from transformation of a vascular nsevus, from occlusion and dilatation of a portion of a vein, or from effusion of blood which subsequently becomes encysted by the condensation of the surround- ing areolar tissue. They are chiefly met with in the cervical and parotid regions (in the former locality constituting hematocele of the neck), though they also occur in other parts of the body. These cysts contain blood, which may be clotted and partially decolorized, or which may be liquid. In the latter case it may have been fluid from the first, and Avill then coagulate when evacuated, or may have been clotted at first and subsequently re-lique- fied. The Avails of these cysts may be simply membranous, or may be deeply ribbed, and the cyst walls may, in some instances, present the characters of a sarcoma or recurrent fibroid tumor. These cysts occasionally resemble, in their outward appearance, encephaloid tumors, Avith which indeed they may coexist. The treatment ordinarily to be recommended for sanguineous cysts, is excision, Avith precaution against hemorrhage if the cyst be connected Avith a nievus or bloodvessel; or, if the tumor be very large, it may be re- duced in size by repeated tappings, and then laid open, as has been success- fully done by Erichsen. Amputation may occasionally be required, as in a remarkable case reported by Moore, in Avhich the cyst Avas developed in the course of the popliteal nerve, and in which loss of blood during an attempt at excision necessitated the removal of the.limb. Oily Cysts.—Cysts containing oil or fatty matter alone are very rare, though fatty substances not unfrequently occur in cysts, as the result of de- generation of other materials, or as a curdy residue from milk. Oily cysts do, however, occasionally occur in the orbital and superciliary regions, and in the breast. The treatment should consist of excision. Colloid Cysts occur in the kidney and thyroid gland, in the latter situa- tion constituting a variety of goitre. Their contents vary in consistency 476 TUMORS. from that of serum to that of firm jelly, being clear or turbid, and of very variable color. The treatment of cystic goitre consists in tapping and the injection of iodine, or the formation of a seton. Seminal Cysts.—This is the name used by Paget for most examples of the affections usually knoAvn as encysted Hydrocele, Hydrocele of the Cord, and Spermatocele. Seminal cysts possibly arise in some cases from dilata- tion and subsequent isolation of a portion of a seminal tubule, but usually originate in the so-called " non-pedunculated hydatids " which are remnants of the Wolffian body of foetal life. They may be single or multiple, and may occur in any part of the spermatic cord, though usually just above the epididymis. Their walls are of areolar tissue, sometimes lined Avith tessel- lated epithelium, and they contain a milky fluid in which spermatozoa are commonly found. The treatment consists in the injection of iodine, or in the use of a seton; or, if these fail, in free incision of the sac, Avhich is then alloAved to heal by granulation. B. Compound or Proliferous Cysts. These are such as have the power of producing vascular or other organized structures, Avhich may be enclosed within the original cyst wall, or may pro- ject from its surface. It is sometimes very difficult to distinguish a true pro- liferous cyst from a mass of simple cysts closely aggregated together, the latter indeed constituting a considerable proportion of what are known as multilocular cysts. Complex Cystigerous Cysts are chiefly met with in the ovary, and in the chorion, in the disease of that membrane known as the hydatid mole, in which the cysts are probably merely secondary formations (see p. 482). Complex ovarian cysts present a parent cyst with numerous secondary cysts variously arranged, which project into its cavity (endogenous), or from its surface (exogenous growths). Dr. Wilson Fox has carefully investigated the mode of origin of these tumors, and believes that the parent cyst origi- nates, like the simple ovarian cyst, in the Graafian vesicle. Into the interior of the parent cyst, tubular gland structures, or villous or papillary groAvths (which Dr. Fox looks upon as everted follicles), project, and it is by the dilatation and constriction of these tubules, or by the adherence of these papillary growths, that the secondary cysts are formed. The treatment of these ovarian cysts will be considered when we come to speak of ovariotomy. Cystigerous cysts occurring in other parts of the body, could hardly be dis- tinguished from multiple simple cysts aggregated together, and would require the same treatment, viz., total excision. Proliferous Cysts with Vascular Intra-cystic Growths occur in connec- tion with various glands, especially the mammary and thyroid, though they are also seen in the prostate, in the lip, and in other parts of the body. This class of cysts embraces many of the tumors described by Brodie and others as sero-cystic sarcomata. These cysts may be single or multiple, their walls being formed of thin areolar tissue, and closely adherent to surround- ing structures. Their contents at first are fluid, but subsequently a vascular growth, apparently of glandular structure, which may be well formed, rudi- mentary, or degenerate, springs from some point of the interior, and, in- creasing more rapidly than the cyst, gradually encroaches on its cavity, Avhich it aftervyards entirely fills, sometimes at last perforating the cyst Avail, and protruding as a fungous mass. The form of these growths varies in different cases; sometimes they appear as layers of coarse granulations, sometimes as CUTANEOUS PROLIFEROUS CYSTS. 477 nodulated caulifloAver-like masses, sometimes as clusters of delicate leaf-like processes, and again as masses of closely-packed lobules. Their color, con- sistency, and degree of vascularity, are equally various. The course of these tumors is very chronic. The diagnosis from cancer may be made by observ- ing the sIoav progress of the sero-cystic sarcoma, its occurrence at an earlier age (usually from thirty to forty, though it may occur at a much later period), the healthy character of the skin over the tumor, the feeling of fluctuation, if the cyst still contain fluid, and the freedom from disease of the neighbor- ing lymphatic glands. Even when ulceration takes place, and the intra-cystic growth protrudes as a fungous mass, the surrounding integument has not the infiltrated appearance which it has in cases of cancer. Before the skin gives way, it may present a bluish-black color over the most prominent part of the cyst, an appearance which is of itself quite characteristic. The treatment consists in total excision, which will usually be followed by a permanent cure, though, if any portion of the growth be allowed to remain, the tumor will be apt to recur; it may even do so after repeated removal, and when every care has been taken in the operation. Virchow records a case in which the tumor traversed the chest wall and involved the lung, and in which metastatic growths existed in the lungs, mediastina, liver, ribs, verte- brae, pelvic bones, dura mater, and sphenoid bone. These tumors have therefore, occasionally, a clinically malignant character, but, as pointed out by Paget, the recurrent are essentially like the primary groAvths, and never become truly cancerous. Proliferous cysts may coexist with cancer, as in the ovary and testicle. Cutaneous Proliferous Cysts.—These are defined by Paget as "cysts within which, in the typical examples, a tissue grows, having more or less the structures and the productive properties of the skin." In the majority of cases, no true cutaneous lining can be recognized, but the cysts are found to contain epidermal scales, sebaceous matter, fat granules, cholestearine, and rudimentary hairs. These cysts are chiefly met Avith in the ovaries and sub- cutaneous tissue, but have also been seen in the testicle, lung, kidney, blad- der, brain, and tongue. Among those in the subcutaneous tissues, such as are congenital approach most nearly to the typical character. These occur usually in the orbital region, close to the external angular process of the frontal bone: they have a round or oval contour, and consist of a thin cyst Avail, of a more or less cutaneous structure, pretty tightly filled with oily or sebaceous matter, Avith or without hair. These cysts are sometimes deeply seated, and may adhere to the periosteum, or even erode, or possibly perfo- rate, the subjacent bone. The treatment consists in total excision, which, in the orbital region, requires careful dissection. The common non-congenital cutaneous cysts may occur in any region of the body, but are most frequent in the scalp. In this situation they are very loosely attached, so that they may commonly be readily removed by transfixing and laying open the tumor, and, after evacuating the contents, pulling out the cyst Avail Avith forceps. In other parts of the body they may require more careful dissection. These sebaceous tumors, as they are ordinarily called, sometimes appear to have very thick Avails, OAving to the accumulation of epithelial debris in their interior. In some cases a dark spot is observed on the surface of the tumor, which marks an orifice through which a probe can be introduced, and through which the contents of the cyst may perhaps be evacuated. In these cases, it is probable that the cyst has originated from obstruction of a sebaceous duct, though in other instances these growths appear to be autogenous formations. Seba- ceous tumors may become inflamed, when the cyst, if small, may be loosened and throAvn off by suppuration; in other cases, ulceration takes place, and 478 TUMORS. the contents of the cyst protrude, becoming dry by exposure, and constituting some of the so-called " horns " of the face or other parts. Occasionally the protruded contents of a cutaneous cyst become vascular, and present the appearance of a fungous, bleeding mass, Avhich may be mistaken for cancer. The treatment, as already observed, consists in total excision, but this should not, as a rule, be done unless the patient be in good general health at the Fig. 202. Sebaceous tumors and horn. (Bryant.) time, as the operation, though in itself a trifling one, has not unfrequently been followed by fatal erysipelas. Sebaceous cysts in the auditory canal, or in the orbital region, may occa- sionally prove fatal by perforating the skull, and inducing meningeal and cerebral inflammation. Hence, early excision is particularly imperative in these cases. Dentigerous Cysts, or cysts containing teeth, occur in the ovaries and testes, but are chiefly interesting to surgeons when met Avith in the upper or lower jaw. These cysts appear to be tooth capsules, from which the teeth, though well formed, have not been extruded, and which become enlarged by the accumulation of fluid. The treatment consists in making a free opening into the cyst, taking away a portion of its wall, and, after extracting the misplaced tooth, stuffing the cavity with lint. Non-Malignant Solid Tumors and Outgroavths. The term Outgrowth is here used in the sense in which it is employed by Paget to denote the " Continuous Hypertrophies " which are occasionally met Avith, in which the limiting and investing capsule of a Tumor or " Discon- tinuous Hypertrophy" is absent. These outgrowths differ from the infiltra- tions of malignant diseases in that, in the former, the neAV material is homol- ogous Avith that which surrounds it, while in the latter it is quite different, causing indeed degeneration and Avasting of the normal tissue in which it is placed. Fatty Tumors and Outgrowths.—These are the most common of all the non-malignant tumors, and have been described by surgical writers under FATTY TUMORS AND OUTGROWTHS. 479 various names, such as Lipoma, Steatoma; etc. The Fatty Outgrowth consists of an accumulation of fat in the subcutaneous tissue of some part of the body, and may be either single or multiple. It is usually annoying only on account of the deformity produced, but is occasionally painful. A favorite seat of the fatty outgrowth is the neck, where it gives the appearance knoAvn as a double chin. It also occurs in the abdominal walls, and may be met with in other situations. Brodie succeeded in procuring the absorption and disappearance of a growth of this kind by the internal use of liquor potassse, but usually excision would be the only means likely to effect a cure, and this could rarely be advisable, for the resulting scar would probably be as dis- figuring as the disease itself. The Fatty or Adipose Tumor, or Lipoma Circumscriptum of systematic Avriters, is a much more common affection. It usually occurs in the trunk, especially the upper part, or in the proximal portions of the limbs, though it may be met with in any region of the body, as beneath the tongue, in the sole of the foot, or in the scrotum. A peculiarity of the fatty tumor is its proneness to shift its position, in obedience to the law of gravity; thus a lipoma has been known to pass from the groin to the perineum, or from the Fig. 203. Fig. 204. Structure of a fatty tumor; a, isolated cells Fatty tumor; the lobated appearance well showing crystalline nucleus of margaric acid. shown. (Miller.) (Bennett.) abdominal wall to the thigh. The usual seat of a fatty tumor is in the sub- cutaneous tissue, though cases are on record in which these growths have been found in the intermuscular planes, in contact with bones or joints, in the nerves, and in the fat around internal organs. Fatty tumors are always invested by capsules, fibro-cellular in structure, and of varying density; from the capsule, septa pass inwards, dividing the tumor into lobes of various size. The capsule is dry, and supplied with bloodvessels, and separates the tumor from the surrounding structures. Its layers have less cohesion among themselves than adhesion either to the tumor or to the neighboring tissues. The skin adheres to the capsule more closely at the points at Avhich the septa pass off than at other parts, thus giving a dimpled appearance to the mass Avhen it is lifted aAvay from the subjacent structures. The fat of an adipose tumor does not differ materially from the ordinary normal fat by Avhich the mass is surrounded, though, according to Butlin, the individual cells of the tumor are muoh larger than those of adipose tissue in general. The devel- opment of fat in a tumor is like that of natural fat, the gradual formation of fat cells from connective tissue corpuscles being, according to Weber, as 480 TUMORS. quoted by Paget, traceable in these tumors. Fatty tumors derive their vas- cular supply chiefly from arteries that ramify in the capsule, though, in addition, a large vessel frequently passes directly into the mass. Fatty tumors are usually single, but may coexist in large numbers, fifty- eight having been observed in one case by B. P. Harris, of this city. They are most common in early adult and in middle life, and, as a rule, groAV very slowly. They occasionally attain a very large size, one being referred to by Gross which weighed not less than seventy pounds. Fatty tumors are usually, though not ahvays, painless. They occasionally inflame and ulcerate (par- ticularly such as are pendulous), and may contain oily cysts, or bony or cal- careous nodules. The diagnosis can commonly be made by observing the smooth, indolent, lobated character of the SAvelling, the sensation of elasticity or semi-fluctua- tion communicated to the touch, and the peculiar dimpling, corresponding with the position of the interlobar septa, when the skin is rendered tense by compressing and lifting the mass. Another point, insisted on by Labbe, is that by thus manipulating the skin the general surface becomes red, Avhile the positions of the interlobar septa are marked by white lines. The surgeon may also avail himself of the knowledge that all fatty matters become hardened by the application of cold, and thus aid the diagnosis by directing a spray of ether upon the surface of the tumor. The treatment consists in excision, which may be practised in any case in which an operation of any kind would be admissible. A single incision may be made, corresponding as much as possible with the long axis of the tumor and the natural curves of the part, and, the capsule being then split with the knife, the whole mass may be often enucleated, by traction aided by the handle of the instrument. Occasionally, however, prolongations of the tumor may extend into deeper parts, and require more careful dissection. The cure is usually permanent, though, if any portion of the tumor be left, reproduction may possibly occur. In the case of pendulous growths, and particularly if ulceration have occurred, it may be proper to remove an elliptical portion of skin with the tumor. Should excision be in any case contra-indicated, attempts may be made to disperse the tumor by injections of alcohol or ether, which are said to have proved successful in cases recorded by Hasse, of Nordhausen, and SchAvalbe, of Weinheim. Fibro-cellular Tumors and Outgrowths are such as in their anatomical characters resemble the ordinary areolar or connective tissue. The Out- growths are more common than the tumors, and constitute most of the softer and more succulent kinds of Polypi, as well as the Cutaneous Outgrowths, or Wens, which are so frequently met with in the generative organs, and other parts of the body. In the polypi, the fibro-cellular is commonly associated Avith gland structure, Avhile in the cutaneous outgrowths the skin itself appears to be hypertrophied. Closely connected with these fibro-cellular outgrowths are the cases of Elephantiasis Arabum, Scleroderma, etc., which are chiefly observed in the scrotum and lower extremities, and Avhich are occa- sionally accompanied with a dilated state of the lymphatics, with or without lymphorrhcea, and more rarely Avith a nsevoid condition of the skin and sub- jacent tissues. If these Avens are of moderate size, they may be readily removed, but if very large, the operation, though justifiable, becomes a rather formidable proceeding. When met with in the form of " Barbadoes leg," attempts may be made to reduce the swelling by the continued use of firm compression by means of the elastic bandage, and, as advised by Olavide, of Madrid, by the internal and external use of iodine; and if these fail, it may FIBRO-CELLULAR TUMORS AND OUTGROWTHS. 481 occasionally be proper to resort to ligation of the main artery of the limb1— an operation Avhich has been performed under these circumstances Avith good results by Carnochan, Crosby, and numerous other surgeons, but which is, according to Fayrer, usually productive of only temporary benefit. The statistics of this mode of treatment have been particularly studied by Casati, Wernher, Fischer, Leonard, and Leisrink, the latter of whom has collected Fig. 205. Fibro-cellular tumor of labium. (Holmes.) about 30 cases, from an examination of Avhich he concludes that though the operation frequently fails, yet it is often productive of benefit, and occa- sionally effects a complete cure. Leonard, of Bristol, refers to 69 cases, of which 40 ended in recovery (3 of these after digital compression of the artery); in 13, relief Avas afforded; and only 16 were totally unsuccessful. Casati has analyzed 24 cases as follows:— Ligation of Cases. Recovered. Relieved. Disease returned; no benefit. Died. Iliac artery,..... Femoral artery, .... Popliteal artery, .... Spermatic artery, . . . Axillary artery, .... Brachial artery, .... 5 12 1 2 1 3 5 1 2 2 4 i 2 1 3 2 i Total, . . . 24 10 5 3 6 1 The sciatic nerve was resected in a case of elephantiasis by Dr. Morton, of this city, with the effect of considerably reducing the size of the limb, but the case ter- minated fatally five months after the operation. 31 482 TUMORS. Fibro-cellular Tumors are comparatively rare affections. They are chiefly met Avith in the deep intermuscular planes of the limbs, the scrotum, labium, and vaginal wall, but are occasionally seen in the subcutaneous tissue, or in other parts, as the testicle, tongue, or orbit. These tumors occur as firm, round, or oval masses, tense, somewhat elastic, and invested Avith a thin cap- sule of areolar tissue. In this respect they markedly differ from the cutaneous outgrowths met with in the same regions, for these are continuous Avith the surrounding structures. On laying open a fibro-cellular tumor, it is found to consist of opaque Avhite, intersecting bands of contractile tissue, the inter- spaces being filled Avith a more or less viscid serous fluid, of a yellowish-green or yellow hue. This fluid flows or may be squeezed out, the filamentous structure then contracting, and assuming a firmer and denser appearance. The tumor, in fact, closely resembles a mass of oedematous areolar tissue. Under the microscope, the elements of ordinary connective tissue are seen— undulating filaments, with nuclei (rendered more distinct by acetic acid), and elongated cells of various forms. Yellow elastic tissue is very rarely found, but cartilaginous or bony nodules are occasionally observed. These tumors are met with in late adult life, and increase in size rather rapidly, more, however, by serous distension than by absolute growth. They are usually painless, giving trouble only by their position and weight, Avhich sometimes exceeds forty pounds. Fig. 206. When very large and dependent, they may cause ulceration or sloughing of the surrounding skin. The treatment consists in excision, the growth being enucleated as a fatty tumor from its capsule. The operation usually results in a per- manent cure. Myxoma, or Mucous Tumor, is a name given by VirchoAV to a rudimentary form of fibro-cellular tumor, which on section has a quivering, jelly-like appearance, the contained yellow fluid readily flowing away, and the microscopic appearances of the tumor present- ing oval, elongated, or branched corpuscles, with indistinct fibrillar, and imperfectly formed filaments. The structure of the tumor re- sembles, in fact, embryonic con- nective tissue, or the so-called mucous tissue of the umbilical cord. Mijxo- mata occur in the connective tissue of the brain, eye, nasal septum, breast, nerves, neck, or extremities, and in suitable cases may be excised Avith a prospect of permanent relief. When met with in the eye, they require ex- tirpation of the globe. The disease of the chorion knoAvn as the hydatid mole, is believed by VirchoAV to be an example of myxoma, consisting in hypertrophy of the proper tissue of the villi of the membrane in question. The cysts which are met with in this disease are, according to Paget, prob- ably not essential, but merely secondary formations (see page 476.) Fibrous Tumors and Outgrowths (including Fibro-muscular, Flbro-cystlc, and Fibro-calcareous Tumors).—Fibrous or fibroid tumors and outgrowths Structure of myxoma. (Holmes.) FIBROUS TUMORS AND OUTGROWTHS. 483 (also called desmoid, chondroid, and tendinous) are such as anatomically resemble the ordinary fibrous or ligamentous tissue. Under the head of fibrous outgroAvths, may be included most of the firmer polypi met with in the uterus, nose, pharynx, etc. Fibrous tumors have naturally a round or oval shape, and are smooth, or but slightly lobed on the surface. Under the influence, hoAvever, of gravity or pressure, they deviate from the normal form, becoming pyriform Avhen pendulous, and when confined in a cavity, becoming gradually moulded to its shape. Fibrous tumors are usually surrounded Avith a capsule of connective tissue, and when cut into present a basis-substance, commonly of a yellowish or bluish-gray color, intersected Avith very numerous opaque white bands. These Avhite fibres are variously arranged, sometimes in concentric circles, sometimes in undulating bundles which interlace Avith each other, and some- times again matted closely together, so as to appear to the naked eye as a nearly uniform, white, glistening mass. The tumors are more or less lobed, and divided by septa of areolar tissue, the vascularity of the groAvth being Fig. 207. Fig. 208. Structure of fibro-muscular tumor of the uterus. (Bennett.) greatest in those tumors which are most loosely arranged. Beside the char- acteristic fibres seen in sections of these tumors, there are commonly fusiform cells and nuclei perceptible; and elastic fibres, plates or spicule of bone, and cartilage, may occasionally be found mingled with the fibrous tissue. In the uterus, and occasionally in other situations, the fibrous tissue may be so mixed Avith non-striated muscular fibre as to entitle the tumor to be called Fibro- muscular; if the muscular fibre be in excess, the tumor becomes a Myoma (YirchoAv), the Muscular Tumor of Vogel. The Fibro-cystic and Fibro- calcareous varieties are the result of secondary degeneration, and may occur in either the ordinary fibrous or in the fibro-muscular tumor. In the fibro- cystic tumor the cyst may be single, but more frequently there are a number of cysts, variously scattered through the mass; this is well seen in the disease of the testicle to Avhich Cooper gave the name of " hydatid testis." The occur- rence of calcareous degeneration in fibrous tumors is chiefly seen in those met Avith in the uterus, and indicates a cessation of growth in the morbid mass. Fatty degeneration occasionally, though rarely, occurs in fibrous tumors. The favorite seats of fibrous tumors are the uterus, the nerves (Avhere they constitute the disease called neuroma)1 the bones and periosteum (especially Structure of fibrous tumor. (Erichsen.) 1 Or the false neuroma. (See Ohap. xxviii.) 484 TUMORS. about the jaws), the subcutaneous areolar tissue, that in the neighborhood of joints, the tendinous sheaths, the testes, and the lobules of the ear, Avhen pierced in order to Avear ear-rings; they are also met Avith, though more rarely, in the breast, prostate, submucous and subperitoneal areolar tissues, and possibly in other localities. Fibrous tumors are usually solitary, except in the uterus and nerves, where they are commonly multiple, and may exist in large numbers. They are of slow groAvth, are indolent, and attain sometimes a very large size—weighing perhaps over seventy pounds; they may persist for thirty years, or even longer. Sometimes they become oedematous, and soften internally, the outer part giving way or sloughing, and the disintegrated interior being discharged; an irregular cavity is left, from which fungous and bleeding granulations may protrude, giving the part a decidedly cancerous appearance. The diagnosis of fibrous tumors may usually be made by observing their smooth and regular outline (unless distorted by compression), their uniform firmness, their mobility (when in the subcutaneous tissue), their slow growth and painlessness, and the healthy character of the surrounding tissues. When growing in, or connected Avith, bones, the diagnosis from other forms of tumor is often very difficult, and sometimes almost impossible, until after removal of the groAvth. The treatment consists in excision, in situations admitting of this operation, the tumor being enucleated from its* capsule, if this can be done, and if not, removed by careful dissection. When the tumor springs from bone, as in cases of epulis, it is necessary to remove, with the growth, the osseous sur- face to which it is attached. Recurrence is rare, except in the case of the tumors met with in the ear, Avhere the growth presents some analogies to the keloid seen in cicatrices. Occasionally, however, fibroid tumors occur Avhich are truly malignant, and which resemble cancerous growths in every point except their structure; these have indeed been called Fibrous Cancers, but Malignant Fibroid Tumor would seem to be a better name. Cartilaginous Tumors, or Enchondromata (including Fibro-cartilaginous and Mixed Tumors)1 — The anatomical and chemical characters of these growths are essentially those of foetal cartilage. Enchondromata are com- monly lobulated, and (in parts unconnected with bone) invested with a dense connective-tissue capsule, from which proceed septa which divide the lobules from each other. On section, these tumors present a glistening, bluish, or pinkish-Avhite appearance, and differ from other non-malignant groAvths in that they shoAV, under the microscope, a considerable diversity of structure in specimens derived from the same tumor. The intercellular substance has a more or less fibrous appearance, and is often so markedly fibrous as to render the name Fibro-cartilaginous appropriate. The cells vary greatly in number, size, shape, and mode of arrangement, and are sometimes so fused with the basis-substance that the nuclei alone are perceptible. The nuclei themselves vary in different specimens, occasionally seeming shrivelled, or containing oil globules, or having a granular appearance. Cartilaginous tumors are commonly hard and resisting, though sometimes soft and compressible; they are always elastic. They interfere but little Avith surrounding structures, which remain healthy, though displaced by the groAving mass; if the part be exposed to friction, a bursa sometimes forms over the prominent part of the tumor. Enchondromata usually occur at an early period of life. 1 The "loose cartilages" met with in joints present certain analogies to enchon- dromata, but will be more conveniently considered in another part of the volume. CARTILAGINOUS TUMORS. 48") These tumors are most frequently seen in connection with bones (when they may groAV beneath the periosteum, or in the medullary cavity), but also occur in or near the parotid gland, in the testis or mamma, and occasionally in other localities. Their rate of increase, and the size to which they may Fig. 209. Fig. 210. Large enchondroma of scapula. the result of inflammation and Fig. 211. Structure of enchondroma. (Erichsen.) attain, are both extremely variable; Paget mentions a cartilaginous tumor Avhich, after four years, was but half an inch long; and another Avhich, in three months, occupied nearly the whole length of the thigh, and was as large round as a man's chest. The principal changes which occur in en- chondromata, are ossification and degenerative liquefaction. Ossification may take place in the older portion of a tumor, Avhile the rest is still groAving, or may occur in the form of de- tached bony nodules scattered through the mass. As a result of degenera- tion, or possibly of arrested development, a honey-like or jelly-like fluid is often found in one or more parts of an enchondroma, giving a soft and fluctuating character to the tumor. As ulceration, an enchondroma may pro- trude and slough, leaving a large sup- purating and offensive cavity, and death may occur from exhaustion under these circumstances. A large proportion of the so-called Mixed Tumors contain cartilage as one element of their structure. Thus, nodules of cartilage may occur in fibro-cellular tumors, and, on the other hand, enchon- dromata may contain cysts, glandular tissue, or myeloid structure — and may even be apparently mingled with ence- phaloid, in the same general mass. Cartilaginous tumors are usually solitary, except when occurring in the bones of the hands, where they are commonly multiple. The bones most frequently affected, after those of the hand, are the femur and tibia, and, next to these, the humerus, ribs, pelvis, and last phalanx of the great toe— though enchondromata have been occasionally seen in almost every bone of the body. When growing near the articular extremity of a long bone, a cartilaginous tumor is usually seated betAveen the periosteum and bone, gradually eroding the Avail of the latter, and involving it in its own mass. The articular extremity itself is probably never involved. Enchondromata Multiple enchondromata of hand. (Druitt.) 486 TUMORS. in the middle of the shaft of a long bone are rare, and, when met with, commonly grow both externally and internally, the bone wall finally yield- ing, and the tumors coalescing. In the hand, enchondromata arise within the bone, the walls of which they gradually expand; but in the rare cases of single enchondromata in this situation, the tumors are subperiosteal, as in the long bones. The diagnosis may usually be made by observing the various characters which have been described as belonging to the enchondroma, especially its hardness combined with elasticity; but when occurring in certain situations, as within the jaw, the diagnosis from other innocent tumors may be impossi- ble until after excision. The treatment of cartilaginous tumors consists in removal of the growth by enucleation, dissection, excision, or amputation, according to the locality and other circumstances of each particular case. Enchondromata rarely recur after removal, though they may do so when of a soft and rudimentary structure: when mixed with cancer, the latter affection runs its course inde- pendently. A case has been recorded by Moore, in which a pure enchon- droma gave rise to secondary deposits in the lungs by a process analogous to embolism. Osseous Tumors and Outgrowths; Exostosis.— Osseous Tumors are very rare except in connection with bone, and may be defined, in the words of Fig. 212. Fig. 213. irf%# m......... Ivory-like exostoses of the skull. (Miller.) Paget, as exostoses or bony outgrowths, " Avhose base of attachment to the original bone is defined, and groAVS, if at all, at a less rate than its outstanding mass." Osseous tumors consist solely of pure bone; they may arise from the ossification of cartilage, or may be developed, as normal bone, from the periosteum or other fibrous tissue. They are usually solitary, and Avhen multiple are often symmetrical and hereditary. Tavo varieties of bony tumor may be recognized, the cancellous (consisting of a thin layer of compact substance, with cancellated struc- ture and marrow internally), and the compact, hard, or ivory-like, bony tumors, which consist, as their name im- plies, of hard and solid bone. The cancellous tumors usually constitute the ultimate stage of the cartilaginous tumors already described; they are indolent, and when thoroughly ossified rarely grow; they are situated outside of the bones with which they are connected, and in suitable cases may be treated by excision. A favorite locality of this form of bony tumor is the last phalanx of the great toe, where it grows from the Cancellous exostosis, growing from the low- er part of the femur. (Druitt.) GLANDULAR TUMORS. 487 inner margin of the bone, lifting up the nail and causing troublesome ulcera- tion of the skin; it is very seldom that, any but the great toe is affected. The treatment consists in excision, taking care to remove, Avith the groAvth, the bony surface from Avhich it springs. Birkett has recorded a remarkable case of cancellous exostosis of the frontal bone. The ivory-like bony tumors are rare, except in connection Avith the cranial bones (Fig. 213), where they may be small, superficial, and perhaps pedun- culated, or may originate in the diploe or frontal sinus,1 etc., where they may grow both inAvardly and outwardly, in the form of large nodulated masses, involving the orbit, causing protrusion of the eyes and great deformity, and perhaps inducing fatal compression of the brain. For the superficial variety, excision may occasionally be attempted, though the operation is sometimes rendered impossible by the hardness of the tumor. For the deep orbital groAvths, attempts at excision are not to be recommended, but as a cure has sometimes followed necrosis and spontaneous separation of the mass, it may be proper to expose the most prominent part of the tumor, and apply nitric acid or caustic potassa, as recommended by Stanley, in hope of inducing exfoliation. Those exostoses which are not pedunculated, and which, therefore, are properly called Outgrowths (Osteonuda), in contradistinction to osseous tumors, do not, as a rule, admit of removal. A favorite seat of these growths is in the superior maxillary bones, Avhence they may spread to other bones of the face, causing great deformity, or even death, by interference Avith the brain. If limited to the jaw, and to one side, excision of the bone might be properly tried; but if bilateral, or involving neighboring parts, no operation should be attempted, except, perhaps, the application of caustics, as in the frontal and orbital groAvths already referred to. Glandular Tumors.—These, which are also called Adenomata, or Adenoid Tumors, are such as in their structure resemble the normal glands, whether the secreting, lymphatic, or 1 According to Dolbeau and others, many of these ivory-like tumors originate in the mucous membrane of the nasal fossae and other cavities of the face; their attach- ments to suiTOunding parts are then very slight, and their enucleation compara- tively easy. (See a Critical Keview by Kendu, in the Archives Gene'rales de Medicine for August, 1870.) Colignon reports a case in which such a growth was successfully removed by Demarquay from the maxillary sinus. (Gaz. Med. de Paris, Fev. 21,1874.) 488 TUMORS. lobated, and may be flattened by pressure. They have commonly a distinct investing capsule of connective tissue, and are but slightly vascular. On section, they appear of a gray or yellowish-white hue, of variable density and elasticity, and are frequently intermingled Avith cysts. The labial and parotid adenomata may also contain nodules of cartilage or bone. Their growth is extremely variable, and, though usually indolent, glandular tumors, especially of the breast, are occasionally the seat of great pain. They occasionally disappear by absorption: thus a mammary adenoma may be entirely removed Avithout operation, upon the restoration of the sus- pended functions of the mammary gland itself, or of the uterus. The treatment consists in the use of pressure, with the application of sorbe- facients, and, Avhen these fail, in excision, which can usually be readily effected by enucleation. The interstitial injection of alcohol is recommended by Schwalbe, of Weinheim. Lymphoid Tumors.—This name is used by Prof. Turner as equivalent to the Lymphoma of Virchow, "to express those new formations Avhich, in their essential structure, are composed of corpuscles like the round, pale corpuscles that form the characteristic cell-elements of the lymphatic glands." Fig. 215. Lymphoma.—A, a thin section of a lymphomatous tumor of the mediastinum, b, a similar section, from which most of the cells have been removed by pencilling, so as to show the reticulated network, and the nuclei in its angles. This network is much more marked than that often met with. X 200. (Green.) In many cases these lymphoid tumors occur in parts Avhere lymphatic glands are known to exist, but in other instances they have been met Avith as en- tirely independent formations. They are frequently multiple. They have been observed by Virchow in the liver and kidney, by Church in the mes- entery and extra-peritoneal tissue, and by Murchison in all these organs, as well as in the intestine and heart, The treatment recommended by Billroth and Czerny is the use of arsenic both internally and by parenchymatous injection ; excision is occasionally justifiable. Vascular or Erectile Tumors (Angeiomata) are of most frequent occur- rence in the skin and subcutaneous tissue, though they may also be found in any structure which is itself vascular. They are subdivided, according to their structure, into the capillary, arterial, and venous vascular tumors. The arterial variety constitutes the disease knoAvn as Aneurism by Anasto- mosis, while the capillary and venous vascular tumors are what are com- monly designated as Ncevi. The diagnosis and treatment of these affections Avill be considered in the chapter on diseases of the Vascular System. Lymphatic Vascular Tumors, erectile, and usually congenital, have been oc- casionally described. They closely resemble some of the venous vascular tumors, but contain a fluid resembling lymph, instead of blood. Papillary Tumors (Papillomata) resemble in structure the ordinary papillae of the cutaneous and mucous tissues. They occur in the skin where NEURALGIC TUMORS. 489 they form the common cutaneous warts, and some of the so-called horns, met Avith chiefly about the face and head; and in the mucous membranes, Avhere the papillary structures may occur in connection with fibro-cellular groAvths, in the form of mucous polypi, may be scattered over a consider- able extent of surface, giving the part a villous appearance, or may be ag- gregated into distinct tumors: the mucous membranes chiefly affected are those of the larynx, colon, rectum, bladder and urethra. I have seen a well- marked papilloma of the tongue in a boy, the affection being attributed to the patient's habit of smoking stumps of segars which he picked up in the street. According to R. W. Taylor, the Avarty form of lingual ichthyosis is a true papilloma. Finally, papillary groAvths may occur in serous tissues, particularly the arachnoid; the Pacchionian bodies are, according to Von Luschka, merely enlargements of the villi normally existing in this part. The papillary tumors, above referred to, are of a non-malignant character, and must not be confounded with Villous Cancer (see p. 502). The treat- ment of papillomata consists in excision, ligation, or the application of caustics, according to the size and situation of the growth. Neuralgic Tumors.—This is a group embracing such tumors as are, with- out any perceptible reason, the seat of intense neuralgic pain. They are usually fibrous or fibro-cellular in structure, though adipose, fibro-cartilagi- nous, or even glandular tumors may occasionally be similarly affected. The Painful Subcutaneous Tumor or Tubercle, which is the most common of the neuralgic tumors, is usually seen on the limbs, particularly the lower, but occasionally on the face or trunk. It is rarely more than half an inch in Fig. 216. Painful subcutaneous tubercle on the forearm. (Smith.) diameter, has a round shape, and is firm, tense, and elastic. It is usually single, and is much more common in Avomen than in men—in both respects differing from the ordinary neuroma, Avhich is frequently multiple, and is oftenest seen in the male sex. The painful subcutaneous tubercle is an affection of adult life. In many instances, the most careful dissection has failed to show any con- nection betAveen these tumors and nerve fibres, though it is believed by many Avriters that the painful subcutaneous tubercle is really a "true neuroma" (see Chap. XXVIIL), containing an excessive formation of ner- vous elements.1 1 See Labbe and Legros, in Journal de I'Anatomie, de la Physiologie, etc., t. vii. 490 TUMORS. The so-called "irritable tumor of the breast" is properly termed a neu- ralgic tumor, being, indeed, often really a painful subcutaneous tubercle, though occasionally a simple adenoma. The pain in all of these cases is of a paroxysmal character, and is often compared to an electric shock. During the paroxysm, the tumor itself commonly becomes sensitive and swollen. The treatment consists in excision, AA'hich operation may be expected to afford permanent relief. As a palliative measure, circumferential pressure, Avith a ring placed around the tumor, may be occasionally resorted to with advantage. Pulsating Tumors.—These are such as have a pulsation, due to the state of the bloodvessels in the tumor itself, independently of its proximity to a large vessel. The pulsating tumors are the arterial vascular (aneurism by anastomosis), the myeloid, and the encephaloid—the two latter pulsating only when the tumors are partially surrounded by bone. The chief interest per- taining to pulsating tumors is the liability of mistaking them for aneurisms, an error Avhich has occasionally been committed by the most distinguished surgeons. Floating Tumors are tumors felt in the abdomen, which change their place and float away, as it were, under the surgeon's manipulations. They consist in some cases of movable kidneys, but are probably sometimes loosely- attached ovarian cysts, portions of thickened omentum, etc., or even fecal accumulations. Phantom Tumor is the name given to an apparent tumor which vanishes spontaneously, and which usually consists of a partially and spasmodically contracted muscle. In other cases an accumulation of gas, or a thickened or fatty omentum, has been known to simulate an ovarian tumor, and laparotomy has actually been performed under these circumstances. The usual seat of phantom tumors is in the abdomen, though they are occasion- ally seen in other localities. Semi-Malignant or Recurrent Tumors. Recurrent Fibroid Tumors.—It has been remarked, in describing almost each form of non-malignant tumor, that under certain circumstances it may These recurrent tumors differ in gen- eral character from the non-recurrent growths of the same varieties, in being softer and more friable, rather more juicy, and somewhat more glistening MYELOID TUMORS. 491 on section. Under the microscope they exhibit a large proportion of cells, and fewer formed fibres, with large and often free nuclei and nucleoli. Under the name of Fibro-nucleated Tumor, is described by Bennett a group of recurrent tumors very analogous to the recurrent fibroid of Paget, and Avhich, under the microscope, exhibits filaments, with elongated, oval, nucleolated nuclei. The treatment of recurrent tumors consists in excision, which may be re- peated as often as the tumor reappears. A permanent cure is occasionally obtained after repeated removals, though more often the patient ultimately dies from exhaustion caused by the ulceration of the tumor, Avhich commonly returns Avith a shorter interval after each operation. Esmarch is said to have prevented the redevelopment of recurrent tumors by the administration of large doses of iodide of potassium. Myeloid Tumors are such as in their microscopic characters resemble fetal marroAV. The characteristic myeloid cells are round, or irregularly oval, clear, or slightly granular, from two t° -giro °^ an mcn m diameter, and containing from two to ten, or even more, nucleolated nuclei. Beside these, there may be free nuclei, and lance-shaped, caudate, or spindle-shaped Fig. 218. "Giant-celled sarcoma," or myeloid tumor, a points to a part where cysts were being formed by the softening of the tissue of the tumor; b, to a focus of ossification. (Billroth.) (fibro-plastic) cells, Avhence the name sometimes used of Fibro-plastic Tumor, though this is more appropriate to the recurrent fibroid variety. These tumors are rarely found except in the bones, Avhere they usually occur as internal groAvths. When not so situated, they have commonly a firm, fleshy feel, but are occasionally soft and easily broken. On section, they have' a yelloAV or gray, glistening appearance, marked Avith spots of redness, Avhich do not seem to depend upon their vascularity. They not unfrequently contain cysts, and are often partially ossified. Myeloid tumors commonly originate in early adult life, and are usually single, of sIoav growth, and indolent: the surrounding structures are, as a rule, healthy, though per- haps greatly distended and displaced. The diagnosis from purely non-malignant tumors of bone is rarely possible before operation: Avhen seated on the surface of a jaw (almost the only 492 TUMORS. locality in which it occurs externally), a myeloid may perhaps be distin- guished from a fibrous tumor by its greater softness and elasticity. The treatment consists in excision (with the surface of bone from Avhich it groAvs), or, in the long bones, in amputation at a higher point;1 as a rule, recurrence is not as much to be feared as Avith the other tumors of this class, provided that early extirpation has been resorted to. Secondary myeloid tumors have, hoAvever, occasionally been met with in the lymphatic glands and in the lungs. Those tumors which present calcareous or osseous nodules are considered by S. W. Gross to be more malignant than others, and he suggests that the mineral salts contained in these nodules may act as car- riers of the infecting material which produces the secondary groAvths. Sarcoma.—This term is used by Virchow and other German pathologists to designate a group of tumors which possess an analogy " not only Avith granulations, but also with true flesh of recent formation, or in process of Fig. 219. development." (Virchow, Path, des Tumeurs, trad, par Aronssohn, t. ii., p. 183.) Connective-tissue tumors " become, under certain circumstances, richer in cells, and enlarge, Avhilst their interstitial connective tissue becomes more succulent, nay, in many cases disappears so completely, that at last scarcely anything but cellular elements remain. This is the kind of tumor Avhich . . . . ought to be designated by the old name of sarcoma." (Virchow, Cellular Pathology, Chance's edit., p. 486.) The following are Virchow's subdivisions of sarcomata, according to their cellular structure:— (a) Reticulo-cellular Sarcoma; like the typical connective-tissue (fibro- cellular) tumor, but with a larger proportion of cells. (b) Spindle-celled Sarcoma; containing fusiform or fibro-plastic cells; cor- responds with fibro-plastic, recurrent fibroid, and fibro-nuckated tumors. 1 Successful cases of excision of the lower ends of the ulna and radius for myeloid tumors of those parts have been reported by Lucas and Morris. SARCOMA. 493 Cells often arranged in lamellae, bundles, or trabecular (lamellar, fasciculate, and trabecular sarcomata). (c) Globo-cellular or Round-celled Sarcoma; often mistaken for medul- lary cancer, but can be distinguished by observing that the cells of the sarcoma are in constant relation with the intercellular substance, whereas the cancer cells are intimately connected Avith other cells alone. Glioma is a variety of round-celled sarcoma, originating in the neuroglia or delicate connective tissue of the brain, auditory nerve, or retina. Under the microscope, the tumor is found to consist of round or oval, and some- times caudate or stellate, corpuscles, with a greater or less amount of a faintly fibrillated stroma. These tumors occur in the outer layers of the retina, in very young children, and, as they grow, cause increased intra- ocular tension. They may prove fatal by extending backwards Avithin the cranium. Complete and early extirpation of the eyeball is the only treat- ment to be recommended, though even this will not ahvays prove successful. (d) Colossal or Gigantic-celled Sarcoma; contains very large cells, Avith numerous nucleolated nuclei; corresponds with the myeloid or myeloplaxic tumor. Billroth also describes an alveolar sarcoma, in which the cells are grouped in alveoli, the microscopic appearances of the groAvth thus closely resembling Alveolar sarcoma. (Billroth.) those of carcinoma; and a pigmentary or melanotic sarcoma, in which the cells contain pigment matter. If in portions of a sarcoma the process of cell-development is so rapidly carried on that no intercellular substance is formed, those portions become cancerous, and a mixed variety of tumor results, which might properly be called Carcinomatous Sarcoma. The Intercellular substance in sarcomata usually contains albumen, casein, or mucin (Avhence another subdivision might be made into albuminous, case- ous, and mucous sarcomata), and, under the microscope, appears homogeneous, granular, or fibrillar. Finally, sarcomata are distinguished by the vascularity upon which depends their characteristic succulence. They are often the seat of parenchymatous extravasations, these "hemorrhagic infarctus" sometimes giving rise to new productions of pigment matter. The treatment of the sarcoma consists in excision, but the groAvth almost invariably recurs, and ultimately leads to a 494 TUMORS. fatal termination. For further information upon the subject of sarcomata, the reader is referred to the nineteenth lecture of Virchow's Avork on Tumors, from which this account has been principally taken. Malignant Tumors. The division of tumors into malignant and non-malignant is, as has been already observed, not perfectly satisfactory; for some of those Avhich, from their structure, Ave should class as benignant groAvths, are in their clinical characters almost, if not quite, as malignant as some of those to Avhich Ave apply the latter name. A Recurrent Fibroid may, for instance, run a more malignant course than an Epithelioma. The term Malignant Tumor is used by Paget, Moore, Pemberton, and other Avriters, as synonymous Avith Cancer, and Epithelioma is by them considered to be merely a variety of cancerous disease. It is, hoAvever, upon the whole, better, I think, to separate epithe- lioma from cancer or carcinoma (from which, indeed, it differs in a good many points), though its clinical characters are such as to make it convenient to retain it among malignant tumors. Cancer or Carcinoma.—There are two principal forms of cancer, the hard or schirrous, and the soft or medullary—the terms melanoid, hcematoid, etc., being applicable to varieties of these, rather than to distinct and independent forms of cancer. Hard and soft cancer may coexist in the same patient, and even in the same tumor; but they are not interchangeable—that is to say, a mass of scirrhous tissue never becomes medullary, nor vice versa. 1. Scirrhus, or Scirrhous Cancer, is the most common form of cancer, and is more frequenly seen in the female breast than in any other locality, though it also occurs in lymphatic glands, skin, muscle, and bone; in the tongue, tonsils, intestinal canal, lungs, liver, eye, testis, ovary, uterus, etc. Scirrhus is more frequent in women than in men, and occurs more often in persons between forty-five and fifty years of age, than at any other period of life; it is rarely if ever seen in childhood. It is usually supposed that the develop- ment of scirrhous cancer is in some Avay connected with the cessation of the menstrual flow, but statistics do not support such a view. Scirrhus is sometimes predisposed to by inheritance, and its development is sometimes directly traceable to the reception of an injury, or other local cause. It ap- pears to be proportionally more common among married than among single women. Scirrhus usually occurs in persons who are otherwise healthy, and is at first unattended with much pain; so that it may frequently exist for some time before its presence is discovered. Course.—Scirrhus originates as a small nodule, and grows Avith very vari- able rapidity in different patients, or even at different times in the same patient. Scirrhus is infiltrated1 among the tissues in Avhich it occurs, and increases in size by gradually involving the surrounding structure. Even Avhen to the naked eye, and to the touch, the parts around a scirrhous tumor appear quite healthy, the microscope may reveal the presence of cancer ele- ments, so that scirrhus is said to be often surrounded Avith a halo of cancerous matter. In its first stage, a scirrhous tumor is, as has been said, very small; indeed, 1 Cullingworth has, however, reported a remarkable case of mammary scirrhus which was completely surrounded by a distinct fibrous capsule. A case of encapsu- lated scirrhus has also been recorded by Wheeler, of Dublin. SCIRRHUS, OR SCIRRHOUS CANCER. 495 it sometimes renders the part in which it occurs smaller than normal, by inducing contraction of the neighboring tissue. Even in its earliest stage, hoAvever, scirrhus has usually its characteristic hardness, a peculiarity Avhich is so marked as to have given the disease its name. As a scirrhous tumor Fig. 2-21. Fig. 222. touch, the pain in the tumor Scirrhus of breast( in stage of ulceradon (From a patient is aggravated by handling, at Episcopal Hospital.) As the scirrhous mass in its groAvth approaches the skin, the latter becomes adherent, the shortening of various subcutaneous fibres giving a dimpled or pitted, somewhat brawny or lardaccous, appearance to the part, and, in the case of the breast, inducing retraction of the nipple. After a time, ulceration occurs, either (1) super- ficially, Avhen the adherent skin, having become infiltrated and congested, becomes excoriated or cracked, a small, superficial, indolent ulcer resulting; or (2) as the result of disintegration of the cancerous tissue at a deeper point, Avhen a yellowish-gray mass, consisting of cancerous debris with ill-formed pus, works its Avay, abscess-like, to the surface, and is evacuated, leaving an excavated ulcer, Avhich constantly enlarges as the cancer itself groAvs, and continues to discharge an ichorous and offensive fluid, which often excoriates the neighboring parts. The latter form of ulceration has certain features, such as elevated, knobbed, and everted edges, a hard and nodular base, can- cerous Avails, and a peculiarly offensive discharge, Avhich, when combined, serve to characterize the so-called Cancerous Ulcer. The ulceration of a scirrhous tumor may persist for a long time, and even cicatrization may occasionally occur, the cicatrix being thin, red or livid, with an irregular surface, and much disposed to reulcerate. More commonly the ulcer, as has been said, constantly enlarges, though not so rapidly as the cancer itself; considerable portions of the tumor may become, from time to time, inflamed, and slough, and hemorrhage may occur from the fungous granulations, or from the ulceration in\rading neighboring vessels, until finally the patient dies exhausted by the profuse and fetid discharge, pain, and loss of blood. Scirrhus (Avhich is at first usually solitary) not only groAvs in the locality 496 TUMORS. Fig. 223. in which it first occurs, but becomes diffused, by multiplication, in other parts of the body.1 The most frequent seat of secondary deposits is unquestion- ably the lymphatic vessels and glands in the neighborhood of the original tumor; next, in the tissues around, but not immediately connected with, the point of original disease; and lastly, in distant organs, especially the liver, lungs, and bones. T. W. Xunn believes that in cases of multiple cancer the disease has originated in the superficial lymphatic plexus, or netAvork, described by modern anatomists, and hence applies to such cases the name of " lymphatic cancer." It is occasionally possible to trace the occurrence of secondary cancerous deposits to a process analogous to embolism, but more often the effect only is seen, without the mode of its production being recog- nizable. According to Cohnheim and Maas, embolic transference of fragments of malignant and other tumors is constantly going on in patients thus affected, but the embola do not persist and form neAV growths except in particular states of the con- stitution ; the disease thus remaining a local affection until some deterioration of the patient's health permits the development of secondary groAvths. Colomiatti believes that cancer some- times spreads along the nerves of a part before the lymphatics become affected. When any of the important internal viscera are affected by secondary cancerous deposits, a marked state of constitutional depression is often produced, which has received the name of Cancerous Cachexia; the older writers, in- deed, looked upon this cachexia as a condition peculiar to cancer, and described it as occur- ring in almost every case of the disease. Sir Charles Bell's vivid picture is that usually referred to, and the continued emaciation, leaden hue of countenance, pinched features, and livid lips and nostrils, of which he speaks, are undoubtedly seen in cases of scirrhus, but probably not more often than in other exhausting and painful diseases; in fact, Avhile cases of external cancer often run on to a fatal termination without the development of any cachexia Avhatever, the cachectic state which accompanies internal cancer is not, in itself, distinguishable from that seen in cases of visceral disease of a non-cancerous nature. To complete the natural history of scirrhus, its duration must be briefly referred to: a few cases last ten or twelve years, or even longer, and, the tumor ceasing to grow, and perhaps cicatrizing if ulcerated, the patient may at last die from some other cause. I have myself operated upon persons in whom the disease had lasted six and eight years. The large majority, how- ever f about three-fourths), of patients Avith scirrhous tumors, die Avithin four years from the time Avhen the growth is first discovered, and the expectation of life, as far as figures bear upon the subject, may be said to be about two years and half—as many dying before as after that period. The earlier the age at which scirrhus appears, the more rapid, usually, is its course. Morbid Anatomy.—When a scirrhous tumor, in its early stage, is cut Secondary growths of scirrhus ler.) (Mil- 1 It is often said that the secondary growths in cases of scirrhus are of an encephaloid nature, and such is occasionally the fact; in most instances, however, the secondary tumors are, as stated in the text, of the same character as the primary growths. SCIRRHUS, OR SCIRRHOUS CANCER. 497 into, it is found very hard and resisting, and the growth creaks, as it is said, under the knife. When laid open, both the cut surfaces are usually found to be concave, a very significant feature, and one which, when present, is eminently characteristic of scirrhus. The section is smooth and someAvhat glistening, bleeds rather freely at first, is of a pale grayish-Avhite hue, some- times with a slight purple tint, and is often marked Avith white or yellow lines and spots. The tumor appears evenly tough and resisting in all direc- tions, and has no distinct margin, being evidently infiltrated into the normal structures of the part. By scraping or pressing the tumor, a grayish-white, gruel-like fluid can usually be obtained, which is diffusible in water, and contains cancerous matter, mingled with the softened tissue of the part, and Avith the exuded contents of the neighboring vessels; this constitutes the so-called cancer-juice, the denser structure which remains being called the stroma. Under the microscope, the cancer-elements may often be seen to be clearly infiltrated among the interstices of the normal tissues of the part. The can- cer-elements themselves consist of two parts, viz., a pellucid, dimly granular, or fibrillar basis-substance, and somewhat cloudy cells, of variable size— usually round or oval, but sometimes angular, caudate, fusiform, lanceolate, etc.—commonly containing one, but often two, large nuclei, and occasionally Fig. 224. Fig. 225. Cells from a scirrhus of the mamma. Microscopic appearance of scirrhus. X 250. (Green.) (Green.) still more—and frequently mingled with a certain number of free nuclei. The nuclei themselves contain one, two, or even more nucleoli, which are large, bright, and well defined. The size of the scirrhus-cell varies from 161o0 to jjn> of an inch in diameter, the most usual size being about yruir or tttW of an inch; the average length of the nucleus is about jttu oi" an inch. It is thus seen that there is no distinctive cancer-cell; the nature of the groAvth is to be recognized by the great multiplicity of forms seen in the same specimen, and by the fact that the cells are closely packed together in groups, Avithout the intervention of any recognizable intercellular substance. Beside these, which may be regarded as the normal elements of scirrhous cancer, cells are often seen which are withered, or in various stages of degen- eration ; the cells may be shrivelled, containing oil globules and granular matter, or may be completely disintegrated, the nuclei being set free, and ap- pearing to be mingled with granular matter and molecular debris. In addition to the cancerous elements themselves, a scirrhous tumor shows, under the microscope, various structures, glandular, muscular, fibrous, areolar, etc., which belong to the tissues in AAThich the cancer happens to be groAving, and Avhich are present in varying quantities, being least apparent Avhen the cancer-structure itself is most abundant. The anatomical characters of scirrhus, Avhen occurring as a secondary de- posit, as, for instance, in the lymphatic glands, do not differ in any essential respect from those above described. The surface, however, does not com- 32 498 TUMORS. monly become concave on section, nor are the Avhite fibrous lines so Avell marked as in the primary tumor. Scirrhus, in some cases, appears as a spreading, comparatively superficial affection, rather than as a tumor: it is thus met with on the surface of the thorax, sometimes originating in the skin itself, at other times in the mam- mary gland, or as tubercles in the deeper planes of tissue, but always at last involving both superficial and deep structures, and surrounding the chest Avith a mass of cancer, appropriately called, by the French, cancer " en cuirasse." The course of this form of scirrhus is often extremely chronic, patients living in this condition for over twenty years, in spite of the pain and occasional hemorrhages which attend the disease Avhen ulceration is present; partial cica- trization even sometimes occurs, giving the part somewhat the appearance of a serpiginous chancroid. Under the name of Acute Scirrhus, many writers describe a form of the disease in which the tumor is less hard and more elastic than in ordinary scirrhus, does not appear concave on section, is more succulent, has usually smaller cells, grows more rapidly, and altogether runs, as the name implies, a quicker course than the average. Acute scirrhus occurs at a comparatively early age, and forms to a certain extent a connecting link with medullary cancer. Fig. 226. 2. Medullary or Soft Cancer (Encephaloid) is so called from its often presenting a brain-like appearance when laid open. It occurs in the uterus and other internal organs, in the testis, eye, bones, intermuscular spaces, mammary gland, lymphatics, etc. It is rather more frequent in women than in men (though less markedly so than is the case with scirrhus), and may occur at any age, more than one-fourth of the whole number of cases of ex- ternal medullary cancer being met with in persons under twenty, and nearly two-thirds in those under forty. The influence of inheritance is about as well marked in medullary as in scirrhous cancer, while the proportion of cases in which previous injury is supposed to act as an exciting cause is nearly twice as great. The victims of encephaloid are less often in robust health, before the appearance of the disease, than are those affected Avith scirrhus. Course.—Medullary cancer appears as a solitary growth, except in the sub- cutaneous tissue, where it is often mul- tiple. I had under my charge in the wards of the Episcopal Hospital, some years since, a man fifty-one years old, who, beside a large encephaloid tumor of the left shoulder, had smaller masses of the same kind upon the neck, chest, abdomen, back, arms, and thighs. The growth of medullary cancer is commonly very rapid, sometimes, according to Paget, exceeding a pound per month. On the other hand, cases are occasionally met with in which the growth of medullary cancer is spontaneously arrested, the tumor re- maining without change for a number of years. Medullary cancer may occur, like scirrhus, as an ill-defined infiltration, or as a distinct tumor in- Medullary cancer in stage of ulceration ; tumor protruding. (Druitt.) MEDULLARY OR SOFT CANCER. 499 vested by a tolerably complete capsule. It has no tendency to draw in adjacent parts, as scirrhus does, but distends and displaces them. The skin over a medullary cancer becomes thin and tense, and finally gives way, just as it would in the case of any other rapidly-growing tumor, so that the ulceration over a mass of encephaloid presents none of the peculiar charac- ters Avhich have been described as belonging to the " cancerous ulcer." When ulceration has occurred, however, the cancer, being freed from the restraining pressure of the skin, appears to grow with increased rapidity, and soon pro- trudes through the opening—the exuberant mass usually becoming inflamed, sloughing, and bleeding, and constituting the bleeding fungus, or Fungus Hcematodes, of the older writers. Medullary cancer occurring in bone is sometimes attended with a distinct pulsation (see p. 490). The course of medullary cancer is commonly towards an early death, but occasionally—even after ulceration—large masses of encephaloid matter may slough away, cicatrization folloAving, and thus leading to at least a temporary recovery. Medullary cancers sometimes wither, becoming shrivelled and concentrated, and finally temporarily disappearing; in other cases they un- dergo fatty degeneration, ceasing to grow, and becoming " obsolete." Usually, hoAvever, while this change occurs in one tumor, others continue to increase. Calcareous degeneration is a rare occurrence, and, when seen, is usually com- bined with the fatty change above referred to. The occurrence of hemor- rhage and of sloughing in medullary cancer has been already mentioned. More rarely, inflammation of such a growth ends in suppuration, and in this way, too, temporary disappearance of the tumor may be effected. Medullary, like scirrhous, cancer tends to multiplication in various parts of the body, and there is reason to believe that, in many cases, fragments of the primary growth are detached and carried by the general circulation to re- mote organs, where they lodge and grow as independent centres of disease. The pain of medullary cancer is usually much less than that of scirrhus; indeed, when pain is observed, it appears to be referable to the organ affected, rather than to the diseased mass itself. The general health fails in many cases of medullary cancer more rapidly than can be accounted for by the amount of disease. The cachexia thus caused does not appear, however, to be of any specific constitutional nature, for it often rapidly disappears when the morbid growth is removed, the patient quickly regaining flesh and strength. The average duration of medullary cancer is decidedly less than that of scirrhus, more than three-fourths of those affected dying within three years, and the expectation of life being, in general terms, not more than a year and a half. Morbid Anatomy.—Medullary or soft cancer is, as its name implies, com- monly a soft, compressible tumor, giving a deceptive feeling of fluctuation, though it is sometimes comparatively firm and elastic, approximating in character to the acute variety of scirrhus. The tumor has a rounded or oval outline, but is often markedly lobated, the lobes extending through muscular, fibrous, or bony interspaces, to a considerable distance from the position of the principal mass. These outlying projections are apt to acquire deep at- tachments, or may surround and inclose important structures, such as the carotid artery, jugular vein, or phrenic nerve. The superficial veins, over a soft cancer, are usually enlarged and tortuous. When a medullary cancer is surrounded with a capsule, the latter, which is of thin connective tissue, often sends in septa, which may separate the lobes of the tumor, or, if it be not lobated, merely traverse its substance. The capsule is vascular, tense, and may or may not be adherent to surrounding structures. AVhen cut into, the contained tumor protrudes, or, if very soft, oozes out like a thick fluid. When laid open, a medullary cancer has com- 500 TUMORS. Fig. 227. Microscopic appearances of medullary cancer. (Green.) monly a lobated appearance, the various lobes, with their investing septa, being often distorted by mutual compression, and having the appearance of a mass of cysts filled with intra-cystic growths. The substance of a medullary cancer varies in color, being usually grayish-white, but sometimes tinted with yellow, pink, or violet. In the softer tumors, it has but little consist- ency, being friable or pulpy, like softened brain-matter, or grumous and shreddy; Avhile in the firmer varieties, it is compact and resisting, is some- what glistening on section, and occasionally presents a fibrous appearance. By pressing or scraping a medullary cancer, a considerable quantity of a turbid, creamy "cancer-juice" is obtained, which is readily diffusible in water—the "stroma" which remains be- ing in comparatively small amount, and appearing filamentous, spongy, and quite vascular. The structure of the infiltrated form of medullary cancer does not differ essentially from that above described. The microscopic appearances of ence- phaloid are even more variable than those of scirrhous cancer. The normal or typical form of the medullary cancer corpuscle is a nucleated cell, closely resembling that seen in scirrhus, but differing in its mode of arrangement—the cells in ence- phaloid being not closely packed to- gether, but loosely aggregated in a com- paratively soft or fluid basis-substance. The following are among the chief varia- tions observed in the corpuscular structure of medullary cancers: (1) there may be free nuclei, with few or no cells, scattered through a nebulous or granular basis-substance: the nuclei are usually oval, 251oo f° 2 61oo 0I> an inch long, bright, well defined, and containing large and often double nu- cleoli; (2) large elongated or caudate nuclei, containing granular matter, or one or more large nucleoli; (3) large round or oval nuclei, resembling lymph corpuscles, and containing numerous shining granules, but no dis- tinct nucleoli; (4) very numerous elongated and caudated cancer cells, re- sembling the cells of the recurrent fibroid tumor, and giving the mass a fibrous appearance on section; (5) large round cells, containing granules, and either no perceptible nucleus, or one which is smaller and more granular than that of the ordinary cancer cell; and (6) multi-nucleated cells, or parent cells containing numerous smaller cells. These various forms of cancer corpuscle may simply float in a turbid liquid, which is sometimes called "cancer-serum;" in other cases, this liquid is itself diffused through the interspaces of a spongy basis-substance, Avhich may be homogeneous, may present imbedded nuclei, or may have a fibrillated appearance; Avhile in other cases, again, there may be a distinct framework, or skeleton, of delicate filamentous, fibro-cellular, fibrous, or even osseous structure. Still further variations in appearance are caused by the occurrence of fatty degeneration, giving rise to yelloAV, scrofulous-looking masses, or by the intermingling of cartilaginous, cystic, or other morbid growths. 3. Other Varieties of Cancer.—Of the other forms of cancer mentioned in the classification on page 473 I shall say but little, as they are compara- tively rare, and are indeed probably but modifications of those already described. Melanoid or Melanotic Cancer is medullary cancer, with the super-addition HJEMATOID CANCER. 501 of black pigment in the elemental structure of the growth; it bears the same relation to ordinary encephaloid that the pigment or melanotic sarcoma does to the other varieties of that group of tumors (p. 493), or that melanoid does to ordinary epithelioma. Melanotic cancer usually occurs as a sepa- rable mass, rather than as an infiltration, and its favorite localities are the skin and subcutaneous tissue. The pigment is commonly in the form of granules or molecules, but may occur in larger nucleus-like corpuscles; it Fig. 228. corresponds with the normal pigment of the choroid coat of the eye, with that of the rete mucosum in the black races, and with that found in the lungs and bronchial glands of old people. The course and natural history of melanotic cancer are very much those of encephaloid; it has, however, a still greater tendency to spread, by multiplication, in the subcutaneous Fig. 229. Hsematoid cancer of breast. (Miller.) tissue, as Avell as to involve internal organs. It is peculiarly apt to grow beneath pigmentary cutaneous moles. Hivmatoid Cancer is simply cancer (usually medullary) which contains clots of blood, the result of interstitial hemorrhage; when protruding through ulcerated skin, it constitutes the Fungus Hcematodes of Hey, War- drop, and others (Fig. 229). 502 TUMORS. Osteoid Cancer.—" I believe," says Paget, " the most probable view of the nature of osteoid cancers Avould be expressed by calling them ossified fibrous or medullary cancers, and by regarding them as illustrating a calcareous or osseous degeneration." Osteoid cancer usually occurs in bone (particularly in the loAver part of the femur), but is also seen in the intermuscular spaces, the lymphatic glands, etc. When met Avith in bone, it may occupy either the interior or exterior, or both, and has usually an elongated oval or bi-convex shape, according to the nature of the bone in which it occurs; it has a smooth surface, is hard, nearly incompressible, painful, and often tender when touched. The bony part of the tumor is; as it were, infiltrated into that part Avhich is unossified, and differs from ordinary bone in being chalk-like and pulverulent, in hav- ing small and irregular bone corpuscles, in containing no medulla (its inter- spaces being filled Avith cancer-matter), and in having an undue proportion of phosphate of lime. It is extremely compact in its central portions, and nodulated at its periphery, the nodules being often formed of closely-set lamellae, with edges directed outwards. The unossified part of the tumor is very hard, tough, and incompressible, and, under the microscope, appears homogeneous (abundant nuclei being made apparent by the addition of acetic acid), or may present fibres of various sizes, and variously arranged, mingled Avith ordinary cancer cells, granule-masses, and oil globules. Osteoid differs from other forms of cancer in being most frequent in the male sex, and in persons under thirty years of age; its development is often traceable to a previous injury. The course of osteoid cancer is rapid and painful, with multiplication in lymphatics and in distant parts, and early occurrence of constitutional disturbance or cachexia. Death usually occurs within the first year of the disease; but two instances are mentioned by Paget in which, after removal of the primary growth, life was prolonged for twenty-four and twenty-five years, respectively. When early death oc- curs, it is due to the development of secondary growths, which are sometimes of the nature of ordinary medullary cancer. Villous Cancer.—Under this name have been included many innocent growths which have a villous or papillary structure (see page 489), as well as a villous or warty form of epithelioma. The term villous cancer may still, however, according to Paget, be properly used for certain growths, met with chiefly in the urinary bladder, which have a stroma presenting what Rokitansky calls dentritic vegetation, the interstices being filled with the ordinary cell-forms of medullary cancer. Colloid, or, as it is also called, Alveolar or Gum Cancer, occurs as a pri- mary affection, chiefly in the alimentary canal, uterus, mammary gland, and peritoneum. It is also met with, as a secondary growth, in the lymphatic glands, lungs, and other parts of the body. Colloid cancer consists of a stroma of more or less delicate white fibrous tissue, forming alveoli or cysts of various sizes, AA'hich contain the colloid matter. The fibres of this stroma, under the microscope, often exhibit elongated nuclei, and sometimes elastic fibres are mingled with them. The colloid substance itself generally appears structureless, but contains corpuscles, consisting (according to Lebert, as quoted by Paget) of (1) cells, free, inclosed in mother-cells, or grouped like an epithelium—these small cells (-^Vff to 20106 of an inch in diameter) being granular, of irregular shape, and containing small nuclei, if any—they are probably ill-formed cancer cells; (2) large oval, round, or tubular mother- cells, ^-5- to ^j-g of an inch in diameter, sometimes with a lamellar surface, and containing one or more nuclei, Avith granules, and sometimes complete nucleated cells; and (3) large laminated spaces, y^-g- to ■£$ of an inch in diameter, with elongated nuclei between the lamellae of their walls, small NATURE OF CANCER. 503 nucleated cells and nuclei in their interspaces, and brood-cells in their internal cavities. The diversity in structure between colloid and other cancers is attributed by Paget, and, apparently, with good reason, to the occurrence of colloid cystic disease in ordinary encephaloid groAvths. Colloid cancer occurs as an infiltration, and sometimes attains an enor- Fig. 230. Colloid cancer. Showing the large alveoli, within which is contained the gelatinous colloid material. X 300. (Rindfleisch.) mous size, particularly in the peritoneum. Its course is much the same as, though rather slower than, that of medullary cancer. Fibrous Cancer is the name adopted by Paget, in the last edition of his classical lectures on Surgical Pathology, for those rare cases of fibrous tumor which run a malignant course, and which have already been referred to under the name of Malignant Fibroid (p. 484). Nature of Cancer.—I do not purpose to enter into any discussion as to the Nature and General Pathology of Cancer, but would refer the reader for information upon these topics to Sir James Paget's lectures, and to Mr. Moore's essay in Holmes's System of Surgery, where will be found very fully and ably set forth the facts and arguments which bear upon the subject.1 Mr. Moore, as is well known, was a prominent advocate of the " local ori- gin" theory of cancer, while Sir James Paget, after mature consideration of the AA'hole subject, adheres to the doctrine of a cancerous diathesis. That a local cause, traumatic or otherwise, can, without any previous predisposition on the patient's part, give rise to the formation of a cancer, it is hard to believe; at the same time, cancer may undoubtedly (from a practical point of view) be looked upon as, at first, a local affection—its early manifestations being of a local nature, and the only applicable treatment being of a topical character; even when "cachexia" precedes the appearance of a cancerous tumor, the removal of the latter may relieve, at least temporarily, the cachectic condition. With regard to the anatomical origin of cancer, the prevailing vieAvs are: (1) that of VirchoAV, who believes that the cancer-cells 1 See also the works of Virchow, Billroth, and Kindfleisch, Dr. J. J. Woodward's "Toner Lecture" (1873), and an interesting paper on the Development of Cancer, published by Waldeyer in Virchow's Archiv, and analyzed in the Archives Gene'rales dc Mrdec.ine for October, 1873. 504 TUMORS. originate in a transformation of connective-tissue corpuscles; (2) that of Thiersch and Waldeyer, who maintain, on the other hand, that cancer can only originate in tissue of an epithelial type; (3) that of Maier, of Frei- burg, who holds an intermediate opinion, believing that fibrous growths may be transferred into sarcomata, and these in turn into true cancers ;x (4) that of Koester, who believes that the cancer-cells are derived from the endothe- lium of the lymphatics; and (5) that of Classen, Woodward, and Thin, who regard them as altered white blood corpuscles which have migrated from the bloodvessels in the manner described by Cohnheim. While none of these vieAvs can be considered as positively established, the second and fifth are those which seem to have found most favor with modern pathologists. Diagnosis of Cancer.—The diagnosis of cancer, whether scirrhus or en- cephaloid, can commonly be made by carefully observing the symptoms, physical and rational, which have been described, and by comparing these, and the history of the case, with those of the various forms of non-malignant tumor—thus arriving at a correct result by a process of exclusion. Scirrhus is most apt to be confounded Avith a fibrous or glandular tumor, and with the induration resulting from chronic inflammation ; encephaloid, with a fatty, cystic, or vascular tumor, with chronic or cold abscess, and (when pulsating) with aneurism. In many cases, microscopic examination after removal can alone be relied upon to establish the diagnosis, and even this will not always afford certain information as to the innocence or malignancy of the tumor. Prognosis.—The prognosis of cancer is always unfavorable: in the very large majority, if not in all cases, the disease will terminate in death in spite of treatment, which, however, will often serve to prolong life, and to render the condition of the patient comparatively comfortable—and death, aa hen it does occur, comparatively painless—and may even postpone the fatal termi- nation indefinitely, the patient dying, without return of the disease, from some intercurrent affection. Treatment of Cancer.—The General Treatment of cancer consists in the adoption of such measures as may be required to maintain the general health. The diet should be mild but nutritious, and the patient should be placed in the best possible hygienic conditions. Tonics, and especially cod- liver oil and iron, may be advantageously administered, the latter, according to Mr. Moore, preferably in combination with chlorine. Arsenic has been very favorably spoken of by Esmarch, Tholen, Parker, of New York, and W. L. Atlee, of this city, and silica has been recommended by Mr. FaAvcett Battye, of London. Chian turpentine has recently been vaunted as a remedy for cancer, but the evidence in its favor is at least open to question. Ano- dynes are of great service, particularly in the later stages of cancer, when the greatest comfort may be often afforded to the patient by the repeated use of hypodermic injections of morphia. The pain of inflamed cancer is, according to Paget, often due to coincident gout, and may be relieved by the administration of dilute liquor potassse, a favorite remedy of Brodie's in these cases. The Local Treatment may be palliative, or may aim at eradication of the disease. As a palliative measure, the part should be protected from external irritation by being covered with a layer of cotton-wadding, or with a soft 1 According to Maier and Creighton, the essence of cancer consists in its property of infecting the neighboring tissues; thus a growth which, while confined to a glan- dular organ, and retaining in structure and function the type of the normal tissue, is an adenoma, becomes cancerous as soon as it infects the adjoining tissues. TREATMENT OF CANCER. 505 and Avell-fitting plaster, which may be medicated with opium, belladonna, or any other anodyne that may seem appropriate; the application of a freezing mixture, as recommended by Arnott, may occasionally serve to retard the progress of the disease. When ulceration is present, the part should be kept clean, and may be dressed with a solution of the permanganate of potassium, of chloral, or of carbolic or acetic acid; the injection of the latter acid into the cancerous mass itself has been advised by Broadbent, under the impres- sion that it might dissolve the cancer-cells, but the plan has not been found generally useful. The injection of alcohol is recommended by Schwalbe and Hasse. If hemorrhage occur from the ulcerated surface, it may be checked by the use of the persulphate of iron. Compression, by means of gum-elastic pads or other contrivances, has been extensively used by Reca- mier and others, and appears to be sometimes effective in controlling pain, though it is extremely doubtful if it have any really curative influence. The same may be said Avith regard to the use of electricity, which has lately excited a good deal of attention as a remedy in these cases. The Radical Treatment of cancer consists in removal of the morbid growth, by the use of the knife, or by the application of caustics. Caustics are only to be recommended in cases of ulcerated cancer, in which, from the superficial extent of the disease, or from its locality, the operation of excision is contra- indicated. Various substances have been used as cauterizing agents, such as arsenious, nitric, or sulphuric acid, the caustic alkalies (especially the " Vienna paste," or potassa cum cake), and mineral salts, of Avhich the best is probably the chloride of zinc. This may be diluted Avith four or five parts of flour, and made into a paste with water ( Canquoin's paste), being then laid upon the denuded surface, and allowed to remain from six to tAventy-four hours, according to the intensity of the effect desired to be pro- duced ; a slough having been formed, this may be deeply incised, and the caustic reapplied. Another mode of using the chloride of zinc is by intro- ducing the caustic, in the form of arrows, concentrically around the circum- ference of the tumor (cauterisation en fleches), as recommended by Maison- neuve—or a caustic solution maybe hypodermically injected, as recommended by Sir J. Y. Simpson, and more recently by Richet. Delahousse has employed the actual cautery as a modification of Maisonneuve's method. Excision (or amputation, if this operation be from the position of the cancer considered preferable) is the mode of treatment to be chosen in any case in which it is practicable. The propriety of resorting to excision, in suitable cases of cancer, is shoAvn by the folloAving circumstances: (1) it is at least possible, if unlikely, that a permanent cure may be obtained ; (2) if the dis- ease return, it Avill probably run a more chronic, or, at any rate, a not more acute course, than if the cancer had not been removed; (3) the average duration of life is shown by statistics to be increased by operation, from one to tAvo years in the case of scirrhus, and from four months to a year in the case of encephaloid; (4) there is reason to hope that if the disease return after operation, it may do so in some internal organ, Avhen its course and termination will be comparatively painless; and (5) even if the recurrence of the cancer be inevitable, a temporary interval of comfort and usefulness Avill have been secured to the patient—an interval which in favorable cases may extend to several years. The propriety or impropriety of operating in any particular case depends much upon the locality of the cancer, and the age, general condition, etc., of the patient. But in general terms it may be said that, in the case of a primary groAvth, an operation is called for, provided that the entire mass of diseased structure can be safely removed. Adhesion to either the skin or subjacent structures, ulceration, or even moderate lymphatic complication, though un- 506 TUMORS. favorable features, are not in themselves contra-indications. If, however, the disease be so extensive that the probability of its being thoroughly extirpated is doubtful, if there be multiple tumors, if the skin be widely infiltrated, or if the deep-seated lymphatic glands, or internal viscera, be evidently involved, the operation can rarely be deemed justifiable. Sciatic pain is regarded by DeMorgan as strongly significant of general contamination of the system, and in the case of melanotic growths, visceral implication may, according to Nepveu, be recognized by the discovery of pigment matter in the blood and urine. If, from the age of the patient, the size or locality of the tumor, or any other circumstance, the operation should be in itself likely to be attended with unusual danger, excision should not as a rule be practised—the prospec- tive benefits, in such a case, being insufficient to counterbalance the risks of treatment. Operations for rapidly growing cancers are less likely to be attended with benefit than when the disease is chronic, but such cases are precisely those in Avhich operative interference is most urgently demanded. Cases of very chronic and indolent, atrophic cancer, as it is sometimes called, may, indeed, do better occasionally without operation; but these cases should be constantly watched, and the tumor should be removed on the first mani- festation of active growth. In all other cases, if an excision is to be done at all, it should be done as early as possible; not only is the operation in itself thus less dangerous, but the chances Fig. 231. of permanent benefit are much greater than if the operation be de- layed. Recurrent Cancer may be removed by operation under the same circum- stances AAdiich justify excision of the primary groAvth. Epithelioma, or, as it is called by Paget and others, Epithelial Cancer, is usually met with in, or im mediately below, the skin or mucous membrane, and very commonly at points Avhere these structures join each other, its most frequent locality being the muco-cutaneous surface of the loAver lip. It also occurs in the tongue, prepuce, penis, scrotum, labia, and nymphse, and more rarely at the anus, in the buccal mucous mem- brane or upper lip, in the mucous linings of the respiratory, alimen- tary, and urino-genital tracts of either sex, the skin of various parts, the lymphatic glands, bones, dura mater, etc. From its primary seat Epithelioma of lower lip. (From a patient in the it Spreads, involving in its growth University Hospital.) any structures with which it meets. When it occurs as a secondary affection, it may be in the neighborhood of its original position, but more often in the proximal lymphatic glands. It is occasionally, but rarely, seen in the internal organs, such as the liver, lungs, and heart. Epithelioma is most frequent in the male sex, and rarely occurs before middle life, the lia- bility to its development appearing indeed to increase with the advance EPITHELIOMA. 507 of years. Inheritance is rarely traceable in this form of disease, while a large proportion, probably a majority, of cases appear to have originated from an injury or other local cause. Thus epithelioma of the lower lip is often attributable to the habit of smoking a short pipe; in the tongue, the disease may originate from the irritation caused by an uneven tooth; in the extremities, it is seen in the seat of old ulcers; while in the scrotum of chimney-SAveepers, it is produced by the irritating contact of soot. It fre- quently occurs in the seat of indurated and incrusted warts. Epithelioma, folloAving chronic inflammation, is also seen in the so-called " tar-cancer" Avhich occurs in the Avorkmen employed in coal-tar and paraffine manu- factories. Course.—Epithelioma is usually single, and in most cases runs its course in from eighteen months to three years. The duration of the disease varies a good deal Avith its locality, epitheliomata of the tongue and penis being commonly the most, and those of the scrotum and lower extremities the least, rapidly fatal examples of the disease. Ulceration occurs at an early period, and gradually spreads, involving the superficial, and sometimes the deep, lymphatic glands, and leading to a fatal result by inducing gradual exhaus- tion, Avithout the development of any special cachexia, and, as a rule, without the occurrence of secondary deposits in other parts. Morbid Anatomy.—Epitheliomata may occur as superficial, flat, or exuberant growths, in which case they occupy the cutaneous or mucous structures them- selves, involving the papillse to a greater or less degree; or as deep-seated, flat, or rounded tubercles, when they occupy only the subcutaneous or sub- mucous tissues. When first seen by the surgeon, the superficial form of epithelioma may appear as a warty excrescence, which soon undergoes ulcer- ation, or as a fissure or small ulcer covered with a dry scab, and with deeply indurated base and edges. The warty epithelioma sometimes assumes a truly villous form, and has been regarded as a variety of villous cancer (see page 502). The deep form of epithelioma (which is very rare) appears as a round, firm, somewhat elastic tumor, over which the skin or mucous membrane is more or less tightly stretched, finally giving way, and alloAving the mass to protrude. Intermediate varieties are more common, in which both integu- ment and subjacent structures are simultaneously involved. Though, how- ever, the differences betAveen these forms of epithelioma may at first be Avell marked, they usually soon disappear, the superficial variety tending to involve the deeper structures, Avhile the deep form of the disease may, at a late period, become exuberant. Occasionally epitheliomata are quite promi- nent, forming sometimes even pedunculated and pendulous tumors. The epitheliomatous ulcer, whether originating as a superficial excoriation or as a fissure, gradually tends to assume a uniform character. It is usually excavated, oval or elongated, and with hard base and edges. Its surface is uneven, nodulated or Avarty, florid, and disposed to bleed; it furnishes an ichorous and very offensive fluid, which tends to form dark-colored crusts or scabs. The general form of the ulcer resembles the " cancerous ulcer " of scirrhus; the induration varies from a line to half an inch or more in thick- ness, and is due to the infiltration of epitheliomatous material. A vertical section of an ordinary epithelioma shoAvs at the upper border a scab, or, if this be detached, a whitish slough-like layer, consisting of loosely aggregated epithelial scales, which have been detached from the deeper structures, and which may be readily removed by washing. The main substance of the growth has commonly a somewhat shining, grayish-Avhite hue, is close-textured, firm and rather elastic, and occasionally presents a striped appearance due to its papillary structure. Squeezing or scraping brings out a curdy, yelloAvish-white material, which resembles the comedones 508 TUMORS. or sebaceous contents of hair-follicles, and Avhich, according to Paget, unlike "cancer-juice," does not readily become equably diffused when mixed Avith water. This distinction is, however, Avanting in the case of very soft epithe- liomata. Epithelioma is infiltrated into the tissue in Avhich it occurs, and the normal structures can therefore often be traced into the epitheliomatous mass. Under the microscope, the characteristic structures of epitheliomata are Concentric globes of epithelioma. (Green.) larger, with more distinct nucleoli, and much resembling the nuclei of scirrhous or medullary cancer (see pages 497 and 500); (3) brood-cells, or cells containing nuclei undergoing development into nucleated cells, the suc- cessive formation of one cell within another sometimes giving a peculiar laminated appearance; and (4) laminated capsules, nests, or epidermic or concentric globes, consisting of concentric layers of epithelial scales, con- taining in the central space granular or oily matter, cells, or free nuclei, and apparently resulting from a continuation of the process of endogenous cell-formation described as giving a laminated appearance to the simpler brood-cells. These nests or concentric globes are met with in other epider- mic formations, but are better marked in epitheliomatous than in any other structures. The cells of epithelioma above described vary with the nature of the sur- face in A\liich the growth occurs; thus, while in the lower lip they resemble the cells of ordinary tessellated epithelium, in the mucous membrane of the intestine they have a cylindriform appearance. Very rarely, melanoid matter is mingled with the epitheliomatous structure, constituting the mela- notic form of the disease. Diagnosis.—The diagnosis of epithelioma from scirrhous and medullary cancer may usually be made by observing its locality—commonly a mucous or muco-cutaneous surface—its frequent origin from sources of local irrita- tion, its early and wide-spreading ulceration, and the absence of any ten- dency to involve distant organs, or to produce a cachectic condition. When occurring on the fingers, lips, or tongue, epithelioma may occasionally be mis- taken for a chancre in the same situation. In any case of doubt, the patient EPITHELIOMA. 509 should be submitted to antisyphilitic treatment, the effect of Avhich will usuallv suffice to make the nature of the case apparent. Prognosis.—The prognosis of epithelioma, when promptly treated, is much more favorable than in the case of other malignant tumors. The average gain of life by operation is about tAvo years and a half, and several authentic cases are on record in Avhich no recurrence of the disease Avas observed for twenty or even thirty years after excision of the primary groAATth. The late Mr. Collis, indeed, went so far as to declare that no recurrence (in the case of epithelioma of the lip) was to be anticipated, provided that excision Avas thorough, and that caustics had not previously been used. Treatment.—As a rule, it may be said that glandular complication, if ex- tensive, should forbid operation in cases of epithelioma. If, hoAvever, the neighboring lymphatic glands be enlarged and irritated merely, without being infiltrated, or if the glands, though infiltrated, can themselves be removed, an operation may be proper, though, in such a case, the prognosis should ahvays be very guarded. Constitutional treatment, except such as may be required by the general state of the patient, is as useless here as in the case of cancer ; the only hope is in complete extirpation of the epitheliomatous mass; and this, to be successful, should be done at as early a period as possible. The treatment may consist of excision, strangulation, or the use of caustics. Caustics are only to be recommended when, from the locality or superficial extent of the epithelioma, the use of the knife would seem to be contra-indi- cated. The best caustics are probably the potassa cum calce, chloride of zinc, and acid nitrate of mercury. According to Busch, the use of alkaline lotions, especially a solution of soda, may occasionally effect a cure in the early stages of the disease. Pillate, of Orleans, recommends the chlorate of potassium, but there seems to have been some doubt as to the real nature of the affection in the cases reported by this surgeon. Excision is the mode of treatment to be preferred whenever it is practica- ble. The incisions should be carried wide of the diseased structure, and may be so arranged as to allow of the extirpation of any glands that it may be thought proper to remove. In certain situations, as in the hand or loAver extremity, the extent of the disease may be so great as to render amputation a better operation than simple excision. Strangulation may occasionally be required, if the locality of the epithe- lioma be such as to forbid excision, or if the part be so vascular as to cause Fig. 233. fear of hemorrhage. In such a case, the part to be removed may be insu- lated by means of tAvo or more strong ligatures, Avhen it Avill slough, and become detached in the course of a feAv days, or removal may be effected by means of the elastic ligature, as recommended by Dittel, of Vienna; in other situations, as in the tongue, the process introduced by Chassaignac, and known as Ecrasement lineaire, will be preferable. One or more ecraseurs may be used, the chain of the instrument being passed, if necessary, through the base of the growth by means of a needle. The screw should be slowly worked, and the handle turned not more than once in fifteen seconds. Recurrent Epithelioma may be treated in the same manner as the primary groAvth. 510 TUMORS. Excision of Tumors. No rules of universal application can be given as to the mode of excising morbid growths. It may be said, however, in general terms, that the incision (for, in the case of innocent groAvths, there should usually be but one) should be in the direction of the long axis of the tumor, and should correspond as far as possible Avith the natural folds of the part. In the case of non-malig- nant tumors, no skin need be removed, unless the growth be very large; but if the tumor be malignant, it Avill usually be necessary to remove a portion of the cutaneous investment, whether it be or be not ulcerated, and the incisions in this case may be elliptical (Fig. 231), or in Fig. 234. the form of a double S (Fig. 235). .*------s,^^ If the tumor be encapsulated, it should be removed if "^------->" possible by enucleation, the finger and handle of the knife being used in the deeper parts, instead of the cutting edge of the instrument: Avhen it is necessary to resort to dissection, the growth should be loosened first at the part at Avhich its main vessels enter, so that if these are cut, they they may be secured once for all.1 In removing a non-malignant growth, the knife should be kept close to the tumor, so as to avoid wounding the important structures to which it may be attached, but if the growth be malignant, the surgeon should keep Avide of it, Fig. 235. in all his manipulations, so that no portion may be allowed to y, remain. If possible, a tumor should never be cut into until it yS is removed: neglect of this precaution may lead to hemorrhage f I (for the tumor itself may be very vascular), and if it be a / \ malignant growth, particles may escape from it, which will act ( \ as germs in promoting the recurrence of the disease. If the \ ) tumor be of moderate size, the first incision should be made \ / sufficiently free to alloAv removal of the whole mass; in the J/ case, however, of a very large tumor, it is well to expose only S a portion of it at first, enlarging the wound at a later stage of the operation when necessary; the loss of blood will thus be less than if the whole incision had been made at the beginning. If, when a tumor is exposed, it be found that its deep attachments cannot be safely interfered with, the best thing left for the surgeon to do is to strangulate the base of the growth with strong ligatures, and cut off the remainder: no operation, however, should be undertaken, unless it appear that the whole tumor can be safely extirpated. After the excision of a tumor, the surgeon should carefully explore with his finger the Avhole surface of the wound, so as to make sure that no portion of the growth has been allowed to remain: this is particularly important in dealing with a malignant tumor, and, in such a case, any suspicious struc- tures that cannot be removed, may be touched Avith the actual cautery, or with a solution of chloride of zinc. The lips of the wound may then be approxi- mated with a feAv points of suture and adhesive strips, and lightly dressed with a strip of lint dipped in olive oil, or any other simple application that may seem appropriate. If the cavity left by the removal of the tumor be large, a drainage tube may be introduced, and the part should be supported Avith a compress and bandage, to prevent oozing or accumulation of pus. 1 Ronciere advises that the cellular tissue around a tumor should be blown up with air to facilitate its excision. DISEASES OF THE SKIN AND ITS APPENDAGES. 511 CHAPTER XXVII. SURGICAL DISEASES OF THE SKIN, AREOLAR TISSUE, LYMPHATICS, MUSCLES, TENDONS, AND BURSAL Diseases of the Skin and its Appendages. The consideration of the ordinary cutaneous affections, which are com- monly spoken of as " skin diseases," does not properly come within the scope of this work; but there are certain morbid conditions of the skin and its appendages which require surgical manipulations in their treatment, and which may, therefore, be here appropriately referred to. Verrucse or Warts.—Warts consist of hypertrophied cutaneous papillae, which may project, each papilla by itself, or, as is more usual, ensheathed by a common investment of thick- ened scaly epithelium. They occa- Fig. 236. sionally attain a considerable size, constituting some of the so-called horns met with in various parts of the body. Anatomically, they be- long to the papillary variety of tumor. The simple warts* which appear upon the hands and face come without any apparent cause, and often disappear spontaneously. In other cases, they remain per- manently, becoming of a dark color, and occasionally forming a nidus for epitheliomatous forma- tions, as do sometimes the analo- gous groAvths knoAvn as moles. The treatment consists in the applica- tion of nitrate of silver in sub- stance, nitric or chromic acid, or the muriated tincture of iron—or in ligation or excision, if the wart be pedunculated. Warts occa- sionally have a moist, muco-cuta- neous covering, and are irritable and disposed to bleed; the glyce- rate of tannic acid will often be found a useful application in this form of the disease. Warts not unfrequently occur upon the muco- cutaneous surfaces of the anus, or of the genital organs in either sex, and in the latter situation are often spoken of as venereal warts or vegeta- tions: they are not, hoAvever, necessarily of a venereal origin, but may be produced simply by the irritation of frequent sexual intercourse, or may Warts around the anus. (Ashton.) 512 SURGICAL DISEASES OF THE SKIN. even result from the accumulation of smegma and want of personal clean- liness. They are particularly apt to occur in persons Avith congenital phimosis. The treatment consists in the application of nitric or chromic acid, or poAvdered calomel, or in paring or snipping off the growths Avith a sharp knife or scissors, and cauterizing the surface from which they spring. Warts of the generative organs, and occasionally those of the hand, appear to be communicable by contact. Corns are local indurations and hypertrophies, usually confined to the cuticle, but occasionally involving the papillae of the true skin. Corns result from intermittent pressure, as from wearing badly-fitting boots, and are chiefly seen on the feet, but occasionally on the hands, knees, elboAvs, and, according to Hulke, even on the tongue. Hard Corns are such as form upon exposed surfaces, as on the edge of the foot, and are consequently dry and indurated, while Soft Corns are such as occur in situations Avhere they are kept moist, as between the toes, where they assume a spongy, mucous appearance, not unlike the mucous patch of syphilis. Bursce&re occasionally developed beneath both varieties of the affection. Soft corns are usually more irritable than the hard, but either may be very painful if inflamed, the Papillary Corn, Avhich occurs principally on the sole of the foot, causing, probably, more acute suffering than any other variety. The treatment of hard corns consists in relieving the part from pressure by the use of suitable shoes or the application of a perforated plaster, in shaving off the surface of the corn and applying the solid stick of nitrate of silver to its base, or in excising the centre of the indurated part with a sharp knife or scissors, after the whole has been softened by the use of a warm water-dressing. Soft corns may be dusted Avith powdered oxide of zinc, or touched Avith nitrate of silver or glacial acetic acid, the toes being kept apart by the interposition of scraped lint or raw cotton. Suppuration occurring beneath a corn requires poulticing and the evacuation of the pus after shaving down the part with the point of a sharp lancet. Onychia is an affection of the matrix of the nails, of which we may recognize two varieties, the simple and the malignant. Simple Onychia, or, as it is vulgarly called, "run-around," consists in an inflamed condition of the matrix of the nail, usually resulting from slight injury, and attended Avith suppuration and loosening of the nail, which be- comes shrivelled and discolored, and is eventually cast off—the new nail which forms being commonly thickened and distorted. This affection occurs chiefly in the hand, and is almost exclusively confined to children. The treatment consists in the use of poultices, or water-dressing, until the nail has separated. The growth of the neAV nail may sometimes be advantageously regulated by the application of an adhesive strip or a layer of wax. Malignant Onychia results from injuries occurring to persons in a depressed constitutional condition, and is usually seen in the thumb or forefinger, or in the great toe, where it sometimes receives the name of toe-nail ulcer. It consists in an unhealthy form of ulceration in the matrix of the nail, which becomes brown or black, and is thrown off, its place being occupied by fun- gous granulations. The disease has little or no tendency to a spontaneous cure, and sometimes leads to necrosis of the ungual phalanx. The treatment may consist in avulsion of any portion of the nail which remains, and thorough cauterization of the matrix Avith solid nitrate of silver—a simple dressing, such as lime-water, being afterwards applied, while the parts are kept well supported Avith strips of adhesive plaster; or, which I think better, in simply trimming the nail to the level of the ulcer, and then applying KELOID OR CHELOID. 513 powdered nitrate of lead, as advised by Moerloose, Vanzetti, and MacCor- mac ; the nitrate forms a thick crust, which separates after several days, leaving a healed, or rapidly healing, surface; the application gives rise to severe pain, Avhich lasts for several hours, but the treatment is prompt and efficient, and has the great advantage of allowing the preservation of the nail. Other plans are recommended by various authors: T. Smith, folloAving Abernethy, advises the application of dilute Fowler's solution, while Van- Fig. 237. Fig. 238. Malignant onychia. (Druitt.) Toe-nail ulcer. (Liston.) zetti recommends the employment of powdered quicklime, and Babacci the application of charcoal and camphor. Syphilitic Onychia has already been referred to at page 459; it requires the application of black or yellow wash, Avith the use of suitable antisyphilitic remedies. Amputation may be re- quired, if necrosis occur in a neglected case of onychia maligna. Ingrowing Toe-Nail is an affection almost exclusively confined to the outer side of the great toe; it results from wearing narrow shoes, which com- press the foot and cause the soft part of the toe to overlap its nail, giving rise to an ulcer Avhich is painful and persistent. A cure may be sometimes effected by dusting the ulcer Avith oxide of zinc, or interposing a little lint, or a strip of adhesive plaster, betAveen the nail and the inflamed part of the toe; but in many cases it will be necessary to remove a portion, or the Avhole, of the nail. This may be done (the patient being etherized) by thrusting one blade of a pair of sharp-pointed scissors beneath the nail up to its root, when the whole nail may be divided at a single stroke; the segment to be removed is then grasped Avith forceps, and torn away from the matrix, this process being repeated on the other side, if necessary, and the part then simply dressed with Avet lint. A new nail grows, Avhich is usually straight and well formed. The shoe must, of course, be so arranged as to free the part from pressure. Hypertrophy of a Toe-Nail, usually of that of the great toe, is occasion- ally met Avith, the laminse of the nail becoming distorted, and constituting a horn-like protuberance Avhich may grow so large as to interfere with Avalking. The treatment consists in avulsion of the nail, which operation usually effects a permanent cure. Keloid or Cheloid (of Alihert) is an affection met with chiefly, if not exclusively, in the scars produced by burns or by wounds, and especially in those produced by flogging, and is to be distinguished from the disease knoAvn as Morphaea or the Keloid of Addison (true keloid), which occurs in healthy skins, Avhere it produces a scar-like appearance. The former appears in the shape of small and shining, indurated elevations, of a dusky red color, 33 514 SURGICAL DISEASES OF THE SKIN. which extend, sending out, as it were, claw-like processes, and are attended during their growth by great itching and considerable pain. In their struc- ture they correspond with the fibro-cellular outgrowths described in the last chapter. The Keloid of Addison begins as a "white patch or opacity" of the skin, surrounded by a zone of redness, gradually spreading and inducing contraction of fasciae and tendons, and giving a " hide-bound " character to the part affected.1 The treatment of either form of keloid is very unsatis- factory. Extirpation with the knife has been tried, but the disease almost invariably recurs. Dr. Addison derived advantage from the use of iodine, both internally and externally, in one case of the variety of the disease known by his name. Warty Tumors of Cicatrices.—Under the name of Warty Timor or Warty Ulcer of Cicatrices, an affection somewhat resembling the keloid of Alibert has been described by Ccesar Hawkins.2 Some of these warty ulcers are non-malignant, being of a fibro-cellular character, but others are really epi- theliomata of a papillary form. When occurring over the anterior surface of the tibia, as in the so-called " Warty Ulcer of Marjolin," they are very often complicated by a carious condition of the bone. The treatment con- sists in excision or amputation, according to the size and locality of the affection; the operation, even when the disease is epitheliomatous, often re- sulting in an apparently permanent cure. Recovery may, according to Collis, be sometimes obtained in the early stage by the application of bis- muth, or of ice. Rodent Ulcer. — This affection, which is also known as Jacob's* Ulcer, is most often seen in the eyelids, cheeks, upper lip, nose, or scalp, but may also occur in other parts of the body. It is a disease of late adult life, and commonly originates in some tubercle or mole, which may have existed for many years. It is usually single, at first rounded, but becoming irregular as it spreads, with indurated base and edge, and a someAvhat abrupt, and but slightly elevated border; it very rarely assumes the character of a tumor. The ulcerated surface is smooth, glossy, and dry, and of a red- dish-yellow color. The pro- gress of the disease, though ex- tremely indolent and chronic, is never spontaneously ar- rested, though partial cica- trization may sometimes occur. The rodent ulcer produces frightful ravages, exposing the orbit, nasal cavities, pharynx, or even the brain, and thus ultimately causing death— Rodent ulcer. (Mackenzie.) though the local character of the affection is strictly main- tained to the last, the lymphatics and distant organs never becoming involved. The microscopic characters of the rodent ulcer are, according to Paget, Hutchinson, and Golding-Bird, simply those observed in ordinary granula- 1 Addison, in Med.-Chir. Transactions, vol. xxxvii. pp. 27-47. According to J. Collins Warren, of Boston, the two forms of keloid cannot be distinguished by their anatomical features. 2 Med.-Chir. Trans., vol. xix. pp. 19-34. 3 See Dr. Jacob's paper in Dublin Hosp. Reports, vol. iv. pp. 232-2-V.). LUPUS. 515 tions; Collis classes the disease among myeloid or fibro-plastic groAvths, while, on the other hand, Billroth, with Moore and J. Collins AVarren, Avho have each Avrittcn excellent monographs upon the subject, look upon it as a form of cancer. The treatment consists in complete extirpation, which is best accomplished, Avhen possible, with the knife. If, however, excision be contra-indicated by the size or locality of the ulcer, or the age of the patient, caustics may be employed, the Vienna or Canquoin's paste, or nitric acid, or acid nitrate of mercury, being respectively preferred, accord- ing to the deep or superficial character of the affection. Perforating Ulcer of the Foot.—This is a curious affection which appears to be less common in this country than in Europe. I have, hoAvever, seen two cases of the disease, corresponding in every particular with the descrip- tions given by Hancock, Duplay, and other writers on the subject. The affection consists in an intractable form of ulceration, usually occupying the anterior part of the sole of the foot, and leading to destructive disor- ganization of the neighboring bones and joints. It often begins as a bunion, appearing to result from undue pressure on the part, or as the result of ex- posure to cold, Avhen it may be mistaken for ordinary frost bite. Poncet and Estlander regard it as analogous to the anaesthetic form of elephantiasis (Lepra ancesthetica), but Duplay and Morat, from dissection of numerous specimens and careful study of the literature of the affection, conclude that the disease originates in degenerative lesions of the nerves of the part, from traumatic or other causes. Fischer, of Breslau, and Savory and Butlin, adopt a similar theory, and the former describes the disease as a malignant form of neuro-paralytic ulceration, but a more recent autopsy recorded by Michaux has failed to confirm this view. Ball and Thibierge have seen per- forating ulcers in connection with locomotor ataxia. Engliscli points out, from a study of 109 cases, that the localization of the disease corresponds Avith the position of the bursa? mucosae of the sole, and concludes that it is caused by a Arascular change analogous to the endoarteritis obliterans or proliferans of Friedlander and Billroth. Perforating ulcer has been not un- frequently confounded with the Mycetoma, or fungus disease of India (tuber- cular disease of the foot, of Hancock). The treatment consists in removing the diseased bone by gouging, excision, or, if necessary, amputation, and in endeavoring to improve the nutrition of the limb by the use of galvanism, frictions, etc. If the cause of the nervous or vascular changes in which the disease originates can be discovered, an attempt should of course be made to remedy the evil so as to prevent a recurrence of the affection. Dubrueil describes, under the name of "dorsal disease of the toes," an inflamed or ulcerated condition of adventitious bursae AA'hich are formed on the back of the toes under the influence of pressure. Despres has described a case of perforating ulcer of the hand. Lupus.—Under this name are commonly included two affections, which may be described as Lupus Non-exedens, or Simple Impus, and Lupus Exe- dens, or Ulcerating Lupus. Lujms Non-exedens appears as a red patch on the skin (usually of the face), attended with brawny desquamation, and sometimes accompanied Avith indolent tubercles. It runs a very chronic course, and produces inconven- ience merely by the deformity and scar-like contraction to Avhich it gives rise. It is usually seen in persons of a scrofulous diathesis. The treatment consists in the administration of tonics, especially of cod-liver oil, with arsenic, and in the local use of a solution of nitrate of silver, gr. x-xx to f|j. Lupus Exedens, Ulcerated Lupus, or Lupous Ulcer, is usually seated on 516 SURGICAL DISEASES OF THE SKIN. the tip or alse of the nose, but sometimes on the upper lip, or in other situa- tions, and is chiefly seen in young persons. It begins as one or more red- dish papules, or tubercles, which soon ulcerate and coalesce. The lupous ulcer may be superficial, when it appears as a fungous, warty, ulcerated sur- face, with prominent nodular granulations, Avhich are often scabbed over by the drying of the discharge, and are sometimes irritable, though seldom disposed to bleed. The ulceration progresses under the scabs, and the affec- tion is liable, at any moment, to assume the deep or phagedoznic form, which was known to the older writers as noli-me-tangere. The phagedenic lupous ulcer is a very painful affection, attended with great destruction of tissue, and accompanied with a fetid discharge. Under its influence, the greater part of the nose may melt away, as it were, in the course of a feAv weeks, and it is to be observed that, when Fig. 240. the ulcer has reached the level of the rest of the face, it may become at least temporarily arrested. The affection rarely proves fatal by itself, and cicatrization may occur, adding to the deformity caused by the dis- ease, by inducing contraction and distortion of neighboring parts. The microscopic appearances of lupus have been investigated by several patholo- gists, among whom Essig finds that the corium is infiltrated with round cells which in some specimens fol- low the track of the vessels and ar- range themselves in heaps around them; spindle-shaped and giant cells are also found in some cases. Ac- cording to Thoma and Thin, the cell-infiltration originates in exuded white corpuscles. Lang believes the giant cells to represent an inter- mediate stage in the process of de- generation of the tissues. Fried- lander looks upon the nodosities of lupus as true tubercles, but Colomiatti considers them essentially distinct. According to Piffard, the superficial or simple lupus presents merely an infiltration of round cells, while the giant cells occur only in the ulcerative variety, and the "cell-heaps" (which alone are characteristic of lupus) in those cases which involve the subcuta- neous tissues. The treatment of the superficial form of lupus consists in the administration of arsenic and cod-liver oil, and in the local use of a solu- tion of nitrate of silver, diluted tincture of iodine, or dilute citrine oint- ment. Kiehl advises the employment, for from half a minute to two minutes, of a solution of caustic potassa (one part to two), followed by ap- plications of finely powdered iodoform. The phagedsenic variety of lupus requires the application of caustics, or of the actual or electric cautery, together with the constitutional treatment already recommended. Volkmann employs erosion, or scraping away the diseased tissue with a sharp spoon or scoop, and Hutchinson prefers this mode of treatment to any other; Dr. Piffard and Mr. Godlee also employ erasion, but the former supplements it with the actual cautery, and the latter, after checking the hemorrhage by pressure with lint, applies an ointment of iodoform and oil of eucalyptus. Squire recommends linear scarification, as in cases of "port-Avine stain." Phagedenic lupous ulcer. (Druitt.) DISEASES OF THE LYMPHATIC SYSTEM. 517 (See (hap. XXIX.) Excision may be resorted to in certain situations, as the upper lip or nose, the resulting gap being closed by a plastic operation, if necessary. Lupus, complicated with a syphilitic taint, requires the ad- ministration of the iodide of potassium. Malignant Diseases of the Skin.—Both cancer and epithelioma may occur primarily in the skin, as Avas mentioned in speaking of those affec- tions. The treatment consists in excision, or amputation, according to the size and situation of the malignant growth. Diseases of the Areolar Tissue. Cellulitis, or Inflammation of the Areolar Tissue may be circumscribed or diffused: in the former case it gives rise to an abscess, and in the latter to diffused suppuration. When depending upon an erysipela- Fig. 241. tous taint, it constitutes cel- lular erysipelas (see pp. 394, 409). Elephantiasis Arahum, or Arabian Elephantiasis, may be described as a hypertrophy of the skin and subcutaneous areolar tissue. In its struc- ture it corresponds with the fibro-cellular outgrowths de- scribed in Chapter XXVI. It is chiefly seen in the scro- tum, and in the loAver ex- tremity, where it constitutes the affection known as Barba- does leg. Its appearances are well shown in the annexed cut (Fig. 241), from a paper by Dr. Isaac Smith, Jr., of Fall River, Mass. This form of elephantiasis is closely analogous to the affections knoAvn by modern patholo- gists as Sclerema or Sclero- derma, as well as to that described by Mott and Stokes as Pachydermatocele, the Eihides of Warren, the Dermatolysis of Wilson, and the Molluscum fibrosum of Pollock and Ford. The treatment consists in the use of pressure, ligation of the main artery of the part, excision, or amputation, according to the circumstances of the particular case (see page 480). ,,MJ«f«S*>j» Elephantiasis Arabum in the lower extremity; Barbadoes leg. (Smith.) Diseases of the Lymphatic System. Angeioleucitis or Lymphangeitis (Inflammation of the Lymphatic Vessels or Absorbents) may occur as an idiopathic affection, as a complication of erysipelas, or as the result of the irritation produced by a Avound, ulcer, or local inflammation, as in cases of gonorrhoea. Its occurrence is usually pre- 518 diseases of the lymphatic system. ceded or accompanied by marked constitutional disturbance, rigors, and febrile reaction. If the inflamed lymphatics be superficial, their course will be marked by a number of fine lines, which soon coalesce into a band about an inch Avide, of a vivid red color, running from the point at which the disease originates to or beyond the nearest lymphatic glands, which are always themselves inflamed. The line of the absorbents is somewhat doughy, and not very tender, and the limb is usually swollen and often erythematous. If the inflammation affect only the deep lymphatics, the affection of the glands may alone be perceptible. Resolution usually occurs in the course of a week or ten days, though suppuration often takes place in the glands, and some- times in the lymphatics themselves; the prognosis is favorable, though death may occur from the supervention of erysipelas, pysemia, or diffuse cellulitis. The only disease with which angeioleucitis is likely to be confounded is phlebitis, from Avhich it may be distinguished by observing that the red line in the latter affection has a dusky hue, and gives a peculiar cord-like and knotty sensation to the touch. The local treatment consists in the application of nitrate of silver along the line of inflamed lymphatics, so as to blacken Avithout blistering the skin ; the limb may then be wrapped in carded cotton. Should suppuration threaten, poultices may be employed, and pus evacuated by early incisions. The constitutional treatment consists in the use of saline diaphoretics and anodynes, with or without stimulants, according to the general condition of the patient. If erysipelas occur, the tinct. ferri chloridi may be given in combination with the liq. ammonii acetatis. Adenitis, or Inflammation of the Lymphatic Glands, ahvays accompanies angeioleucitis, but may also occur independently, as the result of transmitted irritation (as in sympathetic bubo), or of the absorption of morbid matter (as after poisoned wounds, or in chancroidal bubo), or as the result of direct violence, or of over-exertion in walking or otherwise. The so-called bubon d'emblee is, as already mentioned (p. 447), an instance of this form of adenitis. The symptoms of adenitis are those of circumscribed, deep-seated inflamma- tion in general, terminating sometimes in resolution, but more often in sup- puration, or in chronic induration and hypertrophy. The treatment consists in the use of blisters, nitrate of silver, or tincture of iodine, applied around but not over the inflamed gland, Avith poultices and early incisions if suppu- ration ensue, together with the administration of anodyne diaphoretics during the acute stage, and tonics, such as cod-liver oil and iron, especially in the form of the iodide, when the affection assumes a chronic form. The lymphatic glands are affected in Tuberculosis, in Scrofula, and in Syphilis, and are frequently the seat of various morbid growths, particularly the adenoid, and those of a malignant nature. The treatment appropriate to these various conditions has already been described in the chapters on the several affections referred to. Varicose Lymphatics; Lymphangeiomata.—A dilated or varicose condi- tion of the lymphatic vessels has been occasionally met with, and may form a troublesome complication in cases of Arabian Elephantiasis, when, accord- ing to Manson, the lymphatic fluid contains filarise. By spontaneous rup- ture, or accidental Avound, a fistulous opening may be formed, through which the lymphatic fluid escapes, constituting the disease known as Lymphorrheea. The treatment consists in the application of caustic, and in the use of pressure. tumors in muscle. 519 Diseases of Muscles and Tendons. Myositis, or Inflammation of the muscular tissue, may occur as a primary affection, as the result of injury, etc., or may be secondary, depending upon various lesions of other structures, especially of the bones and joints. Its symptoms and treatment have already been sufficiently considered in the chapters on Inflammation in general. Fatty Degeneration of muscle is a not infrequent sequence of inflamma- tion of the muscular tissue, conjoined with long disuse, and may probably in some cases be dependent on the latter cause alone. In some cases, to Avhich the name of interstitial fatty degeneration has been given, the striated character of the muscular fibre is still preserved, the connecting tissue alone being replaced by oily matter; in other cases the change is more complete, the whole muscle being converted into a fatty and granular mass (necrobiotic or intrinsic fatty degeneration). The latter condition appears to depend upon more complete disuse of the muscle than the interstitial form, and is proba- bly incurable. The treatment of the milder cases consists in endeavoring to restore, or at least maintain, the nutrition of the part, by passive exercise, frictions, etc. Rigid Contraction of Muscles.—Another consequence of muscular inflam- mation, especially in persons of a gouty or rheumatic tendency, is rigid con- traction of the affected muscle, giving rise to deformity, and often attended Avith much pain. This is most often seen in the sterno-cleido-mastoid and splenius muscles, the rigid contraction of Avhich causes the affection known as stiff or wry-neck. The pelvic muscles also often become contracted as a consequence of hip disease. Rigid muscular contraction may likewise result from mere disuse, from long-continued spasm, and from paralysis of opposing muscles. Examples of the two latter conditions are seen in cases of club- foot. When rigid contraction persists for a long time, it is accompanied by atrophy and usually by fatty degeneration of the muscular tissue. The treatment of the inflammatory form of the affection consists in the use of stimulating embrocations, and the administration of anodynes, colchicum, iodide of potassium, etc.; while the more permanent cases require the use of elastic extension, or division of the contracted muscle or its tendon. (See Orthopeedic Surgery.) Ricord and others have described a peculiar form of muscular contraction Avhich is dependent upon syphilis; it is chiefly seen in the biceps, and yields readily to the administration of iodide of potassium. Ossification of Muscle is a rare affection, of which cases have been recorded by Abernethy and Hawkins, and which apparently depends on the coinci- dence of muscular inflammation with a tendency to excessive bony deposit. Miinchmeyer gi\Tes this affection the name of progressive ossifying myositis; but, according to Mays, the ossific change begins, not in the muscle itself, but in the intermuscular connective tissue. It is usually accompanied by the development of numerous exostoses, as in a remarkable case recorded by Dr. Hutchinson, of this city. The treatment consists in the repeated applica- cation of blisters, Avith the internal use of colchicum, iodide of potassium, etc. Tumors in Muscle.—Various forms of tumor occur in muscular tissue, the most important being of the cancerous, fibrous, cystic, and vascular varieties. Cartilaginous and osseous tumors are also met Avith, but are comparatively rare. Hydatids are occasionally found in muscle. The treatment of these various affections is to be conducted on ordinary surgical principles. Excision 520 diseases of muscles and tendons. usually presents no particular difficulties, and, except in the cases of malig- nant tumor, may be expected to effect a permanent cure. For the cancerous tumors, unless the case be seen at a very early period, amputation (if the tumor be suitably situated) offers a better chance than excision, and should in most instances be preferred. If, however, the case be seen at a very early stage, an attempt should be made to preserve the limb, by extirpating the tumor with a wide margin of healthy tissue. If practicable, the plan sug- gested by Teevan might be adopted, of dissecting out the entire muscle in which the malignant growth was seated. Tenosynovitis, or Inflammation of Tendons and their Sheaths or Thecal (Thecitis), occurs as the result of injury, as well as in cases of gout or rheu- matism. This disease, which has been well studied by Hopkins, is charac- terized by the appearance of a tender, puffy swelling in the course of the affected tendon, with a peculiar sensation of fine crackling or dry crepitation, best marked when the disease has become chronic. The treatment consists in rest, with the use of iodine, stimulating embrocations, or blisters. Paronychia or Whitlow (Panaris) consists in inflammation of the flexor tendons and sheaths of the fingers. In the mildest form of the disease, the theca is but slightly, if at all, involved, the inflammation being chiefly con- fined to the dense subcutaneous tissue of the pulp of the finger, being, in fact, a mere digital abscess. In the true paronychia, or tendinous whitlow, the theca is principally affected, suppuration often extending in the course of the tendon beneath the palmar fascia (giving rise to palmar abscess), or even to the forearm, involving, perhaps, the remaining fingers, and causing exten- sive destruction of parts by sloughing. In the worst form of the disease, or felon, the phalangeal periosteum is in- volved, often leading to necrosis and exfoliation of considerable portions of bone, with destruction of neighboring articulations. The disease commonly originates from some slight puncture Felon. (Liston.) or other injury to the extremity of the finger, and is usually, though not in- variably, confined to the palmar surface. Paronychia occasionally occurs as an epidemic, without being traceable to any traumatic cause, and is be- lieved by Erichsen to be uniformly of an erysipelatous nature. The symp- toms are those of deep-seated inflammation, with intense throbbing pain and tenderness, much aggravated by the depending position, and with considerable constitutional disturbance. Though suppuration may occur pretty early in the disease, fluctuation is not very apparent, on account of the density of the intervening tissues. Gangrene is occasionally, but rarely, met with. The treatment consists in the application of leeches, followed by poultices, or by soaking the hand in water as hot as can be borne, together with the internal administration of laxatives and anodyne diaphoretics. If relief do not follow in the course of twenty-four hours, a deep incision should be made on one or both sides of the affected phalanx, so as to relieve tension and evacuate any pus that may be present. The incision should not be made in the centre of the finger, lest the sheath be opened, Avhen the tendon would almost certainly slough; nor too far towards the side, lest the digital artery be wounded. The incision should be made from above doAvnwards, so that, if the patient withdraw his hand suddenly, he may rather assist than hinder GANGLION. 521 the completion of the operation. If suppuration extend along the sheath of the tendon towards the palm, the surgeon must follow it up with free incisions, repeated as often as necessary. The strength of the patient must be, at the same time, sustained by the administration of tonics, concentrated food, and stimulus. If necrosis occur, the sequestra must be extracted as soon as they are loosened—partial or complete amputation of a finger being occasionally required, though excision of the phalangeal articulations may sometimes be advantageously substituted. By unremitting care and attention on the part of the surgeon, a hand may often be preserved Avhich Avill prove quite useful, though somewhat stiff and deformed; but occasionally the destructive process continues in spite of treatment, involving the wrist, and eventually requiring removal of the limb. During the whole after-treatment of a whitlow the hand should be supported on a broad splint, to keep the parts at rest and prevent contraction of the fingers. Some surgeons endeavor to abort whitloAV by the application of blisters, tincture of iodine, spirit of camphor, or nitrate of silver ; the plan may occa- sionally succeed, but, if it fail, cannot but aggravate the affection. Ganglion.—A ganglion is a synovial cyst, developed in connection Avith the sheath of a tendon. Erichsen distinguishes two varieties, the simple ganglion, which is found on the tendinous sheath, and the com- Fig. 243. pound ganglion, Avhich consists of a dilatation of the sheath itself, and which often involves several adj acent tendons. Gan- glia vary in size from a third of an inch to two or more inches in diameter, that of the sim- ple ganglion rarely exceeding three-fourths of an inch. Their shape is round or oval,and they contain a clear fluid, varying in consistence from that of se- rum to that of honey, mingled sometimes with irregularly- shaped melon-seed-like bodies, Avhich have been recently studied by Beatson; these are formed of a compact, fibri- nous substance, and appear to ha\re originated from floating masses of fibrin, due to pre- vious inflammation, or to have become separated from the lining wall of the sheath, which is itself often fringed and Avascular. Ganglia occur chiefly in connection Avith the extensor tendons on the back of the hand or wrist, or on the dorsum of the foot, though they are also seen in the palm, extending beneath the annular ligament, or on the side or sole of the foot. Thcv occasion, in some cases, a good deal of pain by pressing on adja- cent nerves, and sometimes interfere considerably Avith the motion of the tendons on Avhich they are seated. The presence of the melon-seed-like bodies may be recognized by the occurrence of a peculiar grating or creak- ing sound "on manipulation. The treatment of the smaller ganglia may con- sist in rupture by forcible compression Avith the thumbs, or by a sudden Compound ganglion. (From a patient in the Episcopal Hospital.) 522 DISEASES OF BURS.E. bloAV, as with a book; or in puncture, and subsequent compression. If these means fail, the interior of the cyst may be scarified, after puncture, Avith the point of a knife; or iodine may be injected; or a seton established. Exci- sion is attended with some risk—diffuse inflammation occasionally ensuing —and should therefore be employed Avith hesitation. For the larger ganglia, and especially those beneath the annular ligament of the Avrist, repeated blisters may be employed, in hope of inducing consolidation; or recourse may be had to iodine injection, or to the seton. Division of the annular ligament Avas recommended by Prof. Syme, and has been successfully resorted to by Dr. Copeland, of Virginia. If suppuration occur, the cyst must be opened, the melon-seed-like bodies evacuated, if there be any present, and the wound allowed to heal by granulation. Excision may be required if the ganglion be of large size and Avith semi-solid contents. Fig. 244. Diseases of Bursas. Synovial bursse exist normally in certain situations, and may be adventi- tiously developed by continued friction or pressure in other localities. The most important bursse, in a surgical point of view, are that between the hyoid bone and thyroid cartilage, and those over the acromion, the condyles of the humerus, the olecranon, the styloid processes of the radius and ulna, the tuber ischii, the trochanter major, the anterior superior spinous process of the ilium, the patella, the femoral condyles, the tuberosity of the tibia, the malleoli, the heel, and the heads of the first and last metatarsal bones. Bursse are also met with beneath the deltoid and gluteus maximus, between the point of the scapula and the edge of the latissimus dorsi, and in the popliteal space. Bursitis, or Acute Inflammation of a Synovial Bursa, is most frequently seen in the bursa patellce, constituting a variety of the disease ordinarily knoAvn as "Housemaid's Knee," from the fact that women who constantly kneel in scrubbing are peculiarly exposed to the affection. Similarly the enlargement of the bursa over the olecranon is known as " Miner's Elbow," Acute inflammation of a bursa is attended with much pain and considerable constitutional dis- turbance. The swelling is superficial, and in the case of the bursa patellae above the bone—a diagnos- tic point of some importance, as in inflammation of the joint the patella is floated up by the articu- lar effusion. The treatment consists in the enforce- ment of rest, with the application of a suitable splint, a few leeches perhaps, evaporating lotions —or poultices and warm fomentations, if more agreeable to the patient—together with the ad- ministration of anodyne and sedative diapho- retics. If suppuration occur, a free and early opening must be made, and the case treated as one of abscess. If the incision be delayed, the pus may diffuse itself somewhat widely around the part, necessitating numerous counter-open- ings. Caries of the patella is an occasional sequence of housemaid's knee, requiring the use of the gouge to remove the diseased bone. Sloughing of the bursa may likewise sometimes occur, leaving a large ulcer which slowly heals by granulation. Enlarged bursa over the pa- tella, the result of pressure; housemaid's knee. (Liston.) BUNION. 523 Simple Enlargement or Dropsy of a Bursa (Hygroma) may result from subacute inflammation, or simply from long-continued pressure. This con- dition in the bursa patellae constitutes the true housemaid's knee, and some- times causes considerable inconvenience by the bulk of the swelling. The fluid in these enlarged bursse may be of the ordinary synovial character, or may be of a darker hue, containing cholestearine and disintegrated blood, Avhen it is not unfrequently mixed Avith numerous rice-like or melon-seed- shaped bodies such as have been described as occurring in compound ganglia, and which appear to consist of imperfectly developed connective tissue, formed originally upon the lining wall of the bursa, and subsequently sepa- rated by the friction and constant motion to Avhich the part is subjected. Fig. 245. Formation of seton with trocar and canula. (Erichsen ) Virchow and others have observed intra-bursal bands, attached by both ends to the wall of the tumor. The treatment consists in the application of dis- cutients, such as iodine or blisters; or in tapping, followed by the injection of iodine; or by the establishment of a seton — the thread being passed through the canula as in Fig. 245. If the bursa contains the rice-like bodies above referred to, they must be evacuated through a tolerably free incision, when the seton may be passed as before. Solid Enlargement of a Bursa is caused by the gradual deposit of organ- ized lymph in the interior of the sac, previously filled with fluid, until the Avhole or nearly the whole of the cavity is obliterated. A bursa, Avhen cut open under these circumstances, presents a laminated appearance, such as is seen in a partially consolidated aneurism. In some cases, according to Erichsen, the tumor is solid from the first, fibroid matter being primarily deposited in the bursa. The treatment consists in the use of sorbefacient remedies, or, if these fail, in excision—taking care not to injure any neigh- boring articulation, and, in the case of the bursa patellae, not to open the deep fascia Avhich is attached to that bone, lest the structures of the ham should become involved in suppuration. Annandale has recorded a remark- able case of bony tumor occupying the situation of the bursa patellse. Bunion.—The term bunion is applied to an enlarged bursa occurring in any part of the foot, the most usual seat of the affection being at the side of, or beloAV, the metatarsal joint of the great toe. Bunions appear to be caused by distortion of the foot from wearing narrow-soled and high-heeled shoes, by Avhich the Aveight of the body is thrown forAvards, while the toes are croAvded together. The distortion consists in the great toe being thrust out- Avards, by Avhich means its metatarsal joint becomes prominent—a large corn usually forming over the projection, and either the normal bursa of the part, or one adventitiously developed, becoming enlarged and painful. The bunion is liable to repeated attacks of inflammation, and suppuration may occur, leading perhaps to the formation of a fistulous ulcer, accompanied by 524 SURGICAL DISEASES OF THE NERVOUS SYSTEM. Fig. 246. a carious condition of the bone and disorganization of the joint, constituting a form of the "perforating ulcer of the foot" of French Avriters. (Sec p. 515.) The treatment consists in the use of poultices or fomentations, followed by the application of nitrate of silver, to subdue inflammation, together with means adapted to restore the toe to its proper place. This may be best accom- plished by the use of Bigg's apparatus (the action of which may be seen from Fig. 246); or, in more severe cases, by dividing subcutaneously the exter- nal lateral ligament of the metatarso-phalangeal joint, or the tendons of the adductor or flexor brevis pollicis. In mild cases, it may be sufficient to pro- tect the part by the application of two or three thicknesses of soap plaster, cut into a horseshoe form, as recommended by Brodie, and by the adap- tation of a loose and well-fitting shoe. If the bunion contains fluid, and is uninflamed, attempts to pro- mote absorption may be made by applying an ointment of the red iodide of mercury (gr. x-|j), which is highly recommended by T. Smith. If this fail, subcutaneous puncture and discission of the sac, followed by the external use of iodine, may be tried, and is, according to Gross, as satisfactory as, Avhile it is certainly a safer method than, excision or incision with cauterization. If suppuration occur, the bunion must be opened and treated as an abscess. If caries and articular disorganization follow, am- putation through the metatarsal bone may be required, and will, I think, in this position, usually be preferable to excision either of the joint or of the head of the metatarsal bone—though the former operation has been per- formed with good results by Kramer, Pancoast, and others, and the latter by several surgeons, including Hueter, Hamilton, Gay, of Buffalo, and A. Rose, who recommends the operation even in cases of simple contraction Avithout caries (hallux valgus). Apparatus for the treatment of bunion. CHAPTER XXVIII. SURGICAL DISEASES OF THE NERVOUS SYSTEM. The affections of the nervous system Avhich specially demand attention from the surgeon, are Neuritis, Neuroma, Neuralgia, and Tetanus. Neuritis. Neuritis, or inflammation of a nerve, may occur as a consequence of rheu- matism, etc., from exposure to cold, or from wounds or other injuries. The chief symptoms are pain, extending downwards in the course of distribution of the nerve and aggravated by pressure, with general febrile disturbance. The line of the nerve is sometimes reddened and swollen, and there may be spasmodic jerking of the muscles of the part, with various reflex phenomena manifested in other portions of the body. The pathological appearances are swelling and increased vascularity of the neurilemma, Avith softening of NEUROMA. 525 the nerve structure itself. The treatment, in the acute stage, consists in the use of local depletion, with the application of ice, or of anodyne and emol- lient fomentations, as most agreeable to the patient, together with laxatiAes and diaphoretics, if there be much fever. The affected part should be kept in a state of absolute rest, and hypodermic injections of morphia, with or without atropia, may be employed if the pain is very intense. Colchicum may be used in cases of rheumatic origin, and iodide of potassium, quinia, etc., Avith counter-irritation, in those of a subacute or chronic character. Neuroma. Fig. 247. Neuromata are tumors developed on or between the fasciculi of a nerve. They are usually fibrous tumors, though a feAv appear to belong to the fibro- cellular variety, a feAv also containing cysts. Billroth and other modern pathologists divide neuromata into the true and false, the latter being the fibrous or fibro-cellular growths commonly found in connection Avith the nerves, while the former, or true neuro- mata, are "composed entirely of nerve filaments, especially of those with double contours; they appear to come only on nerves, and are very rare." Billroth is disposed to regard the " amyaline neuro- mata" of Virchow as really false neuro- mata, or, in other words, as fibrous tumors. Neuromata are almost exclusively con- fined to the nerves of the cerebro-spinal system,1 are most common in the male sex, and groAV sloAvly, sometimes attaining a very large size; they are commonly mul- tiple, not less than 1200 sometimes co- existing, according to R. W. Smith, in the same patient. A neuroma is movable transversely, but not longitudinally, on the nerve upon which it is developed. Neuromata may arise spontaneously, or as the result of injury; they may occur in the continuity of a nerve, or at its cut extremity, as is seen in stumps after amputation (see page 107). They are often, but not always, painful, the pain being usually of a parox- ysmal character, and sometimes excited only by pressure. In idiopathic neuroma the pain is referred almost exclusively to the peripheral distribu- tion of the nerve, but in traumatic cases is frequently felt in other parts, as a reflex phenomenon. When present in very large numbers, neuromata are, fortunately, usually painless. The painful subcutaneous tubercle is believed by many writers to be a "true neuroma" (see page 489). It is advised by BroAvn-Sequard that, in examining a neuroma, the nerve should be firmly compressed above the tumor, so as to diminish the pain caused by the neces- sary manipulations. The treatment consists in extirpation of the tumor, which should, if possible, be dissected from the nerve Avithout dividing the latter; if this cannot be done, Notta's plan might be folloAved, and the cut ends of the nerve approximated by means of a suture (see page 209). For the treatment of neuromata in stumps, see page 107. In cases of multiple Section of a neuroma; three nervous trunks terminating in it. The fibrous arrangement shown, as observed by the naked eye. (Smith.) 1 The " ]>le\iform neuroma," however (a name given by Verneuil), has been found in the solar plexus. 526 SURGICAL DISEASES OF THE NERVOUS SYSTEM. neuromata, operative interference can seldom be justifiable, but under such circumstances a trial may be given to electro-puncture, or the hypodermic use of morphia may be resorted to as a palliative measure. Prof. Kosinsky, a German surgeon, and Drs. Duhring and Maury, of this city, have, hoAV- ever, reported remarkable cases of multiple painful neuromata of the skin, in Avhich temporary relief Avas afforded by excision of the nerves of the affected parts. Neuralgia. Neuralgia is an affection of the nervous system, characterized by intense pain of a paroxysmal form, usually referred to the course of particular nerves. Any discussion as to the nature and pathology of neuralgia in gen- eral would be out of place in a Avork such as this, and I shall therefore consider merely those forms of the disease which come particularly under the notice of the surgeon. Neuralgia occurs usually in persons who are debilitated, and is predisposed to by various depressing causes, such as ex- posure to miasmatic influence, etc. It frequently coexists with hysteria, and not seldom with anaemia. It may be excited by some source of local irritation, as a decayed tooth, piece of necrosed bone, or exostosis, or may be a reflex phenomenon from irritation of another part, as in the toothache of pregnancy. The pain of neuralgia may follow accurately the course and distribution of a nerve, or may be felt over a considerable extent of surface, or in particular organs, such as the breasts, testes, or articulations—as in the cases of so-called "hysterical knee-joint." The pain may begin sud- denly, or may come on gradually, and is, in different cases, of every variety of character and intensity; it is always paroxysmal, and often absolutely intermittent, and is uniformly aggravated by the supervention of any addi- tional source of depression. There are almost always tender spots (points douloureux) in the course of the affected nerve, particularly where it pene- trates a fascia, or emerges from a bony canal, and very constantly there is tenderness over the spinous processes of those vertebrae which correspond to the part of the spinal cord whence the nerve originates. Another pecu- liarity of neuralgic pain is that it is almost always unilateral. Neuralgia is sometimes accompanied Avith spasm of the muscles supplied by the affected nerve; in other cases the surface becomes red, hot, and even slightly swollen, and there is often an increased secretion from neighboring glands, as the salivary or lachrymal. Though any part of the body may be affected by neuralgia, its most frequent seats are the branches of the fifth pair of cere- bral nerves, and the great sciatic; in the former situation it constitutes the disease knoAvn as "tic douloureux." The diagnosis is usually sufficiently easy: from inflammatory pain, neu- ralgia may be distinguished by its paroxysmal character, by the absence of fever, by the superficial nature of the pain (often accompanied with marked cutaneous hyperaesthesia), and by its being relieved rather than aggravated by pressure; if, however, as sometimes happens, neuralgia coexist Avith deep-seated inflammation, it may be extremely difficult to decide how much of the pain felt is to be attributed to one, and how much to the other affec- tion. In cases of neuralgia affecting the joints, the diagnosis may be assisted by remembering that organic disease cannot long exist in an articulation without causing deformity or other physical alteration. The prognosis of neuralgia, as regards life, is usually favorable; the disease, however, is often very intractable, and may cause so much suffering as to render exist- ence almost insupportable. The treatment must be both general and local. As the disease is almost NEURALGIA. 527 ahvays accompanied by debility, tonics are usually required: having first cleared out the boAvels by means of a cathartic, the surgeon may begin at once the use of quinia, in doses of four grains, three or four times a day; this drug, though particularly serviceable in cases of malarial origin, is adapted to all cases of neuralgia in Avhich the paroxysmal element is marked. Arsenic is another remedy of great value, and may be given in the form of arsenious acid, or of FoAvler's solution. Iron is particularly adapted to aiuemic cases, and valerianate of zinc and assafcetida to those which are complicated Avith hysteria. Advantage may often be derived from sea- bathing, or from the systematic employment of electricity, the cold douche, etc. In cases in Avhich there is nocturnal exacerbation, the iodide of potas- sium is found a valuable remedy. The local treatment consists in the appli- cation of sedatives or counter-irritants, and, in certain cases, in excision of a portion of the affected nerve. Chloroform and aconite liniments, and the veratria ointment, are among the most useful applications, but the hypoder- mic injection of morphia is unquestionably the most powerful means Ave possess for controlling neuralgic pain: from eight to fifteen minims of Ma- gendie's solution may be used at a time, the injection being repeated in the course of three or four hours if the pain is not relieved. Advantage may be sometimes derived from the simultaneous administration, by the hypo- dermic method, of morphia and atropia. A quarter of a grain of the for- mer Avith a thirtieth of a grain of the latter may be used, great care being exercised lest a poisonous effect be induced. Chloloform, carbolic acid, and nitrate of silver have also been employed hypodermically with advantage in some cases. Exeldon of a Portion of the Affected Nerve has been not unfrequently prac- tised in cases of neuralgia affecting branches of the fifth pair, and occasion- ally with the happiest results. In many cases, however, the relief has proved but temporary, the pain recurring after an interval of a few Aveeks or months in the same or another branch. The Infra-orbital and Mental Nerves may be reached by simply cutting doAvn at their points of exit from the infra-orbital or mental foramina, the nerves being then isolated and a portion excised. Lasalle advises that the infra-orbital nerve should be sought for in the orbital cavity itself. The Inferior Dental Nerve may be reached by raising a semi- lunar flap from over the ramus of the loAver jaw, and exposing the dental canal by means of a trephine; the nerve is then picked up Avith a blunt hook or director, and a portion of it excised. Prof. Gross has, by repeated applications of the trephine, succeeded in exposing and removing the Avhole extent of the nerve, from its entrance into the inferior dental canal to its exit at the chin—the portions of nerve thus exsected varying in length, in different cases, from tAvo and a half to three inches, and the operation having been apparently followed by the best results. Paravicini, Mosetig-Moorhof, Michel, and Terrillon, recommend an intra-buccal section of the nerve, which, hoAvever, appears to me more difficult and less satisfactory than the ordinary mode of procedure. Dr. A. Brown effected a cure in one case by thrusting . a hot steel Avire into the mental foramen, so as to destroy the nerve. The buccal branch of the inferior maxillary nerve has been divided from without by Michel, Letievant, and Valette, and from Avithin by Nelaton and Panas. The Superior Maxillary Nerve may be reached, close to the foramen rotun- dum, by means of a Y-shaped orsimple curved incision, both walls of the antrum being cut away Avith the trephine, and the loAver Avail of the infra- orbital canal with cutting-pliers and chisels. The nerve being separated from the other tissues in the spheno-maxillary fossa, and traced beyond the Ganglion of Meckel, is divided from beloAV upAvards Avith blunt-pointed, curved scissors. This bold and severe operation, Avhich Avas introduced by 528 SURGICAL DISEASES OF THE NERVOUS SYSTEM. Carnochan, of NeAV York, has been at least temporarily successful in several instances; but that the relief is not permanent, would appear from the re- searches of Conner, of Cincinnati, Avho has collected thirteen cases, in seven of Avhich the pain is known to have recurred, Avhile in only two of the re- mainder was the subsequent history of the patient traced for more than a year. Dennis, of New York, however, finds that more or less benefit has been derived from the operation of neurectomy in 16 out of 21 cases in which it has been resorted to. Neurectomy of the median, musculo-spiral, sciatic, and other nerves of the extremities, has been practised by various surgeons, including Sapolini, Brinton, Morton, Hodge, Golding-Bird, and myself, with at least temporary benefit. If the neuralgia arise from peripheral irritation, so that the affected portion of the nerve can be removed, an operation such as those which have been described, may probably suffice for a cure; if, however, the disease be of central origin, it is obvious that no operation can be of permanent benefit. When neurectomy is in any case resorted to, at least two inches of the affected nerve should, if possible, be removed, and care should be taken that the upper section is made through healthy structure; to prevent reunion, Dr. Mitchell approves Malgaigne's suggestion, that the distal end of the cut nerve should be doubled upon itself. It is almost needless to say that if the neuralgia appear to depend upon the irritation caused by a decayed tooth, or by a spiculum of necrosed bone, the effect of removing this should be tried before proceeding to any graver operation. Prof. Gross has described a form of neuralgia (of which I have myself seen two cases) depending upon a morbid condition of the alveolus, and curable by removing that part Avith cutting-forceps; and Drs. T. G. Morton and E. Mason have cured neuralgia of the metatarso-phalangeal joints by excison of the articulation. The operation of stretching nerves for neuralgia of traumatic origin has already been referred to at page 210, and the same operation has been employed in intractable cases of spontaneous origin by Mackintosh, Bramwell, Spence, Kocher, Nussbaum, Pooley, Bartleet, W. J. Morton, and other surgeons. Of 14 such cases collected by Gen, 10 were successful. The facial nerve has been successfully stretched in cases of spasm of the facial muscles by several surgeons, including Baum, Schussler, Eulenberg, Putnam, Southam, and Godlee. Walsham has successfully stretched the infra-orbital nerve, and Le- Dentu the lingual. The operation of nerve-stretching is not entirely free from risk, five cases recorded respectively by Socin, Langenbeck, Billroth and Weiss, Berger, and Benedikt, having terminated fatally.1 Ligation of the common carotid artery, in cases of facial neuralgia, is advised by Wein- lechner and Patruban, and has been successfully resorted to by F. H. Gross, of this city. 1 Nerve-stretching has been resorted to with more or less temporary benefit in a large number of cases of locomotor ataxia, but in other instances has proved useless, and in some has seemed to be positively injurious. Upon the whole, the weight of evi- dence is against the employment of the operation in this disease. Gillette has with • advantage stretched the median and musculo-cutaneous nerves for congenital epilepsy. McLeod, of Calcutta, Lawrie, and Wallace have successfully resorted to nerve- stretching for anaesthetic leprosy, and benefit has been claimed from the operation by Langenbuch in cases of pemphigus and senile prurigo. K. 31. Simon reports advantage from the same procedure in a case of infantile paralysis, and Blum in one of hysterical tremor of the leg, while W. J. Morton reports good results from nerve-stretching in reflex epilepsy, paralysis agitans, athetosis, lateral sclerosis, and chronic transverse myelitis. SYMPTOMS OF TETANUS. 529 Tetanus. Tetanus is a disease of the nervous system, characterized by persistent tonic contraction of some or all of the voluntary muscles. In the large majority of cases tetanus results from a Avound, or is traumatic, though it is also met Avith (especially in warm climates) as an idiopathic affection. Tet- anus occurs in both sexes and at all ages; excluding, hoAvever, cases of Puerperal Tetanus, and of Tetanus Nascentium (which, according to Parrot, has much closer analogies Avith ursemic ecclampsia1 than Avith true tetanus), it is by far most common in males in early adult life, though, probably, not disproportionately so, in vieAV of the peculiar liability of these to be exposed to traumatic lesions. It occasionally occurs as an epidemic, and appears to be predisposed to by hot Aveather and by sudden changes of temperature. It is more frequent in the negro than in the Avhite. Traumatic tetanus is the form of the disease which particularly demands the surgeon's attention. It may folloAv upon a mere contusion, such as the stroke of a whip, but is chiefly seen after punctured or lacerated Avounds, or after burns and scalds; the extent of the Avound appears to have no causative influence, the slightest being as often followed by tetanus as the most extensive injuries. It may occur after any surgical operation, Avithout regard to its severity. Tetanus is more frequently met Avith in military than in civil practice, the proportion of cases in the Peninsular Avar having been 1 of tetanus to 200 Avounded, in the Crimean Avar 1 to 500, in the SchlesAvig-Holstein campaign 1 to 350, and in our late war 1 to 242.2 Exposure of the wounded to severe cold, and more particularly a sudden change from heat to cold, has been found a prolific source of tetanus in military surgery. The disease is apt to occur in those who are depressed or debilitated; it thus seems occasionally to follow in the wake of secondary hemorrhage. Varieties. — Several varieties of tetanus have been distinguished, accord- ing to the group of muscles affected: thus, Trismus, or Lock-jaw, refers to the clenching of the teeth from tonic spasm of the muscles of mastication; Opisthotonos, to spasm of the muscles of the back, the patient with arched body resting merely on head and heels; Emprosthotonos (very rare), to a similar arching of the body in a forward direction; and right or left Pleuros- thotonos, to a similar bending to one or the other side. Tetanus may occur very soon, even less than an hour, after the reception of a wound, or not for several Aveeks; usually, in temperate climates, from the fifth to the tenth day. The earlier the disease is developed, the more likely is it to prove fatal, cases occurring after the third Aveek offering a comparatively favorable prognosis. Acute tetanus is much more fatal than the chronic form of the disease: of 327 cases of death from tetanus, analyzed by Poland, 79 occurred within two days, 104 in from tAvo to five days, 90 in from five to ten days, 43 in from ten to tAventy-tAvo days, and 11 after tAventy-two days. The most rapid death occurred in from four to five hours, while the longest duration of a fatal case Avas thirty-nine days. Symptoms.—The symptoms of tetanus may come on suddenly, or may be gradually and insidiously developed; occasionally a feeling of general discom- fort precedes for some time the characteristic manifestations of the disease, 1 According, hoAvever, to Marion Sims and P. A. Wilhite, of South Carolina, tetanus nascentium is a traumatic affection resulting from displacement of the occipital or of one of the parietal bones. 2 363 cuses to 87,822 wounded. (Circular No. 6, S. G. O., 1865, p. 6.) 34 530 SURGICAL DISEASES OF THE NERVOUS SYSTEM. or there may be gastric and intestinal derangement, or the Avound (if it have not healed) may become dry and unhealthy-looking. The first decided symptom is commonly a feeling of stiffness, Avith pain on motion, affecting the muscles of the lower jaw and tongue, and those of the back of the neck; in other cases, hoAvever, the cramps are first manifested in the muscles of the wounded limb. In a short time, great difficulty in chewing or swallowing is felt, and trismus soon becomes fully developed, Avith intense pain and slight tendency to opisthotonos; violent pain reaching from the precordial region to the spine, and doubtless due to spasm of the diaphragm, is noAv experienced, and forms a very characteristic symptom of the disease; the abdominal mus- cles become tense, hard, and board-like, and all the voluntary muscles, except those of the hand, eyeball, and tongue, become more or less involved. The countenance assumes a peculiar, old-looking expression, being pale, anxious, and distorted into the so-called risus sardonicus or tetanic grin. This distor- tion of face sometimes persists after recovery, and Poland refers to a case in Avhich it Avas still apparent after eleven years. During the height of the disease, the body is often arched backwards, so that the patient is supported merely by his occiput and heels; Avhile the muscular spasm is tonic, and never entirely disappears, it is paroxysmally aggravated—and the cramps are oc- casionally so violent as almost to hurl the patient from his bed; the pain is greatest during the cramps, which are also accompanied by profuse perspira- tion and great heat of skin (105°-110.75° Fahr., according to Dr. Radcliffe).1 As the disease advances, the reflex excitability is much increased, the slightest touch or the least current of air being sometimes enough to bring on a paroxysm of cramp. Dyspnoea and want of sleep combine to render the condition of the patient still more deplorable. There is no delirium, and little or no fever, the heat of the skin being chiefly confined to the paroxysms, and the rapidity of the pulse being due to exhaustion rather than to febrile disturbance. Among the symptoms of less importance are constipation, retention of urine, priapism (probably due to spinal meningitis), aphonia, accumulation in the mouth and fauces of viscid saliva, self-inflicted lacerations of the tongue or cheek, and permanently dilated or contracted pupils. Death may occur in a paroxysm, from apncea; or, at a later period, from simple exhaustion. There may be a certain degree of muscular relaxtion previous to death, or tetanic rigidity may be, as it were, directly transformed into rigor mortis. Pathology.—The pathology of tetanus is involved in much obscurity. I have called it a disease of the nervous system, because it is through the medium of the nerves and spinal cord that its phenomena are manifested, and because the nervous system alone has as yet been found to present post- mortem changes Avith sufficient constancy to be considered significant. It is, however, quite possible that, as suggested by Travers, J. A. Wilson, Richard- son, and others, tetanus may eventually prove to be a blood disease, due to the absorption of some septic material. The nerve or nerves in the imme- diate neighborhood of the wound are commonly, though not invariably, found to be inflamed, lacerated, or contused, and it is at least possible that, even in those cases in which the nerves appear healthy, they may have been temporarily diseased, and that a nerve lesion has been really the starting- point of the affection. The muscles have frequently been found ruptured, and are, according to L. Conor, the seat of granular and fatty changes, such 1 The temperature may continue to rise even after death; thus, in a case recorded by Wunderlich, the thermometer marked 108° before death, 112.5° at the time of death, and 113.5° a short time subsequently. Dr. Ogle, of London, and Dr. Keen, of this city, have recorded cases in which the evening was higher than the morning temperature. PATHOLOGY OF TETANUS. 531 as have been observed in cases of typhoid fever. Duclaux has seen tetanus prove fatal through rupture of the heart. The most important post-mortem changes of tetanus are found in the spinal cord, and have been particularly investigated by Lockhart Clarke, Dickinson, Charcot and Michaud, Aufrecht, Stirling, and Coats, of GlasgOAV. The first-named writer ascertained, from an examination of six specimens, that there were, in several portions of the cord, marked patches of softening and disintegration affecting the gray mat- ter, the cord itself being altered in shape. The structural change varied from mere granular softening to absolute fluidity, and was accompanied by numerous extravasations of blood. " In the walls of the bloodvessels there Avas no morbid deposit nor any appreciable alteration of structure, except Avhere they shared in the disintegration of the part to Avhich they belonged; but the arteries Avere frequently dilated at short intervals, and in many places Avere seen to be surrounded ... by granular and other exudations, beyond and amongst Avhich the nerve tissue . . . had suffered disintegration. We have reason, therefore, to infer that the lesions of structure had their origin in a morbid condition of the bloodvessels, resulting in exudations with impairment of the nutritive process."1 The following are Mr. Clarke's conclusions as to the pathology of tetanus: (1) it is probable that these lesions are not present in cases Avhich recover, or, if present, are so in but a slight degree; (2) these lesions are not the effect of excessive functional activity of the cord, but result from a morbid state of the bloodvessels; (3) these lesions are not the sole cause of the te- tanic spasms, as similar lesions exist in cases of paralysis unaccompanied by tetanus; and (4) the tetanic spasms depend, first, on an abnormally excitable state of the gray nerve-tissue of the cord, induced by the hypersemic and morbid state of its bloodvessels, with the exudations and disintegrations re- sulting therefrom (this state of the cord being either an extension of a similar state along the injured nerves from the periphery, or resulting from reflex action on its bloodvessels excited by those nerves), and secondly, on the per- sistent irritation of the peripheral nerves, by which the exalted excitability of the cord is aroused—the same cause thus first inducing the morbid suscep- tibility of the cord to reflex action, and subsequently furnishing the irritation by Avhich reflex action is excited. Dr. Dickinson's2 observations tend to confirm those of Mr. Clarke, and add the interesting fact that the situations of the various lesions correspond ana- tomically Avith the side on which the injury exists. " The irritation from the left hand, conveyed, as Ave must suppose, by certain of the left posterior roots, occasioned especial congestion of the left posterior horn, and further changes in the white matter in contact Avith it—that is, in the left posterior and lateral columns. The central and anterior parts of the gray matter were most extensively affected on the side opposite to that of the injury, as might have been anticipated from the decussation in the cord of the sensory fibres. The irritation having reached any column or segment of the cord, appeared to diffuse itself throughout its whole length with undiminished intensity. Although the cervical region must have been the first recipient of the morbid influence, the lumbar part of the cord, both in the white and gray matter, was at least as severely affected." Charcot and Michaud note the same appear- ances that are described by Lockhart Clarke, but believe them to be due to exudation from the bloodvessels, and not to degenerative changes. It is in the posterior commissure of the gray matter of the cord, and especially in the lumbar region, that they have found Avhat they regard as the " essential 1 Med.-Chir. Trans., vol. xlviii. p. 264. 2 Ibid., vol. Ii. pp. 265-275. 532 SURGICAL DISEASES OF THE NERVOUS SYSTEM. alteration" of tetanus; this consists in the development of a large number of nuclei Avhich are variously disposed, and many of which are flattened from mutual compression; the changes are in fact the same as, though perhaps more marked than, those described by Fromman as occurring in cases of subacute myelitis. Coats has observed the morbid changes in the medulla oblongata, as well as in other portions of the spinal cord. Ringer and Mur- rell controvert the ordinary vieAv that tetanus is due to increased excitability of the spinal cord, and believe that it is due to a diminished " resistance" of the cord, which alloAvs impressions conveyed by the afferent nerves to spread through the reflex portion of the central nervous system. According to Ross, very much the same changes are found in tetanus as in hydrophobia, and this writer suggests that the differences in symptoms may be due to the cerebellum being more involved in the former, and the cerebrum in the latter, disease. Amidon has ingeniously tried to connect the various symp- toms met with in tetanus Avith the several lesions discovered after death. Diagnosis.—Tetanus may be distinguished from spinal meningitis by the early fixation of the jawr, and by the occurrence of paroxysmal spasms with permanent muscular rigidity in the intervals—the rigidity of spinal menin- gitis being, in a great degree, voluntarily assumed in order to preArent pain of motion. From hydrophobia, the diagnosis may be made by observing that, in the latter disease, the spasmodic movements are clonic, not tonic, that the face is convulsed and restless (no risus sardonicus), and that deli- rium is as common as it is rare in tetanus. From poisoning by strychnia, the diagnosis is sometimes very difficult, particularly if comparatively small quantities of that drug have been repeatedly administered. It is to be ob- served, however, that in strychnia-poisoning there may be complete intermis- sions between the paroxysms, and that (according to Poland) there is spasm of the muscles of respiration, Avith early and marked laryngismus, but no fixation of the jaw—the patient being able to open the mouth and swallow. Tetanus has been mistaken for rheumatism, and, on the other hand, hysteria has not unfrequently been mistaken for tetanus; the diagnosis, could, how- ever, scarcely be very difficult, unless (as in a case mentioned by Copland) tetanus and hysteria actually coexisted in the same patient. Prognosis.—The prognosis of acute tetanus is invariably unfavorable. It is doubtful Avhether there be any authentic case of recovery under such cir- cumstances. In the subacute or chronic cases, the disease being developed at a comparatively late period, and running a less violent course, there is more hope of a successful issue, and by prompt treatment life may occa- sionally be preserved. It may be said in general terms that the later the development of the disease, the more chance is there of recovery. Treatment.—This should be both general and local. The General Treat- ment should consist in the administration of such remedies as may diminish the morbid excitability of the spinal cord, and at the same time lessen the irritation of the peripheral nerves—it being probably to a combination of these tAvo elements that the production of the tetanic spasm is due. At the same time, concentrated nutriment in a fluid form should be given as freely as practicable, for death frequently results, as has been seen, from pure exhaustion. The modes of treatment Avhich have been proposed for tetanus are almost countless, including such diverse remedies as venesection, actiA^e stimulation, profuse purgation, and the induction of narcotism Avith opium. All means fail in acute cases—each has been occasionally successful in those of the chronic variety. The drugs Avhich have obtained most reputation of TREATMENT OF TETANUS. 533 late years have been opium, conium,1 belladonna, cannabis Indica, woorara,2 bromide of potassium, hydrate of chloral, and the Calabar bean. Of these the first and the tAvo last are those upon which I should, at present, be dis- posed to place most reliance, and of Avhich I would therefore recommend the employment. Eighteen cases collected by Dr. Eben Watson, in AAhich the Calabar bean Avas used, gave ten recoveries and eight deaths; upon the whole, a favorable record. The bean may be given in large doses (Holt- house gave 4i grains of the extract at once, the patient recovering), the only limit to its administration being the effect produced in controlling the spasms. It appears to act as a direct sedative to the spinal cord, and it has the addi- tional advantage that it enables the patient Avhile under its influence to take food Avith facility. It may be given by the mouth or rectum, or by hypo- dermic injection, a third of a grain of the extract being probably a large enough dose for the latter mode of administration. The sulphate of eserine has been successfully employed by Layton, of New Orleans. Opium in large doses may be properly given at the same time Avith the Calabar bean, as suggested by Holthouse, on account of its Avell-known sedative effect upon the peripheral nerves. Demarquay recommends the hypodermic injection of morphia into the masseter, or Avhatever muscle may be chiefly affected. From an analysis of nearly 400 cases, Knecht concludes that chloral is the most promising remedy, 157 cases in which this was given alone or in com- bination having furnished but 59 deaths—a mortality of less than 38 per cent. A cathartic may sometimes be required at the beginning of the treat- ment, to remove any irritating matters from the bowels, and concentrated food and stimulus must be given, throughout the case, in as large quantities as the patient can be induced to take. The inhalation of ether or chloro- form may be occasionally resorted to Avith temporary benefit, and the appli- cation of an ice-bag to the spine might be tried, though its use should be Avatched, lest it induce too great depression. Tracheotomy has occasionally been resorted to, and, according to Richet, may be expected to be of service Avhen spasm occurs in expiration. The inhalation of nitrite of amyl has been successfully employed by Foster, Curtis, Funkel, and Forbes, of this city. The Local Treatment is likewise of importance: the Avound should be ex- plored, and any foreign bodies carefully removed. The afferent nerve or nerves (if any can be recognized) should be divided or partially excised, or, if the operation be otherwise indicated, amputation may be performed, if a limb be the seat of injury. Nerve-stretching, as suggested by Nussbaum and Callender, has been successfully resorted to by Verneuil, Vogt, Wheeler, W. J. Smith, (lark, Ratton, and Ransohoff, but in my own hands, as in those of most Avho have tried it, has failed to given even temporary relief, 33 cases to which I have references having given but 8 recoveries. Though section of the nerve Avill promise best if resorted to at an early period, it should not be neglected even at a later stage of the case. If no special nerve-lesion can be detected, a y\ incision down to the bone maybe made, as advised by Liston and Erichsen, so as to insulate the part. The wound itself should be dressed Avith narcotics—particularly opium, in the form of laudanum, or a solution of sulphate of morphia (gr. v-flj), or, if the Avound is sloughing, powdered opium with charcoal (9j-3j)—and in cases of burn or scald, this will often be the only local treatment which can be employed. The appli- cation of atropia to the end of the divided nerve, or by hypodermic injection, 1 Hypodermic injections of conia have been used with some success by Prof. C. Johnston, of Baltimore. 2 A recovery under the use of woorara has been recently reported by Dr. Maturin, an Irish surgeon. 534 SURGICAL DISEASES OF THE VASCULAR SYSTEM. has occasionally been found useful. If the wound Avere already healed, it would be proper to dissect out the cicatrix, as the entanglement of a nerve filament in the scar might prove to have been the starting-point of the disease. Laurent has collected 54 cases of operation for the relief of tetanus, with 29 recoveries, classified as follows: neurotomy, 13 cases and 7 recoveries; minor amputation, 17 cases and 11 recoveries; and major amputation, 24 cases and 11 recoveries. Knecht's tables give 58 cases Avith 28 deaths. Letievant reports 16 neurotomies with 10 recoveries. But, as justly re- marked by E. Labbee, the recoveries have usually been in chronic cases, in Avhich equally good results may often be obtained by internal treatment alone. During the whole course of treatment, the patient should be kept in a rather dark, warm, and dry room, and should be carefully guarded from currents of air. CHAPTER XXIX. SUKGICAL DISEASES OF THE VASCULAE SYSTEM. Diseases of Veins. Phlebitis.—Phlebitis, or Inflammation of a Vein, may result from injury, or from the absorption of septic material. It is probably (as mentioned at page 173) by means of local inflammatory changes, in conjunction with coagulation of the contained blood, that veins are repaired after division or rupture; and this clotting or thrombosis of the venous contents is the most important element in connection with inflammation of a vein. It may be either a primary or a secondary phenomenon, either the cause or the conse- quence of the changes in the venous coats, to which the term phlebitis is applied; thus the phlebitis of pysemia, and that seen after parturition (phleg- masia dokns), are the results of previous venous coagulation, while in many cases of lacerated wound, fracture, etc., the changes in the venous walls prob- ably precede the formation of a clot. It is in the outer coats of a vein, according to H. Lee,1 who has particularly investigated the subject, that the changes of phlebitis are chiefly found. The cellular coat becomes preter- naturally vascular and reddened, and is at the same time distended with serum, lymph, or pus, either separately or commingled. The circular fibrous coat is similarly affected, but in a less degree, becoming injected and thick- ened. The inner coat loses its normal transparency, becoming wrinkled or fissured, of a dull whitish color, and more or less stained by the venous contents, its hue varying with that of the contained coagulum. The inner and outer coats of an inflamed vein may be separated by the products of inflammation, the various layers of the inner coat becoming disintegrated, or flakes of its lining membrane being cast off into the interior of the vessel. Phlebitis destroys the natural pliability of the venous coats, so that, when divided, an inflamed vein remains patulous like an artery. The formation of a clot in an inflamed vein is caused, as pointed out by Schmidt, by the union of two substances always found in the blood, AA'hich he calls fibrinogen and fibrinoplastin; it is obviously designed by nature to 1 Practical Pathology, vol. i., Lectures II.-IV. diseases of veins. 535 prevent the entrance of morbid materials into the general circulation, and hence, Avhei' the clot is well formed, and in a healthy person, the disease is local and unattended Avith any particular danger. Dr. Nancrede, of this city, has ingeniously suggested that the extension of the clot depends upon the communication of lateral veins bringing fibrinogenetic material Avhich results from the disintegration of tissue, and that hence Avhen, in traumatic cases, the clot has reached beyond the point at which veins carrying such impure blood from the seat of disease reach the main channel, the process of coagulation is arrested. The clot undergoes changes, becoming partially organized, and converting the A^essel into a fibro-cellular cord; or may con- tract so as to alloAV the partial resumption of the circulation; or may per- haps undergo a slow process of solution, and ultimately entirely disappear. Under other circumstances, the result is not so favorable: a large fragment of clot may become mechanically loosened and dislodged, and, being carried into the general circulation, may plug an important vessel (embolism), occa- sionally even causing a fatal termination, as has happened in cases of phleg- masia dolens; or, if the blood be in an unhealthy condition (as in pyaemia), and the clot imperfectly formed, disintegration may follow, with capillary embolism, leading to the formation of pyaemic patches, or the so-called metastatic abscesses (see page 418). Symptoms.—An inflamed vein becomes hard, someAvhat SAVollen, painful, and cord-like; it has, besides, a peculiar knobbed feel and appearance, the knobs corresponding to the positions of its valves. The course of the vein is marked by a distinct, dusky-red line, and the whole limb becomes somewhat stiff, and may be the seat of intense pain, sometimes of an intermittent or neuralgic character. There is always some oedema along the course of the vein and in the parts beloAV, OAving to the obstructed circulation and the con- sequent effusion of the fluid portion of the blood. This oedema may be soft, allowing pitting on pressure, or may be hard and tense. If the vein be deep- seated, the occurrence of tumefaction and pain may be the only evidences of phlebitis. The oedema usually subsides Avith the restoration of the circula- tion through the natural or collateral channels, though it may persist for a considerable period. The constitidional disturbance attending phlebitis is rarely of a grave character. The conditions described by many Avriters as suppurative and diffuse phle- bitis appear to be really examples of diffuse inflammation of the areolar tissue, or of cellular erysipelas, which often extend rapidly in the course of the veins, and which are apt to terminate in pysemia. (See pages 394, 409, 417, and 517.) Diagnosis.—The affection Avith which phlebitis is most likely to be con- founded is angeioleucitis, Avhich, however, maybe distinguished by observing the brighter redness Avhich it presents, and its invariable complication with adenitis. Deep-seated phlebitis may be mistaken for neuralgia, but the diagnosis may be made by observing that the pain of the latter affection is rather relieved than aggravated by pressure, and is not accompanied by oedema. The latter circumstance may also serve to distinguish inflammation of a vein from neuritis. Prognosis.—Phlebitis in itself is rarely attended with risk to life; Avhen, however, inflammation of a vein is a mere concomitant of pysemia, or other grave constitutional condition, the question is very different; and even trau- matic phlebitis, occurring in a person who is broken down in health, should be looked upon as a grave affection. Treatment.—In the treatment of phlebitis, all depressing measures should be avoided, the chief risk of the affection being from deterioration of the general health and consequent disintegration of the venous coagulum. If the 536 surgical diseases of the vascular SYSTEM. tongue be heavily coated, with fever and anorexia, half a grain of blue mass with tAvo grains of quinia may be given every tAvo or three hours, until about three grains of the mercurial have been taken, but beyond this the remedy should not, usually, be pushed. The quinia may be continued, eight or twelve grains being given in the course of tAventy-four hours; and the muri- ated tincture of iron may be added, in combination Avith the spirit of Minde- rerus if the use of a diaphoretic be indicated. In milder cases, of course, less energetic measures will be required. The diet should be nutritious and easily assimilable, and stimulus may be given or Avithheld, according to the general condition of the patient, who should be kept in bed and at perfect rest. The local treatment, in mild cases, may consist merely in the use of warm fomentations or evaporating lotions, as most agreeable to the patient; but if the inflammation appear disposed to extend upAvards, Avith severe constitutional disturbance, an effort may be made to prevent its spread by the operation proposed by H. Lee, Avhich consists in acupressing a healthy portion of the vein at two points about three-fourths of an inch apart, and then dividing the vessel subcutaneously between them. The oedema may be relieved by position, by gentle friction, and by the subsequent use of an elastic bandage. Varix, Varicose Vein, or Phlebectasis, consists in a morbid dilatation of a vein, usually accompanied by thickening of its Avails. Any veins may become varicose, but those most commonly affected are the veins of the loAver extremity, scrotum, and rectum. The varicose condition may be limited to the principal venous trunks of the part, or may affect the subcutaneous venous plexus, giving the appearance of a netAvork of a purple hue. The branches of the internal saphena are most frequently affected among the superficial veins, but it is probable that in the majority of cases the deep vessels are likewise more or less involved. The anatomical conditions of varicose veins vary in different cases: thus, together with the dilatation, there is often elongation, rendering the vessel tortuous; or the Avails may be thinned instead of thickened; or the dilatation may be sacculated, forming pouches which generally correspond to the points of intercommunication Avith other veins. The causes of varicose veins are tAvofold : (1) such as pump into the veins an abnormal quantity of blood, as unusual muscular exertion, walking, etc.; and (2) such as mechanically impede the venous circulation, as the pressure of a tumor, or that of the pregnant uterus. A depressed or feeble state of health appears sometimes to act as a predisposing cause, while in some cases the occurrence of varicosity has been attributed to the effect of hereditary influence. Any occupation Avhich requires the maintenance of the erect posture predisposes to varix. Varicose veins are rare in early life, and are rather more frequent in Avomen than in men. The symptoms of superficial varix are easily recognized, the dilated and tortuous condition of the affected veins being quite characteristic. The patient often has a sensa- tion of Aveight and fulness in the part, with some numbness, and occasionally loss of power, and frequently a dull, aching pain which is aggravated by exercise. The limb is sometimes oedematous. Deep varix is more difficult of recognition, the subjective symptoms commonly existing for some time before the implication of the superficial veins renders the nature of the dis- ease apparent. Muscular cramps are, according to Mr. Gay, quite significant of a varicose condition of the deeper veins. Varicose veins are liable to be attacked by phlebitis and thrombosis, Avhile inflammation of the surrounding tissues may lead to various troublesome conditions, such as the occurrence of eczema, or of ulceration (giving rise to the varicose ulcer), or to a sclere- matous condition of the part analogous to the Arabian elephantiasis. A VARICOSE VEINS. 537 varicose vein occasionally gives way by rupture or by ulceration, the accident leading to profuse, or even to fatal, hemorrhage. The Treatment of varicose veins may be either palliative or radical, the former being alone proper in the large majority of cases. The Palliative Treatment consists in giving support to the part, with gentle and equable pressure, by means of a flannel or India-rubber bandage, or an elastic stock- ing—the general health being maintained by the use of laxatives to prevent constipation, Avith tonics, especially the muriated tincture of iron, if, as usu- ally happens, the patient be in a feeble and relaxed condition. Hemorrhage from a varicose vein may be checked by elevating the limb and applying a firm compress. The Radical Treatment may be employed if the varicose vein be evidently so altered in structure as to be useless for carrying on the circulation (particularly if it be also painful), if its coats be so attenuated as to threaten hemorrhage, or if it be connected with an ulcer which cannot be induced to heal. This mode of treatment consists in the obliteration of a portion of the vein, and it is radical as far as that portion is concerned, Fig. 248. Application of pins to varicose veins. (Miller.) though it by no means insures a. cure of the general disease, Avhich, indeed, in most instances, must be looked upon as incurable. Various means have been proposed for the obliteration of varicose veins, such as (1) the applica- tion of caustic, so as to form eschars over the line of the vessel, or, as recently suggested by Linon, the application of a strong solution of the sulphate of iron; (2) the injection of coagulating agents (chloral is particularly recom- mended by Porta, and other Italian surgeons) ; (3) the hypodermic injection of ergotin or alcohol; (4) the passage of an electric current through the vessel; (5) the subcutaneous section of the vein; (6) its compression at various points by means of a pin passed beneath the vessel, Avith a compress or piece of bougie above, the two being fastened together Avith a thread, or Avire, in the form of a figure-of-8 (Fig. 248) ;x (7) the application of a metallic ligature; (8) simply denuding and isolating the vein, as recommended by Kigaud, Cazin, and Bergeron ; and (9) excision of a part of the vein, a Celsian mode of treatment recently revived by Marshall, Steele, Hoavsc, Davies- Colley, and Dunn. Probably the best plan is that recommended by H. Lee, which consists in (10) securing the vein at two points, about an inch apart, by passing acupressure-needles beneath, but not through, the vessel; apply- ing, over the ends of the needles, elastic bands or figure-of-8 ligatures; and then subcutaneously dividing the vein at an intermediate point. The needles, which are removed in three or four days, serve to approximate, without injuring, the sides of the vein, while obliteration of the vessel takes place at the point of subcutaneous section, the parts healing in about a Aveek. 1 A special instrument for compressing veins in this manner is employed, under the name of "vein-brooch," by Mr. J. R. A. Douglas, of Hounslow. 538 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Vascular Tumors or Angeiomata.1 (Arterial Varix, Aneurism by Anastomosis, Nevus.) Arterial Varix or Cirsoid Aneurism is a disease which consists in the simultaneous elongation and dilatation of an artery. When, as is frequently the case, the capillary network is also involved, the disease receives the name of Aneurism by Anastomosis or Racemose Aneurism, but the two affections are, in every essential respect, the same. The vessels become tortuous, and in parts sacculated, their coats (especially the middle) being thin, and caus- ing the artery to resemble a vein. Fig. 249. This affection is most common about the scalp and face, but may occur in other parts, as the tongue, ex- tremities, internal viscera, and bones; it is chiefly met with in early adult life, and its develop- ment is often attributed to a blow or other injury. Aneurism by anas- tomosis forms a tumor or outgroAvth, of variable size and shape, usually of a bluish hue, compressible, and communicating to the touch a spongy or doughy sensation, accom- panied by a Avhiz or thrill, some- times amounting to pulsation, and synchronous Avith the cardiac im- pulse. This thrill disappears when the arteries leading to the tumor (which are themselves usually di- lated and tortuous) are compressed, and returns with an expansive pul- sation Avhen the pressure is removed. Auscultation gives usually a loud, superficial, cooing bruit, though occasionally a softer blowing sound. The temperature of the part is some- what elevated. The diagnosis from ordinary aneurism may be made by noting the position of the growth (probably at a distance from any large artery), its doughy and compressible character, and the thrill, rather than distinct pulsation, which accompanies the re-entrance of the blood, Avhen, after compression of the neighboring arteries, the pressure is removed. The bruit is more superficial than that of aneurism, and compression of the ar- terial trunks does not so completely mask the physical signs of the disease as in that affection, blood still entering the part from other sources. When occurring in bone, aneurism by anastomosis may be mistaken for encephaloid, with Avhich, indeed, it may co-exist. The treatment should vary with the size and position of the groAvth. Ex- cision or Ligation, in the way which will be described when we come to speak of nsevus, is the mode of treatment to be preferred when the affection is not very extensive, and suitably situated, as on the lip, scalp, or extremi- ties. If excision be employed, the knife must be carried wide of the disease, in order to avoid profuse or possibly fatal hemorrhage. # / v/ ■<&■'// ' A" J Aneurism by anastomosis. (Fergusson.) 1 See page 488. N^VUS. 539 If the tumor be too large for ligation or excision, it will usually be prudent not to interfere, unless the integument be so thinned as to threaten rupture. When it is decided to operate, several methods are open to the surgeon, the most promising being electro-puncture, the injection of coagulating fluids, and deligation of the main artery of the part. The use of coagulating in- jections is generally preferred by French surgeons; Broca has reported a case in which, after the failure of acupressure to the nutritive arteries, he effected a cure by injections of perchloride of iron, the passage of the styptic being limited by surrounding the points of injection Avith rings of lead, and the tumor being attacked in sections by dividing it into lobes by means of tubes of caoutchouc. Bigelow has succeeded by the injection of a saturated solution of nitrate of silver. Heine, from a study of sixty cases, concludes that, for small tumors, simple excision is the best remedy, while for those which are larger, preliminary ligation of the carotid or nutrient arteries, and subsequent excision at one or more sittings, are to be preferred. Ligation of the main artery is the plan which has been most frequently employed, par- ticularly when the affection has involved the orbit. In such a case the primi- tive carotid is the vessel to be tied; but if the disease were limited to the scalp, it might be better to adopt Bruns's suggestion, and tie one or both ex- ternal carotids instead. Thirty-one cases of ligation of the common carotid for erectile tumor, etc., tabulated by Norris, gave eighteen recoveries and eight deaths. In other cases, again, it might be preferable to tie the various arteries in the immediate vicinity of the vascular growth, surrounding the latter at the same time by deep incisions, as was successfully done by Gibson. The only treatment to be recommended for aneurism by anastomosis occur- ring in the long bones is amputation. Naevus is an affection very analogous to the preceding, but differs from it in involving chiefly the capillaries or veins. When congenital, naevus con- stitutes the so-called mother's mark. 1. Capillary Ncevi, which are commonly, if not ahvays, congenital, occur as flattened elevations, of a red or purple hue, usually upon the face or upper part of the trunk, but occasionally in other situations. They may involve a considerable extent of surface, but rarely give any annoyance except from the attendant deformity. Sometimes, however, they ulcerate and bleed. They consist of a congeries of capillary vessels, and may accompany the aneurism by anastomosis on the one hand, or the venous nsevus on the other. 2. Venous Ncevi occur as prominent tumors or outgrowths, of a reddish- purple hue, smooth or lobated in outline, and somewhat compressible, doughy, and inelastic to the touch; they are less exclusively confined to the upper part of the body than the capillary nsevi, and, in their structure, consist of thin, tortuous, and sacculated veins, often interspersed Avith cysts. Venous nsevi may occur subcutaneously, when they form tumors Avhich may be par- tially emptied by pressure, slowly filling again when the pressure is removed, and becoming distended by violent exertion or struggling on the part of the patient. Treatment.—Cutaneous nsevi which are small and not disposed to spread, may often be left without treatment—when they may disappear spontane- ously; and, on the other hand, a nsevus may involve such a large extent of surface as to forbid any attempt at its removal. The shrivelling of small cutaneous nsevi may sometimes be hastened by the application of tincture of iodine. Bradley, of Manchester, recommends tattooing with carbolic acid, and an ingenious instrument for the purpose has been devised by Sher- Avell, of Brooklyn, who supplements the operation by compressing the part by the application of collodion. For the treatment of the diffused form of 540 SURGICAL DISEASES OF THE VASCULAR SYSTEM. nsevus known as " port-Avine stain," B. W. Richardson advises the applica- tion of the ethylate of sodium, while Squire recommends linear scarification Avith a frozen scalpel, followed by compression, the part itself being first frozen with the ether-spray apparatus. The last-named surgeon has also devised an ingenious instrument for the purpose, consisting of a number of thin knife blades placed closely together; the incisions are best made in an oblique direction to the surface. Moderately large, or subcutaneous, or even small cutaneous nsevi, if they are so placed as to cause disfiguration, may be removed by several methods. Various plans have occasionally proved successful, such as vaccination over the growth, the use of a seton, the application of styptics or vesicants, the introduction of heated wires, electro- puncture, or subcutaneous discission Avith compression; the best modes of treatment, however, are commonly the application of caustics, the use of coagulating injections, excision, and ligation. (1.) When the nsevus is superficial, and so situated that the presence of a scar will not be particularly objectionable, the application of nitric acid or the Vienna paste may suffice to effect a cure, the application being repeated if there be any tendency to a recurrence of the affection. Sodium ethylate is recommended by Dr. B. W. Richardson and Dr. J. Brunton in preference to nitric acid, as causing less destruction of the epidermis. (2.) Injection of a solution of the perchloride or persulphate iron, by means of an ordinary hypodermic syringe, may be employed for small nsevi in certain situations, as the eyelid or orbit, where other modes of treat- ment Avould be inapplicable; the quantity injected should be very small (not more than two or three drops at a time), and compression should be made upon the returning veins, lest some of the injected fluid should enter the general circulation, and perhaps cause death, as has actually occurred in cases recorded by Kesteven, Bryant, West, and others. (3.) Excision^ may be practised when the nsevus is of large size, and in the form of a distinct tumor, the incisions being carried wide of the disease, except when, as occasionally happens, the growth is surrounded by a capsule^ and when therefore, as advised by Teale, enucleation may be safely practised! This condition is, according to Erichsen, most common in cases of nsevus associated with fatty or cystic growths. OAven recommends excision Avith Paquelin's thermo-cautery as applicable to the largest nsevi. (4.) Ligation is in most instances the best mode of treatment, and may be applied in several ways. If the nsevus be small, it may be sufficient to pass harelip pins in a crucial manner beneath the growth, and throw a ligature around their ends, or a double ligature may be introduced, and the naevus tied in two halves. In other cases the quadruple ligature should be employed. This may be applied by passing beneath the nsevus two strong needles, eyed at the points, and crossing each other at right angles—the skin over the growth being, if healthy, previously reflected in flaps by means of a crucial incision (Fig. 250). The needles may be passed unarmed, the ligatures— which may be of strong silk or whipcord—being introduced as they are AvithdraAvn. The nooses are then cut, and an assistant holds six ends firmly, while the surgeon knots the other two, this process being repeated until the whole nsevus is strangulated in four sections. Another method is to apply the ligature subcutaneously, as shown in Fig. 251, taken from Holmes. When the nsevus is flat or elongated, a better plan is that described by Lnchsen, which consists in passing a double ligature of whipcord, three yards long and stained black for half its length, in such a way as to have a series of double loops, about nine inches in length, on each side of the tumor (Fig. 2o2). The black loops being then cut on one side, and the white on the other, the ends are secured as in Fig. 253, so as to strangulate the growth NAEVUS. 541 in numerous sections. After the operation the tumor sloughs, and comes away in a few days, leaving an ulcer which heals by granulation. Various modifications must be adopted, according to the locality of the disease. In Fig. 250. Fig. 251. Nxvus ; application of the quadruple ligature. (Liston.) Subcutaneous ligature of naevus. The upper figure shows a single ligature carried round the tumor. The lower (in which no tumor is depicted) shows a double string carried below the centre of the base, then divided into two, A a' and B b', and each of the two carried subcutaneously round half of the naevus, and then tied. (Holmes.) dealing Avith a naevus over the fontanelle, there might be some risk, if the ordinary needles Avere used, of puncturing the membranes of the brain; and hence in this situation, after incising the skin Avith a lancet, the ligature Fig. 252. Fig. 253. Diagram of ligature of flat and elongated nsevus. (Erichsen.) Diagram of tied flat and elongated nsevus. (Erichsen.) should be carried beneath the groAvth by means of an eyed probe. The -calp is so adherent to a naevus in the cranial region that no attempt should 542 SURGICAL DISEASES OF THE VASCULAR SYSTEM. usually be made to preserve the skin in this locality. For nsevus of the tongue, the use of the ecraseur may be advantageously substituted for that of. the ligature. H. Lee has recently recommended, in cases of vascular tumor of the face and neck, the use of India-rubber thread, instead of the common ligature, the elastic contraction of this agent serving to divide the tissues Avithout hemorrhage, and thus effecting rapid and painless removal of the morbid growth. Barwell suggests subcutaneous strangulation with a Avire tightened every three or four days, so as to cut through the base of the nsevus Avithout loss of any skin. Strangulation with acupressure pins has been successfully employed by Bontflower, of Manchester. Though ligation is the safest mode of treating nsevus, I have once met Avith a fatal result from the operation, apparently due to embolism of the pulmonary artery. Moles.—A mole may be considered as a superficial variety of nsevus, and is usually covered with hair. Excision may be practised, if the disease be not too extensive, or Morrant Baker's plan may be adopted, the surface of the mole being shaved off, and the part allowed to heal under a scab. Hem- orrhage during and after the operation may be controlled by pressure. Diseases of Arteries. Arteritis and Arterial Occlusion.—Arteritis, or Inflammation of the Arterial Tunics, may occur as a primary affection, the result of injury or exposure to cold, but in the immense majority of cases is secondary to Arterial Occlu- sion, the result of thrombosis, or more frequently of embolism, the plug being derived from a fibrinous heart-clot. The repair of arteries after divi- sion is, as has already been mentioned (p. 179), due to the formation of a clot, together Avith the union of the cut edges by means of local inflammatory changes. The alterations in the arterial coats produced by inflammation are analogous to those which we have studied in the walls of a vein, as the result of phlebitis. Thus the external coat and sheath become vascular, pulpy, and distended with the products of inflammation; the middle coat contracted, thickened, and softened; Avhile the inner loses its smooth and polished ap- pearance, and becomes pulpy and stained from contact Avith the coloring matter of the blood. The clot which forms in cases of arteritis, and which indeed, as has been said, is commonly the cause of the arterial inflammation, may consist merely of masses of a fibrinous substance, which do not com- pletely occlude the vessel—or may form a complete plug, usually of a conical form, the lower part of Avhich consists apparently of white blood-corpuscles and fibrin, and often adheres to the sides of the artery, while the upper part is of the color of ordinary clotted blood, and projects tail-like into the upper part of the vessel. The symptoms of arterial occlusion consist of acute pain in the course of the affected artery, and in the parts which it supplies, Avith a feeling of ten- sion, great hypersesthesia, and loss of muscular power. If the artery be superficial, it can be felt as a cord, and is either pulseless, or the seat of a sharp and jerking pulsation, according to the degree of its obstruction. If the artery be one of importance, gangrene may result, though, in young and healthy subjects, the collateral circulation may be established with sufficient promptness to avoid this result. The arterial clot may become organized, the vessel being converted into a fibro-cellular cord; or a fragment may be detached and plug the artery at a lower point (this double occlusion almost invariably producing gangrene) ; or the clot may become completely disin- tegrated, and capillary embolism (arterial pycemia) result. CHRONIC STRUCTURAL CHANGES IN ARTERIES. 543 The treatment consists in the administration of opium to relieve pain, and ,of tonics, stimulants, and concentrated food, to maintain the patient's strength, Avith application of external warmth to the affected part in order to avert mortification. The subject of gangrene as the result of arterial occlusion, and the question of amputation under such circumstances, have been sufficiently considered in previous chapters (pages 91, 196). Chronic Structural Changes in Arteries.—The most important of these are Fatty Degeneration, Atheroma, Ossification, and Calcification. 1. Fatty Degeneration occurs in the inner coat of arteries, especially the aorta, carotids, and cerebral arteries, giving rise to small, rounded or angular, whitish spots, which project slightly above the surface; the fatty change takes places in the connective-tissue corpuscles of the part, and at a later period, the intermediate substance softening, the masses of fat granules fall apart, and, the current of blood carrying away the fat particles, vel- vety-looking depressions are pro- duced, Avhich constitute a form of Avhat Virchow calls fatty usure.1 2. Atheroma, Avhich is usually ac- companied by the fatty change of the internal coat aboAre described, appears to occur primarily in the external layer of the inner coat, at the junction of the latter Avith the middle coat, and forms a pultaceous (or atheromatous) mass, consisting of granular matter^ fat globules, plates and Fig. 255. Fatty degeneration in inner coat of aorta. (Green.) Atheroma of the aorta, showing the new growth in the deeper layers of the inner coat, and the conse- quent internal bulging of the vessel. The new tissue has undergone more or less fatty degeneration. There is also some cellular infiltration of the middle coat. i. internal, m. middle, e. external coat of vessel. (Green.) crystals of cholestearine, and half-softened fragments of tissue Avhich have not yet undergone degeneration. During the early stage of atheroma, the appearance presented is that of a Avhitish, someAvhat elevated spot, project- 1 Cellular Pathology, Chance's transl., pp. 339-340. 544 SURGICAL DISEASES OF THE VASCULAR SYSTEM. ing into the vessel, but still covered by a portion of the inner coat of the latter1 (Fig. 255). As the process continues, the inner coat becomes per- forated, the atheromatous mass is evacuated into the vessel, and the so- called atheromatous ulcer results (Fig. 256), just as in the affection knoAvn ulcerative endocarditis. While this change is occurring betAveen the as Fig. 256. Atheromatous ulcer of aorta. (Liston.) inner and middle coats of the artery, its outer coat becomes thickened and indurated, thus tending to maintain the strength of the vessel, Avhich at the same time becomes comparatively rigid and inelastic. Atheroma is usually spoken of as a degenerative change, but, according to Virchow, Billroth, IS'ie- meyer, W. Moxon, and others, should be considered a result of inflammation. Atheroma is often sup- posed to occur as a sequel of syphilis, but, according to Heubner and Ewald, the syphilitic degeneration met with in arteries is a distinct affection (see page 460). 3. Ossification is a rare, but, according to Vir- chow, an occasional change met with in the inner arterial coat. It may coexist with or may take the place of the atheromatous change (atheromasia), and, like that, results, according to VirchoAV, from inflam- matory proliferation. 4. Calcification is frequently met Avith, and, un- like atheroma, often in the peripheral arteries; it occurs chiefly in the middle coat of the vessel, and has no necessary connection with the atheromatous change. It consists in the deposit of earthy matters, principally phosphate, with a little carbonate, of lime, and occurs in the form of plates, rings, or tubes, constituting the several varieties of the affection known as laminar, annular, and tubular calcification. When in the superficial arteries, it is readily recognized by the touch. These various structural changes may exist independently, or, as is more common, may coexist in the same person. They may occur at any age, but are by far most frequently seen in those who have passed the period of middle life. They are more frequent in men than in women, and are said to be pre- disposed to by intemperate habits and by syphilis; when occurring in the limbs, they are usually symmetrical. The effect of these structural changes is, in the first place, to diminish the calibre of the affected artery, and secondly, by lessening its natural resiliency, to lead to its irregular dilatation and elongation; hence, an atheromatous or calcified artery may become tor- tuous, and is peculiarly apt to become the seat of aneurism. Rupture may take place through an atheromatous ulcer, and lead to fatal hemorrhage, as has been occasionally seen in the aorta ;2 while both atheroma and calcifica- tion render an artery more apt to be ruptured by external violence, and in- terfere with the success of haemostatic measures—a ligature perhaps cutting through at once, or becoming prematurely detached and leading to secondary hemorrhage. Finally, the loss of smoothness in the lining surface of an atheromatous or calcified artery, hinders the circulation, and offers a nidus 1 Mr. Moore, in his essay in Holmes's System of Surgery, vol. iii., adopts the view formerly held by Kokitansky, that atheroma is a deposit on the lining membrane of the artery, derived from the blood. 2 Similarly, fatty degeneration of the cerebral arteries is a very common antece- dent to the occurrence of apoplexy. (See Paget, Lectures on Surgical Pathology, 3d edit., p. 106.) ANEURISM. 545 for the occurrence of arterial thrombosis, thus leading indirectly to occlusion and perhaps gangrene, as in several cases collected by H. Lee; or, on the other hand, particles detached from an atheromatous ulcer may produce capil- lary embolism, and give rise to one form of arterial pysemia. Little can be done in the Avay of treatment for these structural changes, beyond attention to the general health of the patient; if wide-spread, they would of course ren- der the surgeon cautious in recommending any cutting operation that was not imperatively required. Should occlusion and gangrene occur, the case should be treated on the principles laid down in previous portions of the work. Aneurism. Aneurism, as the term is used in this work, is a disease of the arteries, consisting in a circumscribed dilatation of one or more of the arterial coats. Varieties.—We have already considered those forms of aneurism which result from wounds (see page 197), as well as the general dilatation of an artery Avhich constitutes the disease known as arterial varix or cirsoid aneu- rism; there remain for discussion three varieties of aneurism, Avhich may be called respectively: 1, the tubular or fusiform; 2, the sacculated; and 3, the dissecting aneurism. 1. Tubular or Fusiform Aneurism.—This is a circumscribed dilatation of all the coats of an artery, in its whole circumference. It is accompanied by elongation of the vessel, with thickening and structural change of its coats. It is most common in the aorta, but also occurs in the iliac and femoral arteries, and has been seen in the basilar artery. Several fusiform aneu- risms may coexist in the course of the same vessel, the intervening portions of the artery remaining healthy. Tubular aneurisms of the aortic arch may attain a very large size, running a chronic course, and doing harm chiefly by pressure on important parts. They may cause death by impeding the circulation, and thus causing syncope; or by compressing other parts, as the oesophagus or bronchi; or, Avhen occurring in the intra-pericardial por- tion of the aorta, by bursting into the pericardial sac (Fig. 257). More com- monly, however, a sacculated aneurism (Fig. 258) forms upon one or other side of the tubular dilatation, and, becoming the more important disease, leads more rapidly to a fatal result. 2. A Sacculated Aneurism is a sac-like dilatation which forms upon one side of an artery, or of a previously existing fusiform aneurism, and which communicates with the interior of the vessel by means of a comparatively small orifice, called the mouth of the sac. Sacculated aneurisms are divided into true and false; the true sacculated aneurism being one in which all the arterial coats enter into the formation of the sac-Avail, and the false sacculated aneurism (Avhich is by far the more common) being one in Avhich, the inner and part of the middle coat having given way, the sac-wall is formed by the thickened outer coat of the artery, Avith perhaps the external layers of the middle coat. A true sacculated aneurism must be of small size, and Avith a large mouth to its sac; for it is scarcely conceivable that a large sac could be formed from the portion of arterial Avail corresponding to the area of a small sac-mouth. It is very probable, hoAvever, that a considerable number of sac- culated aneurisms are at first true, and subsequently, as they increase in size, become false by rupture of the inner coats of the sac-wall. False sacculated aneurisms are further classified by surgical writers as circumscribed and 35 546 SURGICAL DISEASES OF THE VASCULAR SYSTEM. diffused, the aneurism being circumscribed as long as its sac remains entire, and becoming diffused when its sac gives way—the contained blood being then either Avidely spread among the adjoining tissues, or being still confined by an adventitious envelope of condensed connective tissue. The subdivision of aneurisms into true and false is not of much practical importance—the fact being that it is often impossible, even after careful dissection, to dis- tinguish one from the other; while a diffused aneurism is in reality nothing more than an aneurism the sac of which has given Avay. 3. Dissecting- Aneurism is almost exclusively met with in the aorta, and is a rare form of the disease, in which the blood makes its Avay betAveen the coats of the artery itself. A sac may thus be formed in the arterial wall; or the blood may dissect up the coats of the vessel for some distance, at last bursting through the external tunic, and probably causing death by syn- Fig. 257. Fig. 258. Large fusiform aneurism of ascending aorta, Sacculated aneurism of ascending aorta. bursting into pericardium. (Erichsen.) (Erichsen.) cope; or, finally, the blood may re-enter the artery through a softened patch of the inner coat, thus giving the appearance of a double aorta. The only contingency in AAliich a dissecting aneurism would be likely to demand the special attention of the surgeon would be in case the pressure of the effused blood should threaten gangrene, by occluding the trunk of the affected vessel. Causes of Aneurism.—The chief Predisposing Cause is unquestionably the existence of structural changes (particularly fatty degeneration and atheroma) in the arterial walls. Calcification does not directly tend to cause aneurism, but rather lessens the dilatability of the artery Avhich it affects; it has, how- ever, an indirect influence, the Avant of elasticity Avhich it produces tending to increase the strain upon other portions of the vessel, and thus predisposing them to aneurismal disease. Age has been looked upon as a predisposing cause, aneurism usually occurring during the middle period of life; the ex- planation is, that at this age, while atheromatous changes have begun, the laborious occupations of youth are commonly still continued. Similarly, NUMBER, SIZE, AND STRUCTURE OF ANEURISMS. 547 though aneurism is unquestionably much more frequent in the male sex than in the female (about seven to one1), it is probably not more so than might be expected from the greater liability of men to structural arterial changes, and from their being more commonly engaged in occupations which them- selves predispose to aneurismal disease. Any occupation Avhich requires intermittent violent muscular exertion predisposes to aneurism, by inducing occasional violent action of the heart, and consequent over-distention of the arteries; thus hotel-porters, soldiers, and sailors, or those Avho, usually lead- ing sedentary lives, indulge occasionally in athletic sports, are said to be more liable to aneurism than those whose occupation is uniformly laborious. Climate appears to exercise some predisposing influence, aneurism being probably more common in the British isles, and particularly in Ireland, than in any other portion of the world. The disease is comparatively rare in this country. Anything which tends to obstruct the arterial circidation may predispose to aneurism by increasing the tension of the arterial Avails; it is thus, as Ave have seen, that calcification produces its effect, and it is thus that aneurism may be developed above the seat of occlusion of an artery by embolism,2 or above the point of application of a ligature. The position of an artery may itself predispose the vessel to aneurism; thus the exposed situation of the popliteal artery renders it peculiarly liable to the develop- ment of aneurismal disease. The Exciting Causes of aneurism are wounds, bloAvs, and sudden strains. The effect of Avounds has already been considered (see page 1!)7); blows and strains, which may cause rupture of a healthy artery, may still more readily induce partial dilatation of one Avhich is weakened by disease, thus giving rise to a tubular or to a true sacculated aneurism; or (Avhich is commoner) may cause the giving way of the portion of the inner coat which covers an atheromatous patch, leading to the evacuation of the latter, and the conse- quent formation of a false sacculated or of a dissecting aneurism, according to the particular circumstances of the case. Number, Size, and Structure of Aneurisms.—Aneurisms are usually single, but two or more may coexist in the same person. When aneurisms are multiple, they may affect one or different arteries; thus there may be an iliac and a femoral, or a femoral and a popliteal aneurism in the same limb, or, on the other hand, a popliteal aneurism may coexist Avith one of the subclavian or carotid artery, or Avith one of the aorta. Popliteal aneu- rism is frequently symmetrical. When a large number of aneurisms coexist, as in cases recorded by Pelletan and Cloquet, the patient is sometimes said to suffer from the aneurismal diathesis. Aneurismal tumors vary in size, from that of a pea,3 to that of a child's head; the size varies in different situations, according to the degree of resistance offered by surrounding parts, and the force of the distending blood current. The largest aneurisms are hence commonly those which occur in the aorta, or, externally, in the axilla, neck, groin, and ham. If a sacculated aneurism is laid open, its structure, going from without 1 In the internal aneurisms the proportion is four to one, and in the external (ex- cluding carotid aneurism, which affects both sexes equally) it is thirteen to one; dis- secting aneurism is twice as frequent in women as in men (Crisp, Structure, Diseases, and Injuries of Bloodvessels, p. 115). 3 According to Church, embolism is the most frequent cause of intracranial aneu- rism in young persons (St. Bartholomew's Hosp. Reports, vol. vi. p. 99). 3 The* miliary aneurisms found by Charcot and others in the capillary vessels of the brain, in cases of apoplexy, are much smaller, the diameter of these aneurisms rarely exceeding a millimetre, or about ^5 °f an inch. 548 SURGICAL DISEASES OF THE VASCULAR SYSTEM. imvards, is found to be as follows: (1) An investment of condensed areolar tissue, forming an adventitious sac; (2) the true aneurismal sac, consisting either of the thickened external, with, perhaps, part of the middle, coat (false aneurism), or of all the coats (true aneurism), in which case the inner and middle coats may sometimes be recognized by the atheromatous and calca- reous patches which they contain; (3) concentric layers or laminae of decol- orized fibrinous clot, which appear to have been successively separated from the blood, as if by whipping,1 and of which the inner layers are softer and redder2 than the outer; and (4) an ordinary loose "currant-jelly" coagulum, which may be either of ante-mortem or of post-mortem formation. The laminated fibrinous coagulum serves an important purpose in strengthening the sac-wall, lessening the containing capacity of the sac itself, and, by its tough and inelastic character, diminishing the force of the arterial current in the sac, thus, in every way, tending to limit the spread of the disease, and even to lead to its spontaneous cure. The mouth of the sac, which is round or oval in shape, is of variable size, but always of much less area than a section of the sac itself; in a false aneurism the inner and usually the middle coat cease abruptly at the mouth of the sac, and even in a true aneurism they can rarely be traced for more than a short distance beyond the same point. The structure of the tubular, and that of the dissecting, form of aneurism have already been referred to (pp. 545, 54(5); another point in which these differ from the sacculated aneurism is in containing little or no laminated fibrinous clot. Symptoms of Aneurism.—Patients are sometimes conscious of the forma- tion of an aneurism—experiencing a distinct sensation of something having given AATay, or a sharp pain, as if from the stroke of a whip—or (as in the case of intra-orbital aneurism) hearing a sudden sound, as of the explosion of a percussion-cap—a small, pulsating tumor being, perhaps immediately, or soon after, discovered upon examining the part. In other cases, the develop- ment of an aneurism is very gradual, the patient perhaps not becoming aware of its existence until it has attained a considerable size. The symptoms of aneurism may be divided into those which are peculiar to the aneurismal nature of the affection, and those which depend merely upon its size or posi- tion—its pressure effects—and which might equally be due to any other tumor of the same bulk, and in the same locality. The peculiar symptoms of aneu- rism are made apparent by auscultation and manual examination, and depend upon the flow of blood through the aneurismal tumor, and, in the case of the ordinary sacculated form of the disease, upon the communication which exists betAveen the sac and the artery upon which it is developed; in certain inter-, nal aneurisms, the auscultatory signs alone are available for diagnosis. General Characters.—An external aneurism presents the appearance of a rounded or oval tumor, situated in the course of a large artery, somewhat compressible and elastic, and becoming flaccid by pressure on the artery above, and tense by pressure on the artery below, the tumor. If the aneurism contain but little laminated clot, it will be quite soft and compressible, but if, on the other hand, the sac contain a large amount of fibrinous clot, it will be comparatively hard and inelastic; the skin over an aneurism is usually healthy, though stretched; as the tumor groAvs it may, however, become dis- 1 This is denied by W. Colles, who believes that the laminated coagulum is formed by the walls of the sac itself. 2 In a case observed by H. D. Schmidt, however, the older and harder layers of fibrinous coagulum presented the darker color—the difference probably depending, as suggested by this writer, rather upon the amount of haemoglobin contained in the respective layers than upon their relative ages. SYMPTOMS OF ANEURISM. 549 colored, thinned, or even ulcerated, and suppuration may occur in the sub- cutaneous areolar tissue. Muscular Aveakness of the part, stiffness, and a tired feeling, are frequent accompaniments of aneurism. Pulsation.—The pulsation of an aneurism is peculiar, being of an eccentric, expansive character, separating the hands Avhen placed on either side of the tumor—the fluid pressure of the blood entering the sac being, according to a well-knoAvn law of hydraulics, exerted equally in all directions. This pulsa- tion is most marked when the mouth of the sac is large, and when the sac contains but a small quantity of laminated clot—the pulsation of a partially consolidated aneurism, if at all perceptible, being comparatively obscure, and sometimes scarcely distinguishable from that transmitted to a solid tumor by a subjacent artery. The characters of the pulsation are rendered less distinct by pressure above, and more distinct by pressure below, the aneurism, or by elevating the part in Avhich the tumor is seated. By firmly compress- ing the artery above the sac, the pulsation in the latter ceases, and it becomes flaccid ; if now the hands be placed on either side of the tumor, and the compression be suddenly removed, the entering blood redistends the sac, with a forcible, expanding beat Avhich is almost pathognomonic. The pulsation of the artery below the tumor is sometimes greatly diminished; this is a sign of considerable value in certain cases of intrathoracic aneurism, in Avhich the radial pulse of the affected side may be much Aveaker than on the sound side, or altogether absent. This, in particular instances, may be due to arterial occlusion from arteritis, to the rigidity produced by calcifica- tion, or to external pressure, but, in the majority of cases, is probably OAving to the mechanical action of the sac-Avails in equalizing the blood current and thus lessening pulsation, just as the air-chamber does in the ordinary "hydraulic ram." Bruit.—This is the name given to the intermittent sound which is heard by applying the ear to an aneurismal tumor, and which is due to the rush of blood from a narrow into a dilated cavity; the bruit varies a good deal in different cases, being usually of a rasping or sawing character, and most dis- tinct in tubular aneurisms, and in those with large sac-mouths. It may be scarcely perceptible, or entirely absent, in an aneurism Avith a very small mouth, or which is nearly filled with laminated coagulum ; in cases of femoral or popliteal aneurism, the bruit may often be rendered more distinct by causing the patient to lie down, and by elevating the limb. The bruit, which is often accompanied Avith a peculiar thrill, is synchronous Avith the aneuris- mal pulsation, and ceases Avith the latter if the artery be compressed above the tumor—returning immediately Avhen the pressure is removed. Accord- ing to Savory, the thrill is most marked Avhen the aneurism projects from the posterior surface of the artery, so that the vessel lies between the sac and the surgeon's hand. Pressure Effects.—Among the more common pressure effects of aneurism are venous congestion and oedema, from compression of the deep-seated veins. In some cases a varicose condition of the superficial veins may result from the same cause, and gangrene may even follow from the obstruction to the returning circulation. The risk of gangrene may be further increased by pressure of the aneurismal sac upon its own or neighboring arteries, thus leading to an insufficient vascular supply to more distant parts. Pressure upon nerves gives rise to intense pain, usually of a lancinating character, and, in certain situations, may lead to serious consequences by interfering Avith the functions of important parts : thus hoarseness and spasmodic dyspnoea may result from compression of the recurrent laryngeal nerve, dyspnoea, or (as in a case recorded by W. F. Atlee) uncontrollable eructation, from pres- sure on the pneumogastric, and, in cases of intra-cranial aneurism, facial 550 SURGICAL DISEASES OF THE VASCULAR SYSTEM. paralysis, deafness, ptosis, strabismus, or blindness, from compression of vari- ous cerebral nerves. Pressure upon secreting glands, or their ducts, may cause trouble by interfering with the functions of the part. Pressure upon bones and joints often leads to serious consequences, the flat bones (as the sternum or ribs) becoming eroded and perforated, or caries and disorganiza- tion of articulations ensuing, and seriously complicating the treatment of the case. The erosion of bone by the pressure of an aneurismal tumor is often attended by a distressing sensation of burning or boring pain, as in the ver- tebral column in cases of aneurism of the aorta. Finally, serious conse- quences may result from pressure on important viscera: thus dyspnoea may be due to compression of the trachea, bronchi, or lungs; dysphagia to com- pression of the oesophagus; and progressive emaciation to pressure on the thoracic duct—Avhile hemiplegia may result from the compression exercised by an intra-cranial aneurism on the brain. Symptoms of Diffused Aneurism.—When the aneurism becomes diffused by rupture of its sac, the symptoms undergo a certain change. The tumor loses its definition of outline, while it becomes rapidly very much larger; the pulsation, bruit, and thrill become faint, or entirely disappear; the part Fig. 259. Fig. 260. Ribs perforated by an aortic aneurism. Aneurism of the innominate artery, compressing and (Pirrie.) stretching the recurrent laryngeal nerve, and pushing the trachea to the left side. (Erichsen.) becomes oedematous, and often cold and livid, from venous congestion; the pain is suddenly increased, and syncope may occur; the swelling becomes hard, from coagulation—and, in some rare cases, a boundary of clot and condensed areolar tissue serves to limit the further spread of the disease, which may possibly in these circumstances undergo a spontaneous cure. Usually, however, the SAvelling continues to increase, with or without pulsa- tion, or evidence of inflammation, and the case ends in gangrene, from con- joined arterial and venous obstruction; or, the clot becoming disintegrated, with suppuration and ultimate giving way of the skin, death folloAvs from external hemorrhage. In some cases, rupture of the aneurismal sac leads to wide extravasation of blood among the tissues of the part, the accident being accompanied with much shock and pain, faintness perhaps resulting from the loss of blood from the general circulation, and gangrene ensuing at no distant period. TERMINATIONS OF ANEURISM. 551 Diagnosis.—The affections Avith Avhich aneurism is most likely to be con- founded are various forms of tumor, abscess, and simple arterial dilatation. Internal aneurism may be mistaken for rheumatism or neuralgia, but if the disease be situated externally, such an error could scarcely be made, except from Avant of care in the examination of the case. From Pulsating Tumors of a vascular or encephaloid nature, aneurism may usually be distinguished by its more circumscribed form, its more forci- ble and distinct pulsation (which is of a peculiar eccentric character), its louder, deeper and more defined bruit, and its situation in the course of a large artery. If, however, a vascular or encephaloid groAvth occur in a locality in Avhich aneurism is common, as in the popliteal space, the diag- nosis may become extremely difficult—and the most experienced and careful surgeons have, under these circumstances, occasionally been led into error. Cysts, or Solid Tumors, seated over an artery, may have a pulsation com- municated from the latter, and may thus simulate aneurism; the diagnosis may usually be made by observing that the growth can be lifted from, or pushed to one side of, the vessel, when the pulsation will diminish or disap- pear ; that the pulsation itself is not of an eccentric or expansive character; that there is no bruit, or at least merely a dull, beating sound, such as may be produced by compressing an artery Avith a stethoscope; and that the de- gree of tension of the tumor is not affected by compressing the artery at a point nearer the heart. In some cases, however, a tumor may be connected Avith several arteries which surround or penetrate its substance, and the diagnosis in such a case might be impossible. Non-Pulsating Tumors, of a glandular or cancerous nature, may be mis- taken for aneurisms in Avhich consolidation has progressed so far as to ob- scure their pulsation—though the mistake is more apt to be the other way, such an aneurism being taken for a solid tumor. The diagnosis may be sometimes made by observing the mobility of the tumor; thus, by its mov- ing Avith the larynx in the act of deglutition, a lobular enlargement of the thyroid gland may be distinguished from a carotid aneurism. Aneurisms have not unfrequently been mistaken for Abscesses, and have been hastily opened in consequence; the error may arise from an aneurism becoming diffused, ceasing to pulsate, and exciting inflammation and suppu- ration in the surrounding tissues, or from the formation of an actual com- munication between an aneurism and the cavity of an abscess. Errors of diagnosis, under these circumstances, have been made by no less eminent surgeons than Desault, Dupuytren, and Liston. It is probable that, in some of these cases, careful auscultation might reveal a bruit, even if all the other signs of aneurism Avere absent. General Dilatation of an Artery may simulate aneurism, especially one of the tubular variety; the diagnosis is made by observing the absence of the characteristic symptoms of the latter disease. Under the name of mimic or phantom aneurism, Sir J. Paget and Dr. S. West have described localized pulsations of arteries Avhich simulate aneurisms, but are not persistent. For illustrations of the difficulty of diagnosis in cases of aneurism, the student may advantageously consult several papers by Dr. Stephen Smith, of NeAV York, in the American Journal of the Medical Sciences for April and October, 1873, and January, 1874. Terminations of Aneurism.—An untreated aneurism may terminate in a spontaneous cure, or may cause death by pressure on important parts, by inducing syncope, by rupture and consequent hemorrhage, or by causing gangrene. 552 SURGICAL DISEASES OF THE VASCULAR SYSTEM. 1. Spontaneous Cure.—This, which is unfortunately a rare termination, may be effected in several Avays; and it is to be observed that the modes of treatment Avhich will be presently discussed are but imitations of nature's methods of effecting a cure. (1.) Gradual Consolidation by Deposit of Laminated Coagulum.—This is the most frequent mode of spontaneous cure, and is seen almost exclusively in sacculated aneurisms and those occurring in arteries of the second or less magnitude. A case, however, occurred to Stanley, in which an aortic aneu- rism Avas spontaneously cured in this way. The sac of the aneurism, acting as a diverticulum, allows contraction of the artery below, Avhich, together with the enlargement of the collateral branches given off above, tends to lessen the force of the current through the aneurism, and thus to encourage the separa- tion of fibrin and consequent formation of the laminated clot. This mode of cure is imitated in the medical treatment of aneurism, as well as in the surgi- cal treatment by compression on the cardiac side of the sac, by flexion, by the Hunterian mode of ligation, and to a certain extent by Wardrop's opera- tion. A modification of this mode of spontaneous cure is that Avhich is said to occur from the compression of the artery by the aneurism itself, or by another aneurism or solid tumor. (2.) Occlusion of the Artery below or above the Sac by Means of a Fibrinous Plug.—This mode of spontaneous cure is occasionally seen; the artery below the sac may be plugged by the detachment of a fragment of the laminated clot; or, possibly, the artery above the sac, by a similar fragment derived from the heart or a higher aneurism. The former occurrence is imitated in the treatment by manipulation and in Brasdor's operation, and the latter in Anel's method. (3.) Inflammation of the Sac may possibly cause coagulation, and conse- quent cure of the aneurism, though the soft clot formed in this way is more apt to become subsequently disintegrated, leading to suppuration and rupture of the sac. This mode of cure is imitated by the use of direct pressure, galvano-puncture, the injection of coagulating fluids, etc. (4.) Finally, a spontaneous cure may, perhaps, occasionally result from Suppura- tion and Gangrene, leading to the extrusion of the aneurismal sac as a slough, Avhile hemorrhage is prevented by the occlusion of the artery by inflammation. This mode of cure is imitated in Avhat is called the " old operation," or that of Antyllus, Avhich is practically equivalent to an excision of the sac. The evidence of the occurrence of a spon- taneous cure consists in the more or less Stellate rupture of an aortic aneurism gradual disappearance of the aneurismal into the pericardium. (Erichsen.) pulsation and bruit, the sac at the same time becoming firm and contracted, and the cir- culation being carried on by means of collateral branches. 2. Modes of Death.—An aneurism may prove fatal by (1) pressure on important parts, as the phrenic or pneumogastric nerve, the trachea, heart, or lungs; (2) syncope, which may occur from a large aneurism becoming suddenly diffused, and is sometimes the immediate cause of death in cases of aortic aneurism; (3) rupture of the sac and hemorrhage—which may be in- TREATMENT OF ANEURISM. 553 ternal, into the brain or spinal canal, pleura, pericardium, trachea, oesophagus or abdominal cavity—or external, as when an aortic aneurism perforates the sternum and bursts upon the surface of the body; and (4) gangrene, which is apt to occur Avhen an external aneurism becomes diffused, and Avhich is usually complicated with hemorrhage. The rupture of an aneurism on the cutaneous surface is commonly effected by the occurrence of suppuration and pointing, with the formation of a small slough, as in an abscess; on a mucous surface, by the occurrence of a small circular ulcer; and on a serous surface, by the formation of a fissured or star-like opening. Treatment of Aneurism. This may be conveniently divided into the medical or non-operative, and the surgical or operative, treatment of aneurism. The former is the only mode generally applicable to aneurisms of the thoracic aorta, and is the safer mode in certain other cases—while it may be used as a valuable adjuvant to the surgical treatment of aneurism in any situation whatever. Medical Treatment. — This aims to promote the cure, or at least retard the progress, of aneurism, by inducing, if possible, a deposit in the sac of laminated, fibrinous coagulum. To effect this, the patient should, in the first place, be kept at perfect rest—in bed, if possible—and should limit his diet, particularly avoiding irritating or indigestible food, stimulants, and large quantities of liquid. The treatment by position and restricted diet has been very successful in the hands of the Irish surgeons, particularly Bellingham and Jolliffe Tufnell. Small but repeated bleedings were highly commended by Valsalva, and form a prominent feature of the method of treatment which bears his name. They have likewise been employed with success by Pelletan, Hodgson, and others. Venesection has also been advantageously resorted to by Porter, Broadbent, and others, for the relief of dyspnoea, in cases in which this has been a troublesome symptom. Holmes has suggested the withdraAval of blood directly from the aneurism by means of an aspirator; but the plan seems to me a very unsafe substitute for venesection, and I have heard of one case in Avhich it was the immediate cause of death. Various drugs have acquired a certain reputation in the treatment of aneurism, espe- cially the acetate of lead and the iodide of potassium, Avhich is very highly spoken of by Balfour, of Edinburgh. Speir, of Brooklyn, recommends the employment of gallic acid and the subsulphate of Iron, and F. Flint, the ad- ministration of chloride of barium. Digitalis, veratrum viride, and aconite have also been used Avith advantage, Avhile Langenbeck, Dutoit, Plagge, and others, have lately employed Avith success hypodermic injections of ergotine. The local application of ice has been of use in some cases, but is a dangerous remedy, having, according to Broca, induced gangrene of the skin. The pain of a growing aneurism may sometimes be relieved by the use of anodyne plasters or embrocations, Avhile a hemlock or lead plaster may be used to give external support in a case in which rupture of an aneurism is impending. Surgical Treatment.—This embraces a number of different methods which may be considered in succession. I. Ligation.—Ligation may be employed on both sides of the aneurismal sac, constituting Avhat is knoAvn as the uOld Operation;" on the Cardiac Side, as in Hunter's and Anel's methods; and on the Distal Side, as in the plans of Brasdor and Wardrop. 554 SURGICAL DISEASES OF THE VASCULAR SYSTEM. 1. The "Old Operation." — This, Avhich until the early part of the last century, Avas, with the exception of amputation, the only operation employed in the treatment of aneurism, is also spoken of as the Antyllian method, from Antyllus, Avho Avas one of the first, if not the first, to employ it. It consists in opening the sac, and applying ligatures above and beloAV, as Avas directed in speaking of traumatic aneurism (see page 197), though it Avould appear that by the older surgeons the ligatures were sometimes applied first, and the sac subsequently laid open, or even totally excised. The operation is often a very severe one, and is more liable to be folloAved by hemorrhage than the Hunterian operation, on account of the artery being tied in im- mediate proximity to the sac, and Avhere, therefore, it may probably be diseased. In certain situations, however, as in the axilla, root of the neck, or gluteal region, this operation may be sometimes properly employed, and Avas, under such circumstances, several times resorted to by the late Prof. Syme, Avith the most brilliant and gratifying success; it may also be practised in cases of diffused femoral aneurism, as a substitute for amputation; and in any locality, if an aneurism have burst or have been accidentally laid open, it may often be the most eligible mode of treatment. A modification of this method, attributed to Guattani, and recently revived by Watson, of Jersey City, consists in plugging the sac, and, if possible, the opening of the artery from which it arises. Fig. 262. Fig. 263. 2. Ligation on the Cardiac Side of the Tumor.—The method of ligat- ing an artery for aneurism which, when practicable, is noAv employed in preference to any other, is that known as the Hunterian Method (Fig. 263), from the illustrious John Hunter, by whom it was first resorted to in 1785. In this operation, the vessel is tied at a distance from the sac (which is not opened), thus securing a healthy portion of the artery for the application of the ligature, and still allowing a certain amount of blood to pass through the sac by means of the collateral circulation; the cure is thus effected by the deposition of lami- nated coagulum, and not by the sudden clotting of the Avhole contents of the tumor. Anel's Method (Fig. 262), Avhich is spoken of by most French writers as identical with Hunter's, con- sists in the application of a proximal ligature immediately above the sac: it was employed by An el in 1710, in a case of traumatic aneurism of the brachial artery, and apparently as a mere experimental variation upon the old method.1 It does not seem to have been repeated, except once by Desault, and fell into oblivion until after the promulgation of Hunter's plan of operation. Anel's method is defective in not allowing any current through the sac, except from the distal end—imperfect coagulation and suppuration being therefore apt to follow—and in requiring the ligature to be applied to a part of the vessel Avhich is very liable to be diseased, thus exposing the patient to a consider- able risk of hemorrhage; the operation is, moreover, difficult, on account of the displacement of the artery by the tumor, and not free from danger. In performing the Hunterian operation, those precautions are to be observed 1 Keyslere subsequently (in 1774) modified the old operation by substituting com- pression for the distal ligature, retaining, however, the incision of the sac (Pelletan, Clinique Chirurgicale, t. i. p. 144). LIGATION ON CARDIAC SIDE OF TUMOR. 555 which Avere mentioned when speaking of ligation in the continuity of arteries (page 188); before tightening the ligature, it is Avell to make distal com- pression for a feAv seconds, so as to insure the distention of the sac. The immediate effect of deligation is to arrest the aneurismal pulsation and bruit, the limb below the ligature rising in temperature,1 and often be- coming painful and hypersesthetic ; loss of muscular power is also occa- sionally met Avith. The consolidation of the aneurism usually begins at once, and in favorable cases is commonly completed in the course of a few days— the tumor gradually contracting subsequently, though it often remains quite perceptible to the touch for weeks or even months. The establishment of the collateral circulation, after the Hunterian operation, usually requires the en- largement of two sets of anastomosing vessels—one around the seat of liga- tion, and another around the aneurism itself—unless in the rare cases in Avhich the sac becomes obliterated, still leaving a channel for the normal Aoav of blood. If, hoAvever, the artery be tied near the sac, as in aneurism of the primitive carotid or external iliac—or in any case by Anel's method—but one set of collateral vessels is needed. If the collateral circulation above the sac be too rapidly established, the operation may fail, the pulsation of the aneurism being reneAved as forcibly as at first; in most cases, hoAvever, enough coagulation takes place Avhile the circulation is temporarily arrested to insure the continuance of the clotting process, and the attainment of ultimate suc- cess. When tAvo sets of collateral branches are enlarged, the loAver arch of anastomosis is commonly first developed, owing to the aneurismal swelling itself having led to previous dilatation of the neighboring vessels. If the loAver anastomosis be defective, consolidation of the tumor may not take place, and suppuration of the sac, or even gangrene, may folloAv. Causes of Failure after the Hunterian Operation.—There are several cir- cumstances Avhich may lead to failure after the Hunterian method of ligation; these are, (1) hemorrhage from the point of ligature, (2) return of pulsation from too free development of the upper collateral circulation—that above the sac, (3) suppuration and sloughing of the sac, often accompanied by hemor- rhage, and (4) gangrene of the limb from the combined influence of arterial occlusion and venous congestion. (1.) Secondary Hemorrhage from the Point of Deligation.—This (Avhich, according to Crisp, usually occurs from the seventh to the fifteenth day) is more frequent in the upper than in the loAver extremity, on account of the greater freedom of arterial anastomosis in the former situation, but is apt to occur in any locality in Avhich large branches are given off in close proximity to the point of ligation—the clots, upon Avhich arterial occlusion after the use of the ligature depends, being, under such circumstances, insufficient to resist the force of the circulation. In order to diminish the risk of hemorrhage, Holmes recommends the employment of carbolized catgut ligatures, and re- ports a case in Avhich he thus secured the carotid and subclavian arteries, the patient dying from other causes, and the autopsy showing that both vessels had been successfully occluded. Callender, hoAvever, from a series of experi- 1 This statement is in accordance with the result of my own observation, and cor- responds with the doctrine of Holmes ; most writers, however, teach that the tempera- ture at first falls, and subsequently rises when the collateral circulation is established. But, according to Broca, as quoted by Holmes, this rise of temperature does not take place in animals, although in these'the collateral circulation is most rapidly estab- lished. The increased temperature is apparently due to capillary congestion, caused by the sudden removal of the vis a tergo of the heart's action, aided, perhaps, by a positive dilatation of the capillaries, brought about through the agency of the nervous system. 556 SURGICAL DISEASES OF THE VASCULAR SYSTEM. ments made Avith catgut ligatures, concludes that they disappear so rapidlv (in 50 to 60 hours) in the fluids of a Avound as not to give time for the firm occlusion of the vessel, and cases of secondary hemorrhage after the use of carbolized catgut have been reported by the same writer and by Mr. Holden and Dr. Humphry. My OAvn experience in this direction is limited to tAvo cases in Avhich I tied (successfully as regarded recovery from the operation) the common carotid artery for aneurism; as the external coat of the vessel is not divided, I do not see why there should be any special risk of hemorrhage from the disappearance of the ligature, though failure may occur from the artery remaining pervious and thus permitting a return of the blood-current, as indeed actually happened in one of my cases and in others recorded by Heath, T. Smith, Treves, and McCarthy. The treatment of hemorrhage from the point of ligation, in a case of aneu- rism, is the same as for bleeding after ligation in the continuity of an artery in any other case, and is to be conducted as directed at page 196. (2.) Recurrent Pulsation is met with when the upper anastomotic arch allows an unusually free flow of blood into the artery, between the sac and point of ligation, and is proportionally most frequent in cases of carotid aneurism, for in these the circle of Willis allows the collateral circulation to be very quickly established. In many cases the recurrent pulsation consists of a mere thrill, Avithout any bruit; but it is occasionally as distinct as before the operation. It usually occurs within twenty-four hours after the tight- ening of the ligature, though sometimes not for four or six weeks, and more rarely at an intermediate period. The prognosis of these cases is usually favorable, the pulsation again disappearing as consolidation is completed— though occasionally a fatal result ensues from suppuration and sloughing of the sac. Pulsation sometimes recurs several months after the consolidation and contraction of the aneurismal tumor, and the case is then properly called one of secondary aneurism, though it is probable that in most instances the new tumor is developed at a slightly higher point of the artery than the seat of original disease. Enlargement of the sac after ligation, without pul- sation, is due to the reflux of blood from the artery on the distal side. If excessive, it may lead to serious consequences—inducing gangrene, by ob- structing the venous circulation. Usually, however, as pointed out by Pemberton, coagulation occurs, and the aneurism is thus converted into a solid, fibrinous tumor. Treatment.—Before tightening the ligature, in an operation for aneurism, the surgeon should ascertain, by pressure with the finger, that doing so will entirely arrest the pulsation in the sac. By neglect of this precaution, the aneurismal current might be kept up by means of a vas aberrans or unusual arterial distribution, and the success of the operation might be in conse- quence prevented. The treatment of recurrent pulsation may usually be satisfactorily conducted by elevating the limb, making moderate compres- sion upon the sac, and perhaps cautiously applying cold. If the pulsation persist, a ligature may be applied lower down, as in Anel's method; but if sloughing of the sac be imminent, the surgeon's only resources will be am- putation and the " old operation"—the former being indicated in cases of popliteal or axillary, and the latter in those of cervical or inguinal, aneurism. (3.) Suppuration and Sloughing of the Sac.—This may occur as a conse- quence of recurrent pulsation—or may result from imperfect development of the lower collateral circulation (preventing consolidation of the tumor), from the size of the sac itself and the thinness of its walls, from the circula- tion through the sac being completely arrested (leading to coagulation en masse, instead of to the deposit of laminated clot), or from external violence, or even careless handling of the tumor before or after operation. The symp- LIGATION ON CARDIAC SIDE OF TUMOR. 557 toms are those Avhich characterize the occurrence of suppuration in general, the sac finally giving Avay, and (in about tAventy-five per cent, of the cases in which this accident happens) death resulting from hemorrhage. Bleed- ing is particularly apt to occur in those cases Avhich have been marked by recurrent pulsation, and then follows immediately upon the giving way of the sac; in other cases it may not occur for several days; Avhile if suppura- tion takes place at a late period, the arteries communicating Avith the sac may be sufficiently occluded not to allow any hemorrhage at all. Suppura- tion of the sac is most common in cases of axillary and inguinal aneurism, though it may occur in other situations. The treatment consists in laying open the sac, evacuating its contents, and promoting healing by granulation, a provisional tourniquet being applied as a matter of precaution: should hemorrhage occur, an attempt must be made to secure the bleeding orifice Avith a ligature, or by the application of the actual cautery—and, if these fail, amputation should be practised, provided that the situation of the aneurism admits of such a course. (4.) Gangrene of the Limb usually results, as has been mentioned, from the combined effects of arterial occlusion and venous congestion; it is par- ticularly apt to occur in cases of very large or of diffused aneurism, and is predisposed to by loss of blood, by erysipelas, or by the exposure of the limb to undue pressure, cold, or excessive heat. It is most frequent in the lower extremity, and occurs usually from the third to the tenth day, being in- variably of the nature of moist gangrene from implication of the veins. In order to prevent the occurrence of gangrene, those measures should be adopted Avhich Avere advised in speaking of gangrene from arterial occlusion (page 196); in some cases it may be proper (in order to relieve the venous trunks from pressure) to lay open the sac and evacuate its contents—and, indeed, it is one of the recommendations of the old operation, over that of Hunter, that it is less apt to be followed by mortification. If gangrene have actually occurred, amputation must be performed, usually at the shoulder- joint, in the case of the upper limb, and at the junction of the upper and middle thirds of the thigh, in that of the loAver extremity. Beside the above, which are the common causes of death after ligation for aneurism, there are certain special risks in particular situations. Thus Cerebral Disease causes more than one-third of the deaths after ligation of the common carotid (ninety-one out of two hundred and fifty-nine, according to Pilz), and Intra-thoracic Inflammation about tAvo-fifths of the deaths after ligation of the third part of the subclavian (ten out of tAventy-five, according to Erichsen). Indications and Contra-lndlcations for Ligation.—The application of the ligature, in the treatment of aneurism, is indicated (1) in cases in which the disease is active and advancing, and so situated that, while pressure, flexion, etc., are not applicable, the use of the ligature is not attended with unusual risk, (2) in any case in Avhich less dangerous modes of treatment have been tried and failed, (3) in case an aneurism has burst into an articulation, (4) in case an aneurism has become diffused, and yet not so widely diffused as to require amputation, and (5) in case an aneurism has burst or is about to burst externally, and in case, therefore, the operation is imperatively re- quired to prevent death from hemorrhage. The use of the ligature is, on the other hand, contra-indicated (1) by the presence of any complication— such as extensive arterial or cardiac disease, the existence of internal aneu- rism, old age, or the prevalence of erysipelas—Avhich would probably render the operation peculiarly dangerous, (2) by the locality of the aneurism being such that pressure or flexion Avould probably be sufficient to effect a cure, as in manv aneurisms of the brachial, femoral, and popliteal arteries, and (3) 558 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Fig. 264. Fig. 265. by the locality of the aneurism being such that, from the proximity of anas- tomosing branches, or from any other cause, the operation Avould almost certainly terminate unsuccessfully—the imminence of rupture being in such a case the only circumstance that could justify operative interference. Mul- tiple aneurism is usually, though not ahvays, a contra-indication; thus, if tAvo aneurisms exist on the same limb, they may both be cured by the same operation;1 or double popliteal aneurism by ligation of both femoral arteries; in most cases, hoAvever, the existence of more than one aneurismal tumor contra-indicates, though it may not positively forbid, ligation. Though I have said that ligation is contra-indicated in many cases of popliteal aneurism, yet I believe that in other instances it is the best mode of treatment. The operation, however—which, though delicate, is not in itself very dangerous—should not, of course, be indiscriminately resorted to. If the aneurism be quite small, pressure Avill probably suffice for a cure, and even if it fail, will do little or no harm; and hence, in such a case, should certainly be tried. If, on the other hand, the tumor be very large, or if it have become diffused, the risk of gangrene may be so great as to render amputation preferable to either compression or ligation. There is, hoAV- ever, an intermediate set of cases, in which pressure would not be likely to succeed, and in which, if persisted in, it would cer- tainly increase the obstruction to the venous circulation, and thus lessen the chances from subsequent ligation. In such cases, compression should be employed, if at all, with great caution, and ligation should be promptly resorted to, if pressure be not quickly productive of benefit. The surgeon will in this, as in other instances, advance both his own reputation and the interests of his patients, rather by adapt- ing his remedies to the exigencies of each particular case, than by? advo- cating and invariably employing any exclusive mode of treatment. 3. Ligation on the Distal Side of the Tumor.—This operation is attrib- uted to Brasdor, whose name it bears. It was recommended by Desault, but first practised by Deschamps, and subsequently by Wardrop—being in- deed often spoken of as Wardrop's method. Though this surgeon, however, successfully employed Brasdor's operation, the plan which he himself sug- gested, and which properly bears his name, is somewhat different. In Brasdor's operation, the whole circulation on the distal side of the sac is ar- rested—in Wardrop's only a part of the distal circulation, by the application of a ligature to a branch of the main trunk, or to one of several arteries proceeding from the aneurism. Thus distal ligature of the carotid for carotid aneurism would be an example of Brasdor's method, but the same operation for innominate aneurism would be properly called Wardrop's. The former aims to produce entire, and the latter partial, arrest of the circulation Pemberton has recorded a case in which three aneurisms on the same limb were cured by ligation of the external iliac artery. ACUPRESSURE AND COMPRESSION. 559 through the sac. The risks, besides those incident to the Hunterian mode of ligation, are that the sac, being still distended by the cardiac impulse, may continue to increase in size, the operation thus failing, even if suppu- ration and sloughing do not lead to a fatal termination. Hence, except in particular cases, as of aneurism of the root of the carotid, or of the innomi- nate, the distal ligature is not to be recommended. II. Acupressure has been successfully employed in a feAv cases of aneurism, but does not appear to present any particular advantages over the use of the ligature. Various modifications of this method, under the name of temporary ligature, filopressure, etc., have also been employed by Stokes, Dix, and others, but not often enough to enable us to say whether they Avill ultimately be found any better than the methods of treatment Avhich have been longer before the profession. (See page 191.) III. Compression.—Compression may be made directly upon the aneurism, or indirectly upon the artery, at a point above or below the tumor (proximal or distal compression); it may be effected by the hands of the surgeon or his assistants (digital compression), or by means of instruments (instrumental compression). Direct Pressure upon the aneurismal sac Avas introduced by Bourdelot, in the seventeenth century, and has since been successfully em- ployed, from time to time, by various surgeons, but is so uncertain, and occasionally so dangerous, a method, that it is noAv generally abandoned as an exclusive mode of treatment—while Distal Compression, which Avas pro- posed by Vernet, in the last century, failed in its author's own hands, and is rarely employed at the present day, though Varick reports a case of in- guinal aneurism in which it effected a cure in connection with rest in bed and the administration of iodide of potassium. Both direct and distal com- pression may, however, prove valuable adjuvants to pressure on the proxi- mal side of the sac, as in the plan recently adopted by Reid, Wagstaffe, Tyrrell, Sydney Jones, F. A. Heath, Wright, T. Smith, Weir, Freeman, Wheeler, and others, who have cured popliteal aneurisms by pressure with Esmarch's bandage. Stimson has collected 62 cases of aneurism treated in this manner, a successful result having been obtained in 35, Avhile only 2 proved fatal. The treatment of aneurism by Compression on the Cardiac Side of the Tumor Avas employed by Hunter, Blizard, and particularly Freer, in England, and by Pelletan, Dupuytren, and others, in France, but did not attain the position which it now occupies in the estimation of the profession until it was, about thirty years ago, revived and systematized by the Irish school of surgeons, particularly by Hutton, Bellingham, Tufnell, and Carte. It is not necessary, as Avas formerly supposed, to make such firm pressure upon an artery which is the seat of aneurism as to entirely interrupt the flow of blood—and still less to excite such a degree of inflammation as might lead to the obliteration of the vessel; on the contrary, the object being to imitate nature in her mode of effecting a spontaneous cure, by inducing the gradual deposition of laminse of fibrinous clot, it is sufficient to exercise enough compression to simply arrest the pulsation of the sac, without pre- venting the floAV of blood through it. This mode of treatment is particu- larly applicable to sacculated aneurisms, though it may also succeed in cases of the tubular variety, in Avhich, however, the cure is effected rather by the gradual contraction of the aneurismal dilatation, than by the deposit of tibrin. The chances of success by compression are greatest when the sac contains only fluid blood, coagulation in an already partially consolidated aneurism being apt to occur suddenly, and in an imperfect manner. After recovery, the sac is commonly entirely filled up, but in some cases a channel remains, through Avhich the normal circulation is carried on. 560 SURGICAL DISEASES OF THE VASCULAR SYSTEM. During the treatment by compression, the patient should of course be con- fined to bed,1 and the hygienic and other means spoken of under the head of Medical Treatment put in force. Nervous irritability and pain should be controlled by the free use of opium, and in certain cases, in which the needful pressure cannot be otherwise borne, ether or chloroform may be administered by inhalation. 1. Instrumental Compression maybe effected by the use of various forms of apparatus, such as a Signoroni's or a Skey's tourniquet (Figs. 26, 27), Lister's compressor (Fig. 28), Reade's or Carte's apparatus (in the latter of which (Fig. 266) elastic force is applied by means of vulcanized India-rubber bands), or a simple conical Aveight, held in position by means of a leather socket, or, as successfully employed in Bellevue Hospital, NeAV York, a bag of shot suspended from the ceiling.2 In situations in which a considerable extent of artery can be dealt with (as in the thigh), alternate pressure upon Fig. 266. Fig. 267. Gibbons's modification of Charriere's com- pressor. several points may be practised, by means of an instrument such as that represented in Fig. 267, which Avas modified from one of Charriere's, by Dr. Gibbons, for- merly of this city. The points which require special care, in the application of instrumental com- pression, are to see that the artery is fairly pressed against the bone, while the pressure is not so widely diffused as to cause great venous congestion from implication of the deep- seated veins, and to guard against excoriation of the skin by carefully shaving and powdering the part, and by occasionally changing the point of pressure. In situations in Avhich very deep pressure is necessary to control the circu- lation, and in which, therefore, the treatment becomes \rery painful fas in compressing the aorta, common iliac, or subclavian), anaesthesia may be previously induced, as proposed by Murray, and may be steadily kept up for as many hours as may be thought safe. Rapid Pressure Treatment of Aneurism.—Murray, Heath, Mapother, Levis, AgneAV, and other surgeons, have succeeded in curing aneurisms of the iliac and femoral arteries, and even of the abdominal aorta, by completely arrest- ing the flow of blood through the sac by means of instrumental compression, 1 Dr. Buckminster Brown has, however, reported a case in which direct compres- sion effected a cure while the patient continued to walk about. 2 Dr. Sawyer, of San Francisco, employs a shot-bag terminating in a distended India-rubber ball, which gives a certain degree of elasticity to the apparatus. Dr. Palmer, of Minnesota, employs a cork held in position with a plaster-of-Paris collar, and applies pressure by surrounding the whole Avith an India-rubber bandage ; a shot- bag, held in place with elastic bands, is employed by Madruzza, of Perugia. Carte's compressor for the groin. DIGITAL COMPRESSION. 561 applied above or on both sides of the tumor, and kept up in some cases for many hours, the patient meanwhile being under the influence of an anaes- thetic. The mechanism by which the cure is effected in these cases seems to be the coagulation en masse of the contents of the aneurismal sac, the mode of treatment being thus assimilated to Anel's and Brasdor's operations. While " the rapid pressure treatment" is unquestionably a valuable addition to the surgeon's means of dealing Avith aortic and inguinal aneurisms, it can not, in my judgment, replace, in the treatment of aneurisms in other situa- tions, the ordinary mode of making instrumental compression—Avhich aims to effect a cure by inducing a gradual formation of laminated coagulum, and Avhich I believe to be safer, if less brilliant, than the rapid method, which has already led to five fatal results in the hands of British surgeons. 2. Digital Compression, which was first proposed by Vanzetti, of Padua, about twenty-five years ago, and which has been successfully resorted to by Knight, of New Haven, Parker and Wood, of New York, S. W. Gross, Agnew, and many others, myself included, may be employed as an exclusive measure of treatment, or as an adjuvant to compression by means of instru- ments. For its use in the former mode, constant relays of skilled assistants are usually required, and these can frequently not be obtained; hence, though its statistical results are very favorable (the average duration of treatment in successful cases being, according to Gross and Fischer, about three days), it is principally as an aid to instrumental compression that it is likely to be generally resorted to. The employment of digital compression can be much facilitated by Holden's plan of superimposing a weight upon the finger, which can thus keep up the pressure for a considerable length of time Avith- out fatigue. The statistics of digital compression have been particularly studied by Fischer, of Hanover, who finds that 188 cases (in all situations) gave 121 successes, and 67 failures. In 17 of the successful, and in 33 of the unsuccessful, cases instrumental compression and other means were also employed. Death occurred in 19 instances, once after digital compression alone (from gangrene), three times after digital and instrumental compression, ten times after subsequent ligation, three times after amputation, and tAvice after opening the sac. Digital compression is estimated by Fischer to be five per cent, more successful than instrumental compression, and is considered by him superior to any other mode of treatment except flexion, which he thinks should be preferred in any case in which it is applicable. When it is resolved to attempt the cure of an aneurism by pressure, the patient being prepared as has been directed, and the circulation through the aneurism controlled by the application of a suitable instrument, compression should be steadily maintained, if possible, until consolidation is complete, or at least measurably advanced. This may usually be accomplished by using an instrument such as that of Dr. Gibbons, or by employing digital compres- sion during the intervals in which the pressure of the instrument is relaxed. A cure has, indeed, been obtained in cases in Avhich pressure has occasionally been intermittent for several hours at a time, but it seems probable that, Avhen applicable, moderate but continuous pressure is more likely to prove beneficial than that which is more forcible but not steadily maintained. It is well, before applying compression to the cardiac side, to insure the complete distention of the sac by the use for a few minutes of distal com- pression. The contraction of the aneurismal sac may also be promoted by making gentle direct pressure upon the tumor, during the whole course of treatment, by means of a carefully-applied bandage, the action of Avhich may be aided by Corradi's plan of interposing an air-ball between this and the aneurism. 36 562 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Advantages and Disadvantages of Compression. — The advantages of this mode of treatment are very obvious; it is certainly, though not entirely free from risk, far safer (in most cases) than ligation of the artery, and, in cases in Avhich it proves successful, is not materially more tedious. In many in- stances, a cure has been effected in from a few hours to three or four days, and the average duration of treatment, in successful cases, is, according to Hutchinson's statistics (for popliteal aneurism), about nineteen days, or about the same time as is commonly required for the separation of a ligature from the femoral artery. Its disadvantages are that it often fails—124 cases of popliteal aneurism thus treated gave, according to Holmes, only 66 cures— and that when it fails, the chances of subsequent successful deligation are less than they Avould ha\re been had the latter operation been primarily em- ployed. This fact is, indeed, denied by many surgeons, and it is even claimed that previous compression, by favoring the establishment of the collateral circulation, lessens the chance of gangrene after the use of the ligature; but, as long ago pointed out by Porter, the risk of gangrene after operations for aneurism is more from venous congestion than from arterial deficiency; and that compression tends rather to increase than to diminish venous con- gestion, will probably not be doubted. Nor is it fair to assert that the long list of failures after compression is entirely due to want of care in its appli- cation ; for the advocates of the ligature might as justly respond, with the late Mr. Syme, that most of the untoward results of that operation were due to the operator's want of skill—Syme himself, as is well known, having tied the femoral artery thirty-five times, with but a single death. In what cases, then, should compression be used ? The answer should, I think, be somewhat as follows: Compression should be employed, by prefer- ence (1) in all cases in which, from the age or general condition of the patient —from the existence of heart disease, of other aneurisms, or of marked structural change of the arterial coats—or from the prevalence of erysipelas, pyaemia, etc., the operation of ligation would be attended by particular risk ; (2) in all cases in Avhich the aneurism, being detected at an early stage, would be in the most favorable condition for the use of compression, and in which the pressure treatment, if even it failed, would not seriously lessen the prospect of benefit from subsequent ligation; and (3) in all cases, on the other hand, in which the aneurism, from its locality or size, would not prob- ably be amenable to the ligature, and in which, therefore, pressure should be at least tried before resorting to such formidable measures as amputation or the " old operation." Finally, compression may be tentatively employed in almost every case— even in popliteal aneurisms of moderate size, which are those specially adapted to the use of the ligature. If, however, decided benefit be not ob- tained in a short time—three or four days,1 or after a still shorter trial, if venous congestion, oedema, and pain are markedly increased by the treat- ment—the surgeon should, I think, unhesitatingly abandon compression and resort to the Hunterian operation, which, under such circumstances, I cannot but believe to be a preferable mode of treatment. IV. Flexion.—This mode of treatment was introduced by Mr. Ernest Hart, in 1858,2 and has since been successfully employed by ShaAv, Pember- ton, and several other surgeons. Its efficacy depends chiefly upon the inter- ference with the arterial circulation caused by bending the vessel to an acute angle, but is assisted by the direct compression exercised upon the sac by 1 Holmes gives a week as the proper limit. 2 It is said to have been previously employed both by Fergusson and by Maunoir, of Geneva. MANIPULATION, GALVANO-PUNCTURE, AND INJECTION. 563 the contiguous surfaces between which it is thus placed. Flexion is appli- cable in cases of popliteal aneurism, and of aneurism at the bend of the elboAv, or in the axilla. Its application is very simple, consisting merely in the retention of the limb in the flexed position by means of a double collar or figure of 8 bandage. If flexion is to be employed by itself, the limb should be bent so as to completely check the aneurismal pulsation. In most cases, however, it is preferable to employ moderate flexion, using it as an adjuvant to digital or to mild instrumental compression. The statistical results of the flexion treatment have been studied by Stapin and by Fischer; the former Avriter finds that 49 cases gave 26 successes and 23 failures, 11 of the successes having been due to flexion alone, and 15 to this in combination Avith other methods; Avhile Fischer finds that 57 cases gave 28 successes (20 by flexion alone) and 29 failures. It is probable that a combination of flexion with alternate instrumental and digital compression, would be found in many cases as satisfactory as it would be certainly a less irksome mode of treatment than either plan by itself. V. Manipulation.—This method consists in squeezing or kneading the aneurismal sac in such a way as to break up the contained laminated coagu- lum—a fragment of Avhich it is hoped may plug the artery at the distal side, and thus lead to the consolidation of the tumor. This plan was introduced by Fergusson, and has been successfully employed by Little, Teale, and Blackman, of Cincinnati, having been combined by the last-mentioned sur- geons with proximal compression. According to Van Buren, this is the true explanation of the cures reported from the use of Esmarch's bandage, as of many other recoveries attributed to compression alone. The dangers of this mode of treatment are that rupture of the sac and consequent diffusion of the aneurism, or inflammation and gangrene, may be caused by the applica- tion of too much force; and that (in cases of subclavian or carotid aneurism, for the former of Avhich Fergusson employed it) a fragment of clot may occlude the carotid or vertebral artery, and thus lead to grave if not fatal cerebral disturbance. Cases are mentioned by Esmarch and Teale in Avhich death followed the occurrence of this accident during the mere preliminary examination of patients suffering from carotid aneurism, and Tillaux has recently recorded a case of paralysis and aphasia resulting from embolism similarly occurring during the examination of an aortic aneurism. VI. Galvano-puncture was first employed by B. Phillips in 1838, and has since been resorted to in a number of cases of aneurism by Petrequin, Cini- selli, Duncan, Althaus, and others. Both poles of the battery should, as a rule, be introduced into the sac. The great risks of the operation are that coagulation en masse will probably occur, and that sloughing of the aneu- rismal Avail may take place at the points of puncture—an accident which Avould be apt to be followed by hemorrhage. Embolism of the carotid proved fatal in a case referred to by Wheelhouse. The statistics of this mode of treat- ment are not very favorable; 89 cases collected by Duncan gave 12 deaths, and only 31 recoveries, while Petit's collection of 114 cases gives 38 deaths, and only 69 recoveries, many of these, too, not having been permanent. The only cases, therefore, to which galvano-puncture seems appropriate are such as forbid either compression or ligation, and yet require active treat- ment. Guimaraez has reported a case of carotid aneurism cured by the external application of electricity. VII. Injections of Coagulating Liquids, and especially of the perchloride of iron, have been practised upon several occasions, and sometimes with suc- cess. This is, however, a very dangerous method of treatment (the principal 561 SURGICAL DISEASES OF THE VASCULAR SYSTEM. risks being from inflammation, gangrene, rupture, and embolism), and its use is rarely justifiable except in localities in which both cardiac and distal compression can be maintained until coagulation is complete—in localities, in fact, in which either compression or ligation would be equally applicable, and certainly preferable. VIII. Acupuncture, and the Introduction of Foreign Bodies, such as fine wire (Moore, Domville, Murray), watch-spring (Montenovesi and Bacelli), horsehair (Levis, Maury, Stimson), and catgut (Bryant), have been tried— each aiming to effect a cure by furnishing a starting-point for coagulation ; acupuncture, in conjunction Avith proximal compression, proved successful in a case of ilio-femoral aneurism reported by Dr. William Macewen, but the introduction of foreign bodies has proved utterly useless in every case in which it has thus far been employed.1 IX. Strangulation has been successfully employed for very small aneu- risms, two needles or harelip pins being passed beneath the tumor, and a ligature thrown around their extremities, as in cases of nsevus. X. Caustic has likewise been used with success as an application to very small aneurisms. XL Amputation.—Finally, amputation Avould be required, if an aneurism in a limb should become diffused and threaten gangrene, if the pressure of the tumor should cause extensive caries of the neighboring bone, or if hem- orrhage should occur from external rupture. Amputation may also be required in the event of the failure of ligation. Arterio-Venous Aneurism.—As the result of ulcerative action, a preter- natural communication may occasionally be formed between an artery and a contiguous vein, constituting a non-traumatic variety of aneurismal varix. The symptoms and treatment do not differ from those of the traumatic form of the disease, Avhich has been already described (see page 198). Treatment of Particular Aneurisms. From a consideration of the principles laid down in the preceding pages, and from an examination of the statistical results, as far as they can be ascer- tained, of various modes of treatment, Ave may arrive at the following con- clusions as to the best course to be adopted in dealing with aneurismal disease in various parts of the body. Thoracic Aorta.—Permanent benefit can seldom be hoped for from ope- rative treatment in aneurism of the aortic arch. Ligation on the cardiac side of the sac is evidently out of the question, and hence the choice as regards operations is limited to tying the carotid alone (and, unless the innominate be also involved, the left carotid is, as pointed out by Dr. Cockle, the one to be chosen), or to tying this and the subclavian artery as well. The former plan has been adopted in thirteen cases, and the latter in eleven, temporary relief having been afforded in several of each category; the most successful operations have been those of Mr. Heath, one of whose patients lived four and a half years after ligation of the carotid only, and another four years after the simultaneous ligation of the carotid and third part of the subclavian.2 1 Dr. Horace Dobell recommends the injection of melted spermaceti. 2 In another case, however, Mr. Heath failed in attempting the same operation, on account of the aneurism extending much further than had been anticipated. This patient died. THORACIC AORTA. 565 Still less success has attended the treatment by coagulating injections, and that by the introduction of a coil of wire or watch-spring, which was first tried by the late C. H. Moore, and which has been more recently employed by Domville and Murray, and in two cases by Bacelli; no benefit resulted to the patient in Domville's case, while the other four all terminated fatally, as did the case in which the introduction of horsehair was tried by Maury, of this city. Distal pressure proved of benefit in cases recorded by Dr. Lyon and Mr. EdAvards, and referred to in Mr. Heath's pamphlet, as did galvano-puncture in 13 out of 36 cases referred to by Dr. Bowditch, of Boston, and in 69 out of 114 cases collected by Petit. The only treatment, however, to be ordinarily recommended, in a case recognized as aneurism of the thoracic aorta, is the medical and hygienic treatment, described at page 553. Cases of Aortic Aneurism treated by Ligation of Carotid Artery. No. Operator. Result. Remarks. 1 Tillanus, Believed. Died suddenly, five months subsequently. 2 Rigen, Relieved. Died in three months, from strangulated hernia. 3 Montgomery, Died in four months ; sac suppurated. 4 O'Shaughnessy, Died. Died in seven days ; galvano-puncture also used 5 Knowles, K Died of apoplexy. 6 Heath, Relieved. Died 4£ years afterwards, from external rupture. ■ 7 Annandale, Relieved. Tumor still pulsated. 8 Holmes, Relieved. Doing well eighteen months after operation. 9 Callender, Died in twelve months. 10 Bryant, Died. Died in ten days ; pysemia; no clot in sac. 11 Barwell, Wound healed. 12 Ashhurst, Relieved. Died in seven weeks, from suffocation. 13 Kuester, Died. Right carotid tied ; died in forty hours. Cases of Aortic Aneurism treated by Ligation of both Carotid and Subclavian Arteries. No. Operator. Result. Remarks. 1 Hobart, Died. Subclavian tied in first portion ; hemorrhage from carotid on sixteenth day. 2 Heath, Relieved. Life prolonged for four years. 3 Maunder, Died. Died on sixth day, from occlusion of aorta. 4 Sands, Relieved. Hemorrhage from carotid on 43d and 48th days, checked by pressure; not much benefit from ope-ration. Death thirteen months afterwards. 5 Maury, Died. Ligatures came away withput bleeding ; aneurism grew with increased rapidity. Introduction of horsehair tried. Death from external rupture of aneurism. 6 Speir, Died. Carotid constricted with artery constrictor; two days afterwards, subclavian tied ; no hemorrhage from either wound, but death on 34th day from external rupture. 7 Barwell, Relieved. Died fifteen months afterwards. 8 Kuester, Relieved. Carotid tied first, and subclavian some months after-wards. 9 Lediard, Relieved. Patient living seven months after operation. 10 Pollock, Died. Died in ten days. 11 Wyeth, Relieved. Doing well ten weeks after operation. 566 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Innominate Artery.—The chief operative treatment applicable to innomi- nate aneurism is the distal ligature, applied to the carotid, to the subclavian or axillary, or to both vessels, consecutively or at the same time. The carotid alone appears to have been tied for innominate aneurism twenty-four times, with six more or less permanent recoveries, and eighteen deaths. The subclavian or axillary alone has been tied five times, Avith at least tem- porary benefit in three instances. The double ligature has been employed in twenty-eight cases, the arteries having been tied consecutively in five, and simultaneously in twenty-three, only one of the former category and six of the latter proving permanently successful. In four cases which have been already referred to (Hobarth's, Heath's, Maunder's, and Sands's), the aneu- rism was eventually found to have been aortic, while in Cuvillier's case (which was likewise supposed to be one of innominate aneurism) the affected artery was found after death to have been the subclavian. Hodges, of Bos- ton, employed the double simultaneous ligature in a case of supposed innomi- nate or aortic aneurism, but after the death of the patient, which occurred on the eleventh day, no aneurism at all was found, though both vessels Avere dilated; and in a similar case referred to by Stimson as having been ope- rated upon by Doughty and A. B. Mott, by consecutive ligation, when the patient died three years afterwards, the aorta alone was found dilated.1 On the other hand, Cheever, of Boston, in a case of innominate aneurism made an unsuccessful attempt to apply the double ligature; the position of the carotid artery could not be detected, and, in endeavoring to secure the sub- clavian artery, the accompanying vein was ruptured, death following in two hours. It is thus seen that, as far as statistics bear upon the question, the advantage is, upon the Avhole, with ligation of either vessel alone; hence, if the ligature is to be used at all, that artery should be first tied in the direc- tion of which the aneurism appears to be chiefly disposed to spread, the ligation of the other vessel being reserved for a subsequent occasion, if it should be found necessary; as to the part of the subclavian to which the ligature should be applied, I would decidedly recommend the third portion, or that beyond the scaleni; though it is but right to add that Mr. Holmes is disposed to think that, by employing a ligature of carbolized catgut, the risk of hemorrhage would be so much lessened2 that the question of tying the first portion of the artery might properly be entertained. But as the operative treatment by any plan is so unsatisfactory, a fair trial should always be first given to the effect of rest and medical treatment, aided, per- haps, by distal pressure, which proved of benefit in a case under the care of Mr. Syme. In a case of Luke's, repeated bleedings and the use of digitalis effected a cure, while Coote obtained an equally happy result by the enforce- ment of rest and the application of ice. 1 Wyeth, however, believes that there was an aneurism of the innominate in this case, and that it was cured by the operation. 2 The use of carbolized catgut has, however, been followed by secondary hemor- rhage in cases of ligation of the femoral artery recorded by Mr. Holden, Mr. Cal- lender, and Dr. Humphry. INNOMINATE ANEURISM. 567 Cases of Innominate Aneurism treated by Ligation of Carotid Artery. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Operator. Result. Remarks. Evans, Recovered. Lived twenty-eight years subsequently. Mott. Relieved. Died seven months subsequently, from asphyxia. Mott, Died. Death from hemorrhage in three weeks. Key, it Died in a few hours. Morrison, Recovered. Lived twenty months subsequently. Fergusson, Died. Died on seventh day, from pneumonia. Hutton, it Died on sixty-sixth day; suppuration of sac. Campbell, u Died on nineteenth day, from pneumonia. Wright, II Died on sixtieth day ; hemiplegia. Broadbent, it Died in fourth month, from hemorrhage. Hewson, (1 Died on eleventh day. Neumeister, (( Died on fifth day ; hemiplegia. Scott, a Died from rupture of sac. Dohlhoff, II Died on sixth day ; paralysis. Porta, ii Died in fortjT hours, from erysipelas. Villardebo,1 k Died on twenty-first day, from hemorrhage. Ordile, (< Pirogoff, Relieved. Pirogoff, u Pirogoff, Died. Hemiplegia. Nussbaum, u Died from rupture of sac. Nussbaum, i< Died from rupture of sac. Heath, u Mistaken for aortic aneurism, and left carotid tied. Death almost immediately, from anaemia of brain. Desgranges, Relieved. Died twelve months subsequently, from indepen-dent causes. Cases of Innominate Aneurism treated by Ligation of Subclavian or Axillary Artery.2 No. Operator. Result. Relieved. Died. Relieved. Died. Relieved. Remarks. 1 2 3 4 5 Wardrop, Laugier, Broca, Blackman, Bryant, Died two years subsequently, from dropsy. Died in a month, from asphyxia (axillary tied). Died in six months, from gangrene of lung. Died in eight days, from hemorrhage. Improvement continued at last report. Cases of Innominate Aneurism treated by Consecutive Ligation of Carotid and Subclavian Arteries. No. Operator. Result. Remarks. 1 2 3 4 5 Fearn, Wickham, Malgaigne, Bickersteth, J. Adams and F. Treves, Recovered. Died. it k Relieved. Died from causes unconnected with operation. Died in two and a half months ; rupture of sac. Died on twenty-first day, from erysipelas. Died in three months. Died in three months. 1 This appears to be identical with the case attributed to Rompani. Erichsen mentions other unsuccesful cases attributed to Knowles and O'Shaughnessy. 2 Dupuytren's case, usually placed in this category, was one of subclavian aneurism. 568 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Cases of Innominate Aneurism treated by Simultaneous Ligation of Carotid and Subclavian Arteries. No. Operator. Result. Remarks. 1 Rossi, Died. Died in six days. 2 Hutchison, it Died in forty-one days; some doubt as to whether the subclavian was really tied. 3 J. Lane, u Rupture of sac. 4 McCarthy, ti 5 Durham, tt Died on sixth day, from shock. 6 Holmes, ti Died in eight weeks; galvano-puncture also used. 7 Ensor, ti Died in nine weeks. 8 Weir, ti Died in fifteen days; rupture into trachea. 9 Barwell, Recovered. Died subsequently, from bronchitis ; aorta also involved. 10 Kelburne King, Relieved. Temporarily relieved ; died in 111 days, from hemorrhage ; aorta also involved. 11 Eliot, Died. Died on twenty-fifth day, from hemorrhage. 12 Barwell (2d case), Recovered. 13 Id. (3d case), ti 14 Id. (4th case), Died. Died in thirty hours, from effects of anaesthetic. 15 Stimson, Recovered. Died 21 months afterwards, from phthisis. 16 Palmer, Relieved. Died, after four months. 17 Denuce, No benefit. Wounds healed, but no change in tumor. 18 Ransohoff, Died. Death on seventh day. 19 King (of Hull), Relieved. Doing well two months afterwards. 20 Howard Marsh, ? 21 Pollock, Died. Died in eight days. 22 H. W. L. Browne, Recovered. 23 J. L. Little, u Death from pleurisy, three years and four months after operation. Carotid Artery and Branches.—Carotid aneurism is usually looked upon as specially adapted for the treatment by ligation. The operation of tying the common carotid is, however, attended in itself by very considerable risk —the mortality being, according to Norris's statistics, over thirty-six per cent., and according to those of Pilz, over forty-three per cent.1 Of 84 cases in Avhich the common carotid was tied during our late war, no less than 63 (75 per cent.) terminated fatally, and 101 cases collected by Mr. Maunder, of ligation for wound or traumatic aneurism, gave but 34 recoveries. I have myself tied the common carotid in three cases, and each time successfully, as regarded recovery from the operation. As more than one-third (ninety- one out of two hundred and fifty-nine) of the deaths after this operation have resulted from cerebral disease due to the interference with the circu- lation of the brain, it is evident that in any case in which it is practicable to do so, ligation of the external should be substituted for that of the common carotid. If, however, as is usually the case, the aneurism involves the common trunk itself, and pressure proves unavailing, ligation of the primi- tive carotid must be resorted to. Ligation by the Hunterian method has, according to Pilz, been done in eighty-seven cases, with fifty-five known recoveries and thirty-one deaths, the result of one case not having been ascertained. For traumatic aneurism at the root of the carotid, the surgeon may choose between Brasdor's and the " old operation," which has been suc- 1 Both carotids have been tied in twenty-seven cases—once simultaneously (fatal in twenty-four hours), and twenty-six times with greater or less interval between the operation ; only five of the latter cases proved fatal. SUBCLAVIAN ANEURISM. 569 cessfully employed by Syme and Frothingham. For non-traumatic aneu- rism the " old operation " would be unsuitable, for the surgeon could not be absolutely sure that the disease might not involve the innominate, or even the aorta; and hence, in such a case, the distal ligature (first practised by AVardrop) is the plan of treatment most to be recommended. Of nine patients on whom this operation has been performed, four recovered (Ward- Fio. 268. Carotid aneurism. (From a patient in the University Hospital.) rop, Bush, Colson, Wood), two Avere relieved (Wardrop, Delens), and three died (Lambert, Demme, Lane)—a sufficiently favorable record to encourage a resort to the operation under suitable circumstances.1 Internal Carotid and Branches.—Aneurisms of the internal carotid and its branches, including intra-cranial and intra-orbital aneurisms, may require ligation of the common carotid artery, though digital compression Avith medical treatment should always be first tried in these cases. The results of carotid ligation for intra-orbital aneurism are quite favorable, twenty- nine cases, collected by Noyes, having given twenty-five recoveries and but one death, and sixty-four cases quoted by Wolfe, from Sattler, having given forty recoveries, ten failures, and fourteen deaths. The internal carotid artery has been successfully tied in cases of hemor- rhage by Keith, Buck, Briggs, Sands, S. Smith, A. T. Lee, and Barba, but does not appear to have been tied in cases of aneurism. Bramlette's and Byrd's cases, in which the common carotid was tied with both its branches, have already been referred to (page 200). Vertebral Artery.—This vessel has, according to Prof. Gross, been tied on fiA^e occasions, and four times successfully; but it does not appear that the operation has ever been attempted for aneurism of the vertebral artery itself. Compression and styptics, after laying open the sac, proved successful in a case of traumatic aneurism of the vertebral, recorded by Kocher,of Bern. Subclavian Aneurism.—The statistics of this serious affection have been particularly investigated by Sabine, of New York, Koch, and Poland. The folloAATing table shows the results of various modes of treatment in 122 cases collected by the last-named writer:— 1 Pilz gives thirty-eight cases of ligation of the common carotid by Brasdor's method, for all aneurisms, recovery having been obtained in twelve, with twenty-five deaths, and one unaccounted for (Half-Yearly Abstract of Med. Sciences, vol. xlviii. p. 158). 570 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Mode of treatment. Cases. Recovered, or in process of recovery. i Died. Uncer-tain. 1. None, or medical treatment only..... 2. Moxa and hypodermic injection of ergot1 . . 6. Acupressure of axillary and innominate . . 49 1 3 1 2 1 4 1 7 21 11 12 1 1 1 4 1 1 13 1 3 1 *2 1 1 9 i 1 31 2 1 2 6 12 11 12 i 1 4 1 5 9. Operation for ligation of innominate or subcla-10. Ligature of subclavian (3d portion), embracing cases of subclavio-axillary aneurism5 . . 11. Ligature of subclavian (1stportion), subclavio-13. Ligature of innominate, carotid, and vertebral 14. Ligature of subclavian and carotid6 .... 15. Ligature of subclavian, carotid, and vertebral 16. Ligature of axillary 1 /T) -, .. 17. Lilature of carotid^ }(Brasdor)7 ■ • • • 122 33 84 5 From the above figures it will be seen that the most promising methods of treatment are the medical and hygienic, with compression in suitable cases. Manipulation and galvano-puncture are also worthy of further trial. The Hunterian operation is justifiable in cases in which the aneurism is situated in the third portion of the vessel, so that a ligature can be applied outside of the scaleni muscles, or even between them—the case under such circum- stances approximating to one of axillary aneurism. When, however, the disease involves the second portion of the artery, the surgeon can only choose between ligation of the innominate (first practised by Mott), ligation of the first part of the subclavian, and some form of the distal operation. The innominate artery has, in all, been tied in twenty-one cases, of which twenty proved fatal. The only instance of recovery is that in which Dr. Smyth, of New Orleans, tied also the carotid and vertebral, the patient 1 Dutoit has recently reported a case successfully treated by hypodermic injections of ergotine, supplemented by digital pressure on the cardiac side of the sac ; Gay has also recently recorded a case in which compression was employed with marked ad- vantage. 2 Direct compression has proved successful in a fourth case reported by Mr. Holmes. 3 A case cured by distal compression has been recently recorded by Warren Stone, of New Orleans. 4 Dr. Levis, of this city, tried the introduction of horsehairs, with a fatal result. 5 Another (fatal) case has recently occurred in the practice of Sir "W. Fergusson. 6 A successful case has been since recorded by Dr. Little, of New York. 7 Successful cases have since been reported by Prof. Toland, of San Francisco, and Dr. Forbes Moir, of Aberdeen. 8 Unsuccessful cases have been since recorded by Mr. Holden, Mr. H. Smith, and Mr. Heath; no effect was produced in Smith's case, which terminated fatally from rupture of an intrathoracic portion of the aneurism; in Heath's case acupuncture was afterwards tried, but the patient died eighteen days subsequently. In a fifth case, recorded by Mr. Kose, the carotid was also tied, and the aneurism was practi- cally cured four weeks after the operation, though hemiplegia had followed the inter- ference with the cerebral circulation. SUBCLAVIAN ANEURISM. 571 surviving ten years and then dying from hemorrhage from the sac, into Avhich the blood had found its way through the subscapular artery. Cases of Ligation of the Innominate Artery. No. Reporter. Result. No. Reporter. Result. 1 Mott, Died. 12 Pirogoff, Died. 2 Graefe, (! 13 Bujalski, (< 3 Norman, U 14 Id. u 4 Arendt, U 15 Bickersteth, (( 5 Hall, I! 16 O'Grady,1 I! 6 Bland, (( 17 Smyth,2 Recovered. 7 Lizars, (( 18 Porter,3 Died. 8 Dupuytren, (! 19 Hutin,4 u 9 Cooper, U 20 Lynch,5 u 10 Id. (( 21 Buchanan,6 n 11 Gore, (1 The first portion of the subclavian has, including McGill's case of tempo- rary occlusion, been tied nineteen times, and in every instance with a fatal result. Seventeen of these operations were upon the right side, and two (Rodgers's and McGill's) upon the left. Cases of Ligation of the first portion of the Subclavian Artery. No. Reporter. Result. No. Reporter. Result. 1 Colles, Died. 11 Bayer, Died. 2 Mott, u 12 Liston,8 3 Hayden, (I 13 Parker,9 4 O'Reilly, (1 14 Hobart,10 5 Partridge, (! 15 Cuvillier,11 6 Liston, (( 16 Kuhl,12 7 Rodgers, u 17 Ayres,13 8 Auvert, (( 18 Becker,13 9 Id.7 I! 19 McGill,14 10 Arendt, (( We thus have 40 cases of ligation of either the innominate or the first part of the subclavian, or, considering cases of subclavian aneurism only, 31 instances of the proximal operation, with only one recovery—surely not enough to justify a repetition of the proceeding unless in very exceptional circumstances. If the operation is to be done at all, Dr. Smyth's example 1 In this case the carotid also was tied. 2 Carotid and vertebral also tied. 3 Modified acupressure employed in this case. * Operation for secondary hemorrhage. s Operation for hemorrhage after gunshot wound. 6 After opening sac ; patient died in a few minutes. 7 Case of axillary aneurism. 8 Carotid also tied. 9 Carotid and vertebral also tied. 10 Distal operation for aortic aneurism ; carotid also tied. 11 Traumatic aneurism from bayonet wound ; carotid also tied. 12 Operation for malignant tumor of head. 13 For secondary hemorrhage following gunshot wound. 14 First part of left subclavian temporarily compressed with torsion forceps; pleura wounded ; death on sixth day. 572 'surgical diseases of the VASCULAR SYSTEM. should be followed, and the vertebral and carotid secured, as well as the innominate. The distal operation has been somewhat more successful, but is still un- promising. What course then is to be pursued for an aneurism AA'hich involves the first or second portion of the subclavian, and Avhich resists bloodless treatment? Amputation at the shoulder-joint (which Avould act as a modified distal operation) would under such circumstances probably be the best procedure. It Avould, as pointed out by Fergusson, who suggested the plan, have the advantage over the ordinary distal method of diverting the force of the circulation by removing the part which previously demanded an arterial supply. This method has been put in practice by Prof. Spence and Messrs. Holden, H. Smith, Heath, and W. Rose, and in the first- and last-named surgeons' cases with good results; it might also be properly adopted in cases of aneurism of the third portion of the artery, in which, from any circumstance, the vessel could not be reached beyond the scaleni muscles. Willett has suggested that the carotid should be tied (distal opera- tion) in addition to amputation, and this was done in Rose's case above mentioned. Axillary Aneurism.—This, which is a less frequent affection than sub- clavian aneurism, admits of several modes of treatment. Compression upon the third portion of the subclavian, either by the finger, or instrumentally (the patient being anaesthetized), should be tried, and may sometimes prove successful, as in a case recorded by Lund, of Manchester; advantage might also be obtained from the flexion method, the arm being bandaged across the chest. If it be determined to resort to severer measures, the surgeon must choose between ligation of the axillary below the clavicle, ligation of the third portion of the subclavian, the old operation, and amputation at the shoulder-joint. Ligation of the axillary below the clavicle has been done for aneurism (as a Hunterian operation) in 21 cases,1 with 8 deaths, giving a mortality of 38 per cent. The statistics of ligation of the third part of the subclavian, for axillary aneurism, are slightly more favorable, 67 cases, ac- cording to Koch, giving but 23 deaths—a mortality of only 34 per cent. Hence, the latter operation should, I think, be preferred, particularly as on theoretical grounds it would seem to be safer — ligation below the clavicle being of the nature of Anel's, rather than of Hunter's, method. Ligation of the third portion of the subclavian is, however, in itself a very serious operation,2 and it is, therefore, worth while to inquire, Avith Mr. Syme, whether the old operation might not in some cases be preferable. Statistics are as yet wanting to decide this question, but the operation, which was twice success- fully resorted to by Syme himself, is at least worthy of further trial. Ampu- tation at the shoulder-joint for axillary aneurism was successfully performed by Syme, and likewise by Morton, of this city, for hemorrhages and gangrene after ligation of the second portion of the subclavian. Either this, or the "old operation," Avould be necessarily indicated in any case of axillary aneu- rism which had become diffused, or which threatened external rupture or gangrene of the limb. Amputation would probably be the safer proceeding, but would of course have the disadvantage of necessarily sacrificing the 1 Koch gives 26 cases, of which, however, 5 appear to have been for subclavian aneurism (distal operation); one of these was the case in which Porter acupressed the axillary artery, and subsequently the innominate. 2 The mortality for all causes is, according to Norris's statistics, 43 J per cent. (Am Journ. of Med. Sciences, July, 1845), and according to Koch's, no less than 51 per cent. Of 48 cases recorded during our late war, 37 terminated fatally, a mortality of over 77 per cent. ABDOMINAL AND INGUINAL ANEURISMS. " 573 upper extremity. Hemorrhage during either operation might be prevented by compressing the subclavian over the first rib, through a preliminary in- cision above the clavicle. Aneurisms of the Arm and Forearm.—Aneurism of the brachial artery is a rare affection, of which Dr. L. E. Holt has been able to collect but 17 cases, including one of his own. When involving the uppermost part of the artery, immediately below the axilla, it may be treated by compression or by flexion, and, if these fail, by the " old operation" 6r by amputation, either of Avhich Avould probably be safer than ligation of the axillary, whether in the armpit or below the clavicle. For aneurism of the brachial at a loAver point, or of either of its branches, if compression fail, the Hunterian opera- tion should be employed. The traumatic and arterio-venous aneurisms met with at the bend of the elbow, as the result of venesection, are best treated by the " old operation " (see pp. 198, 199). Abdominal and Inguinal Aneurisms.—Dr. Murray, of Newcastle-on- Tyne, cured an aneurism of the abdominal aorta by instrumental compres- sion above the sac, in five hours (the patient being under the effect of chloro- form) ; and Dr. Heath, of Sunderland, is said to have been equally successful by using pressure, Avithout anaesthesia, continued for tAventy minutes—irreg- ular compression for ten hours, with chloroform, having previously failed. A third successful case has been reported by Dr. Moxon and Mr. Durham, a fourth by Dr. Greenhow, and a fifth by Dr. Philipson. This mode of treat- ment is, hoAvever, not entirely free from danger; a patient of Bryant's died eleven hours after the removal of the clamp (which in this instance was ap- plied over the aorta on the distal side of an aneurism of the coeliac axis), an autopsy revealing extensive peritonitis due to the pressure of the instrument; a second case, under the care of Paget and Bloxam, terminated fatally in eight days from peritonitis and visceral infarctus; a third case is mentioned by Holmes as having proved fatal in the practice of Mr. Durham; a fourth (in a case of varicose aneurism of the aorta and left common iliac vein) ter- minated fatally from gangrene of the intestine under the care of Mr. Simon; and a fifth, from a rupture of the sac, in a patient treated by distal compression by Dr. Skcrritt, of Bristol. Still, the successful result in the first-mentioned cases undoubtedly brings within the range of surgical treatment an affection otherwise almost hopeless. The instrument to be employed may be either Skey's or Lister's (Figs. 27, 28), and the pad must be accurately held in place over the aorta, as complete interruption of the circulation is required. The distal ligature has proved futile in cases of aneurism of the aorta, or of its abdominal branches, while the Hunterian operation is manifestly out of the question. Aneurism of the common iliac artery may be treated by compression on the cardiac side of the sac, the patient being in a state of anaesthesia. Cases are recorded by Mapother, Heath, Eck, and others, in which satisfactory cures have been in this way obtained. If possible, the compressing pad should be applied over the iliac artery itself, but if the size of the tumor will not per- mit this, over the aorta. Varick's case of successful distal compression has already been mentioned. Ligation of the abdominal aorta for inguinal aneurism, was first performed by Sir Astley Cooper,1 in 1817, and has been since repeated by James, Mur- 1 Sir Astley Cooper's operation, perhaps the boldest in the history of surgery, has been much criticised—many surgical writers following Guthrie in believing that it is always possible to secure the common iliac through an incision on the opposite side of the abdomen. That this is not always so, is shown by Stokes's case, in which the 574 SURGICAL DISEASES OF THE VASCULAR SYSTEM. ray, Monteiro, South, McGuire, of Richmond, Va.,1 Stokes, of Dublin (by Porter's method of modified acupressure), and Watson, of Edinburgh.2 Czerny, of Vienna, has also tied the aorta for hemorrhage folloAving a gun- shot Avound, after previous ligation of the external and common iliacs, and Czerny, of Heidelberg, for hemorrhage during an operation for extirpation of the kidney. All of these cases proved fatal, though Monteiro's patient survived until the tenth day. In Cooper's, James's, and Watson's cases, the incision Avas made through the linea alba, and in the others on the left side, as in ligating the common iliac. The uniformly fatal result of this opera- tion should forbid its employment, unless under very exceptional circum- stances. If, however, the patient were dying from hemorrhage, and the common iliac could not be secured, as happened in the cases of Cooper, McGuire, Watson, and Czerny, ligation of the aorta would seem to be not only justifiable, but absolutely necessary. Ligation of the common iliac artery (which was first practised, in 1812, by Gibson, of this city, in a case of gunshot injury) may be required in cases of aneurism involving the common iliac artery, or either of its branches. To the 32 cases collected by Dr. Stephen Smith, of New York, may be added a fatal one recorded by Baudelocque, and 34 since reported, viz., the suc- cessful cases of Bickersteth, Brainard, Luzenburg, Cock, McKinlay, Caldas, Chiappini, Richter, and Sands, and the fatal cases of Gurlt, Biinger, Ham- mond, Hargrave, Maunder, Watson, Delisle, Baxter, Czerny, Busch, McKee, Isham, Cutter, Hamilton, Baker, Ingram, Barral, D'Almeida, Pitta, Bar- bosa, Ladureau, Gouley, Carr, C. T. Hunter, and A. B. Mott. Of the whole 67 cases, but 16 terminated successfully—a gloomy record which hardly warrants a resort to this proceeding unless in exceptional cases. It is probable that the old operation would, in some cases of aneurism of the common iliac, be preferable to ligation of that vessel, as it certainly Avould be to ligation of the aorta. This procedure has, however, not yet been em- ployed ; it was attempted by Cooper in the case in which that surgeon tied the aorta, and Avas believed to have been performed in a case of iliac aneurism operated on by the late Mr. Syme. In this instance, the loss of blood was pre- vented by the use of Lister's aortic compressor, and the patient recovered from the operation, but died about three months afterwards from pleurisy—when an autopsy showed the aneurism to have been of the external iliac, the liga- tures having been really applied below the bifurcation of the common trunk. Aneurisms of Internal Iliac and Branches.—Aneurisms of the internal iliac, and of the pudic artery, are extremely rare, there being, according to Erichsen, but one case of each known. Aneurisms of the gluteal and ischi- atic arteries are more common, and may be treated in a variety of ways. Fischer,3 of Hanover, has particularly investigated the statistics of these affections, and from an analysis of 35 cases (14 of traumatic and 21 of spon- taneous aneurism) concludes that the injection of the perchloride of iron is the best mode of treatment. If this method fail, or if it be not thought pro- per to employ it, it Avould further appear that for traumatic aneurisms the incision was made on the left side for a right iliac aneurism, and yet " any attempt to deligate the common iliac would," it was found, " be impracticable," on account of the overlapping and adhesion of the aneurismal tumor. (Dub. Quart. Journal of Med. Science, Aug. 1869, p. 5.) 1 In this case, it was intended to tie the common iliac, but the aneurism was found to involve the aorta, and burst during the examination. (Am. Journal of Med. Sciences, Oct. 1868, p. 415.) 2 For secondary hemorrhage, after previous ligation of the common iliac. 3 Archiv fur klin. Chirurgie (Langenbeck), xi. Band, 3 Heft, S. 827. ANEURISMS OF INTERNAL ILIAC AND BRANCHES. 575 "old operation," as practised by Bell, Syme, Bickersteth, Hussey, and Darby, of New York, and for those of a non-traumatic nature ligation of the internal iliac, are the measures to be preferred. The following table is com- piled from Fischer's paper:— Traumatic. Spontaneous. Aggregate. Mode of Treatment. ■6 u 3 u •6 V P •6 o H •6 u u 3 U 1 1 5 3 10 5 3 3 2 2 10 ■a ]eg, and foot firmlv fixed WnaXsK been adjusted, the limb should be laid on a pillow, or, still better, in a large and loose fracture box. Any tendency to anterior projection of the femur may be counteracted, as advised by Butcher, by using in addition a Tor EXCISION OF THE KNEE-JOINT. 637 anterior splint, while the risk of outward bowing may be prevented by using an external splint, a metal spring and truss-pad, as ingeniously suggested by Swain, or, which I have found sufficient, a simple strip of adhesive plaster carried around the outside of the limb and secured to the inner side of the splint. The object being to obtain firm bony union, the splint should be removed as seldom as possible, and the first application should suffice, if possible, for at least a fortnight; and, indeed, I have occasionally extended this time with advantage to five or six weeks. The statistics of excision of the knee-joint have been investigated by a number of writers, and elaborate tables have been published by Butcher, Heyfelder, Hodges, Penieres, Picard, and many others. The most recent researches upon this subject are those of Culbertson, who has analyzed nearly 700 operations, of which no less than 603 were for chronic disease of the articulation. These 603 cases gave 419 recoveries and 178 deaths, the result in six not having been ascertained; the total mortality of terminated cases was therefore 29.8 per cent. The following table will exhibit the results more in detail:— Eeeovered without further operation ..... 354 or 58.7 per cent. " with useful limbs .......246 or 40.8 " Result undetermined (one amputated) . . . . . 6 or 1.0 " Amputation subsequently (65 recovered, 12 died, and 1 unde- termined) ..........78 or 12.9 " Died after excision.........166 or 27.5 " Death-rate of terminated cases in which no further operation was performed ......... 31.9 " It is thus seen that, even when excision fails, consecutive amputation is attended with comparatively little risk, less indeed than thigh amputation for disease in general. The following table, compiled from Culbertson's, shows in a very satisfac- tory manner the mortality of knee-joint excision at different ages:— Results of Knee-joint Excision at Different Ages. Result Mortality per Age. Total. Recovered. Died. not deter-mined. cent, of termi-nated cases. 19 11 7 1 38.9 5 to 10 "........ 106 88 17 1 16.2 10 to 15 "........ 99 81 18 17.2 15 to 20 "........ 84 58 25 i 30.1 20 to 25 "........ 67 40 26 l 39.4 25 to 30 "........ 55 34 20 l 37.0 30 to 40 "........ 65 38 27 41.5 19 9 10 52.6 89 60 28 i 31.8 603 419 178 6 29.8 It thus appears that the operation of knee-joint excision, which is quite fatal in very early childhood, is not attended with much risk from the age of five up to the period of puberty; while from that time the danger steadily increases, till in adult life the operation is again one of a very serious nature. We may, therefore, probably say, with Holmes, that fourteen is, all things being considered, about the most favorable age—there being then compara- tively little danger of consecutive shortening, while the operation is at the same time not attended with any particular risk to life. Excision of the 638 EXCISIONS. knee-joint should not as a rule be performed during the first five years of life, while it must be deemed an extremely grave procedure in persons past the age of thirty. Of 23 operations in my own hands, the result in 2 is still undetermined; 18 of the remainder have ended in recovery with useful limbs; 1 ended in recovery after amputation ; and only 2 have terminated fatally. Bones of the Leg.—Excision of the tibia is rarely justifiable, but may occasionally be proper in cases of acute necrosis from subperiosteal abscess (see p. 589). The operation requires a single longitudinal incision, the bone being then divided with a chain saw, and wrenched from its epiphyseal attachments with the lion-jawed forceps. Excision of the fibula, which may be required for compound fracture or for necrosis, may be effected by a simi- lar operation, care being taken to prevent subsequent eversion of the foot, by the use of a suitable splint. Ankle.—Excision of the ankle-joint, first employed by the elder Moreau in 1792, may be required for compound fracture or dislocation, or for disease of the articulation. The operation may be performed by means of two lateral incisions, one behind either malleolus, or, which is probably better, by means of a semilunar incision passing around the lower border of the external malleolus, and continued in a longitudinal direction along the line of the fibula. The anterior portion of the incision should not extend so far as to endanger either the extensor tendons or the dorsal artery of the foot. Having divided the peroneal tendons, the surgeon may remove the lower end of the fibula,1 when the astragalus will come into view. If this bone be but slightly affected, it will be sufficient to remove its upper articulating surface with saw or cutting forceps, and to gouge away such portions as may seem diseased, but under other circumstances the astragalus should be re- moved entire. The foot being then inverted, the lower end of the tibia is to be cautiously cleared with the probe-pointed knife, the inner malleolus being cut away with strong forceps, and as much of the articulating ex- tremity of the tibia as may be thought necessary removed with the chain saw; or a second incision may be made on the inner side of the limb, and the extremity of the tibia removed with a narrow saw passed across from one side to the other. The limb may be kept during the after-treatment in a fracture-box, or on a posterior wire splint provided with a foot-piece. The foot must be well supported, lest anchylosis with a " pointed toe" ensue. The statistics of excision of the ankle-joint for disease have been investi- gated by Spillman, Hancock, Poinsot, and Culbertson, the latter of whom has collected 121 cases. The disease, in most instances, was caries or arthritis, but occasionally necrosis, bony tumor, etc. The results may be seen in the following table:— Nature of Operation. Total. Recovered. Died. Result not deter-mined. Mortality per cent, of termi-nated cases. 68 51 5 57 45 5 4 6 7 6.6 11.8 124 107 10 7 8.5 1 Polaillon divides the fibula with a chain saw above the external malleolus, which he leaves attached to the astragalus and calcaneum. EXCISION OF THE BONES OF THE FOOT. 639 The condition of the preserved limb in most of the cases of recovery is said to have been quite satisfactory, Culbertson giving the proportion of useful limbs as 66 per cent., and Stauff, as quoted by Rose, as 75 per cent. Foot.—The only excisions of tarsal bones which require special notice are those of the astragalus and of the calcaneum. Excision of the Astragalus may be required in cases of compound fracture or dislocation (or even simple dislocation, if irreducible), caries, necrosis, etc. The operation requires a semilunar incision on the anterior and outer aspect of the joint. The removal of the bone may often be facilitated by cutting across its neck with strong pliers, when the fragments may be successfully dislodged with elevator and forceps, the probe-pointed knife being cautiously used in the deep portions of the wound ; but in other cases it may be neces- sary to remove the bone piecemeal by means of the gouge. The statistics of this operation (which was first performed in 1582 by a surgeon .of Duisburg, in a case recorded by Hildanus) have been investi- gated by Hancock and Poinsot, the former of whom finds that of 112 patients submitted to total excision, 79 recovered with useful limbs, 2 were cured by amputation, and 19 died, while in 12 cases the result was not ascertained. The mortality of terminated cases was thus exactly 19 per cent. The same writer has collected 28 cases of partial excision of the astragalus, with 18 satisfactory recoveries, one cured by amputation, and one death. Poinsot has collected in all 144 cases, of which 26, or 18 per cent., terminated fatally. Excision of the Os Calcis is occasionally required in cases of caries or ne- crosis of that bone, though in the majority of instances free gouging, or the extraction of sequestra, will suffice. The operation of excision of the cal- caneum may be done by raising a heel flap, as in Syme's amputation, or (as recommended by Erichsen) by turning down an elliptic flap constituted of the tissues of the sole, and then making two lateral triangular flaps, by car- rying a longitudinal cut through the tendo Achillis to meet the former in- cision. A still better method is that of Holmes, in which an incision is made on the level of the upper part of the bone, beginning at the inner border of the tendo Achillis (which it divides), and passing around the back and outer surface of the foot as far forward as the mid-point between the heel and the base of the fifth metatarsal bone, a second incision passing at a right angle from near the anterior end of the former, downwards to the commencement of the grooved internal surface of thfe os calcis. The flap thus formed, which includes the cut peronei ;tendons, is then reflected from the bone, when the ligaments of the calcaneo-cuboid joint being divided, the calcaneum itself can be slightly displaced inwards, so as to facilitate the division of the various ligaments between that bone and the astragalus. This being done, the calcaneum is twisted outwards, and carefully separated from the soft parts on its inner side. The operation is completed by stuffing the cavity with a strip of oiled lint, and by fixing the foot at a right angle with the leg, by means of an anterior moulded splint. Southam, and Lund, of Manchester, employ a single external incision, beginning as in Holmes's operation, but carried forwards to a point midway between the projection of the fifth metatarsal and the tip of the malleolus. From a recent discussion in the Clinical Society of London, it would appear that the result of the operation is most satisfactory when no attempt is made to preserve the periosteum. The statistics of excision of the os calcis, which appears to have been first performed by Monteggia in 1814, have been studied by Burrall,1 of New 1 Bellevue and Charity Hosp. Keports, 1870, p. 91. 640 ORTHOPEDIC SURGERY. York, and by Polaillon1 and Vincent,' of Paris. The last-named writer has collected 79 cases, which resulted as follows: 49 patients recovered with useful limbs, 5 recovered, but without much use of the preserved member, 10 submitted to subsequent amputation, and 5 died, while the result in 10 cases was not ascertained. If we add 6 successful cases reported by McGuire, of Richmond, Va., and Poore, of New York, we shall have a total of 75 ter- minated cases, giving 55 recoveries with useful limbs, and but 5 deaths, a mortality of less than 7 per cent. Vincent's statistics show that subperios- teal excision is more dangerous than the ordinary operation, having given 3 deaths out of 23 cases. The other tarsal bones, or those of the metatarsus or toes, comparatively seldom admit of excision, the disease, when too extensive for successful gouging, usually requiring amputation; I have, however, myself, several times had occasion to resort to excision of one or more bones of the tarsus and metatarsus; and P. S. Conner has collected 35 cases, including 2 of his own, in which two or more bones were removed at one operation, 25 of the whole number having terminated in recovery, 5 in failure, and 5 in death. The same surgeon has also reported a case in which he successfully removed the whole tarsus, the rest of the foot being preserved. When excision is re- sorted to, the lines of incision should be regulated by the position of external sinuses; no rules can be given which in such cases would admit of general application. The joint between the astragalus and calcaneum has been successfully excised by Annandale. CHAPTER XXXIII. ORTHOPAEDIC SURGEKY. Orthopaedic3 surgery is that branch of surgical science which treats of the means of remedying deformities, congenital or acquired. Etymologi- cal ly, the term should be used only with reference to the deformities of child- hood, and might be taken to embrace a great variety of subjects, such as the removal of tumors, the reduction of dislocations, etc. In practice, however, the application of the term is limited to a few particular kinds of deformity, as wry-neck, lateral curvature of the spine, club-hand, or club-foot, and contractions of joints not due to articular disease, while, on the other hand, no reference is intended to the age of the patient in whom these deformities occur. Among those who in this country have particularly illustrated this branch of surgery, may be mentioned J. M. Warren, Bigelow, Brown, Det- mold, Sayre, Bauer, Prince, Mutter, and J. Pancoast. Wry-neck. This affection, which is also known as Torticollis, or Caput Obstipum, is occasionally congenital, but more often originates in children from three to ten years old. It consists in a contraction of the cervical muscles, particu- larly the sterno-cleido-mastoid and trapezius, usually on one side only, but 1 Archives G-enerales de Medecine, Sept. et Oct. 1869. 2 De l'ablation du calcaneum, etc., Paris, 1876. 3 From bptioQ (straight), and nate (child). WRY-NECK. 641 sometimes on both. The head is drawn downwards and inclined to the affected side, being at the same time rotated in the opposite direction. In the congenital form of the disease, and in that which is acquired (if long continued), the deformity is increased by defective development of the cor- responding side of the face and head. The cervical vertebra? undergo rota- tion on their axis, becoming twisted, and serving to maintain the deformity, and ultimately compensatory lateral curvature is developed in the rest of the spinal column. Wry-neck is more common in girls than in boys ; it is apparently due to irritation of the spinal accessory nerve—the non-congenital variety coming on after the eruptive fevers, or as the result of glandular inflammation or ordinary muscular rheumatism. It sometimes occurs as a reflex phenome- non, depending on the irritation of teething, or of intestinal parasites. Many of the cases which are considered congenital are, according to Little, due to injuries received during birth. When both sterno-cleido-mastoid muscles are involved, the affection will usually be found to have a rheu- matic origin. Symptoms and Diagnosis.—The symptoms are easily recognized, the con- tracted muscles being tense and well defined; frequently both portions of the sterno-cleido-mastoid seem equally rigid, but often the sternal portion is alone or principally involved. The diagnosis is usually easy; the deformity may be closely simulated by the contraction of a cicatrix after a burn, or by disease of the cervical vertebra?; in the former event, the nature of the case will be evident upon careful examination, while if spinal disease be present, the fact can be ascertained by observing the localized tenderness on pressure, and the pain produced by moving the spine or by pressing the head downwards, with perhaps the existence of inflammatory thickening and of partial motor paralysis. Treatment.—In the milder form of the affection, especially when of a rheu- matic origin, a cure may be sometimes effected by the use of anodyne and stimulating embrocations, the external application of heat, or, as success- fully practised by Dr. J. M. Da Costa, of this city, by the hypodermic use of atropia; in some cases, in which the disease would appear to consist not so much in spasmodic contraction of the muscles on one side as of paralysis of those on the other, benefit may be derived from the employment of elec- tricity, or from the endermic application of strychnia. Busey, of Wash- ington, employs hypodermic injections of morphia, and enforced motion of the affected muscles while the patient is under the influence of ether. In severer and more obstinate cases, it will usually be necessary to resort to an operation, though if the degree of contraction be not very great, mechanical extension, by means of a suitable instrument, will occasionally suffice. The Operative Treatment of wry-neck consists in the subcutaneous division of one or both of the lower attachments of the affected sterno-cleido-mastoid muscle: the sternal portion may be divided by introducing an ordinary tenotome in front of the upper margin of the sternum, and about half an inch above the line of the clavicle, and, having passed the knife behind the tendon, with its flat surface towards the latter, turning the edge forwards, and cutting the muscle, which is previously rendered tense, with a slight sawing motion from behind forwards. The clavicular attachment may be divided by a similar operation, through a puncture made at its posterior edge; or, which is perhaps safer, a small incision may be made down to the clavi- cle, between the two portions of the muscle, and the clavicular attachment then cut from behind forwards, with a delicate probe-pointed tenotome which 41 642 ORTHOPEDIC SURGERY. is cautiously insinuated between the muscle and the bone, As soon as the tendons have been divided, the punctures should be closed with a little dry lint and an adhesive strip, the patient being then placed in bed with the head well supported; after a few days an apparatus may be applied to effect mechanical extension, while the cure is further promoted by the systematic employment of friction and passive motion. The operation for wry-neck is Fig. 323. Tenotome. one of much delicacy, and not free from risk, the principal danger being from the possibility of wounding the external or internal jugular vein, or the carotid artery; that this risk is not merely imaginary is shown by the fact that, in more than one case, the operation has been followed by fatal hemorrhage. Various forms of mechanical apparatus are employed in the after-treat- ment of wry-neck; in young subjects, it may sometimes be sufficient to apply a broad adhesive strip around the forehead and occiput, and another around the waist, fastening the two together by means of a bandage or elastic band carried from above the the ear of the unaffected side across the chest to the opposite side of the trunk, thus reinforcing the healthy sterno-cleido-mastoid muscle, and so causing the disappearance of the wry-neck. A more elegant appl ance is that of Jorg, which consists of a leather corset and firm head- band, connected by a steel rod worked by a rachet-wheel and key. Swan substitutes for the corset a plaster-of-Paris jacket. Other efficient forms of apparatus act by means of two levers, one pressing on the side of the chin, and the other on the opposite temple. Wry-neck accompanied with Painful Convulsive Spasm of the Affected Muscles is a very intractable form of the disease, and occurs chiefly in female adults. Here division of the sterno-mastoid muscle affords, usually, only temporary relief. Dr. Little has several times obtained a cure by the administration of the bromide of potassium, or of the corrosive chloride of mercury, with attention to the digestive functions: and in other cases, por- tions of the spinal accessory nerve have been excised with benefit by Camp- bell De Morgan, Annandale, Rivington, and Tillaux. The same nerve has been stretched in two cases by Southam, of Manchester; in one with per- manent, but in the other with only temporary, benefit. Another cure by nerve-stretching is attributed to Mosetig-Moorhof, of Vienna. The actual cautery has proved effective in the hands of Dr. C. K. Mills. Lateral Curvature of the Spine. This affection, which appears, in the majority of cases, to depend simply upon relaxation and debility of the spinai ligaments and muscles, is most common in young girls of from twelve to eighteen years of age. There are usually two curves, one occupying the dorsal region, and in most instances presenting its convexity to the right side, and the other or compensatory curve in the lumbar region, and convex to the left. More rarely there are four curves, an upper and a lower dorsal, and an upper and lower lumbar. together with the lateral curvature, there is always a rotation of the bodies of the vertebra? on their axis, this rotation or twisting taking place in the lateral curvature of the spine. 643 direction of the convexity at each portion of the curve. The bodies of the vertebrae are thus more displaced than the spinous processes, which, as pointed out by Judson, of New York, are held in place by their lateral attachments, and which sometimes appear, even in advanced cases, to occupy almost their natural line. The disease affects at first only the ligaments and muscles of the spine, but, in long-continued cases, may give rise to compression or par- tial absorption of the intervertebral cartilages, or even of the bones them- selves. As the result of the twisting of the vertebra? which accompanies the lateral displacement, a certain degree of antero-posterior curvature is some- times superadded—a rounded or hump-like projection occurring in the dorsal region, with a corresponding incurvation of the lumbar spine, the former constituting the condition known as cyphosis, and the latter that called lor- dosis. These are, indeed, but exaggerations of the natural curves met with in every adult spine. In some cases, especially among rachitic persons, they may exist without lateral displacement. Dr. Tuckey, an Irish physi- cian, has described, under the name of acute lateral curvature, a condition which seems analogous to the so-called "hysterical" joint-affections described in Chapter XXXI. Causes.—The common cause of lateral curvature is, as already mentioned, simply debility of the ligamentous and muscular structures which normally support the vertebral column, thus allowing, as it were, the head and upper part of the body to settle downwards, and necessarily forcing the relaxed and weakened spine to yield at its least-resisting point. The physiological changes which occur in the female at the age of puberty, and the customary relinquishment, at that period of life, of the out-door sports of childhood, appear to act as powerful predisposing causes of the spinal relaxation referred to. The very constant character of the displacement—to the right in the dorsal and to the left in the lumbar region—is doubtless due to certain vicious habits and postures, such as supporting the whole weight on the right leg ("standing at ease," in the language of the drill-master), whereby the pelvis is rendered oblique, and the lumbar spine necessarily distorted to the left side; to sitting habitually at a desk with the left shoulder depressed and the right elevated; to over-exertion of the right arm in sewing, etc. Though the dorsal curve is usually most apparent, it is really, according to Shaw, preceded in time of formation by the lumbar. The latter, however, does not become so quickly permanent, on account of the greater flexibility and elasticity of the part, which enable it to resist longer the occurrence of absorption of the articular processes and other secondary changes than can be done by the dorsal spine, fixed as that is by its connections with the thoracic walls. According to Willett, both curves are developed simul- taneously. Among the rarer causes of lateral spinal curvature may be mentioned obliquity of the pelvis from any circumstance, as from anchylosis of the hip- joint after hip disease (here the deformity is principally of the variety called lordosis), and distortion resulting from contraction of one side of the chest after empyema or chronic pleurisy. Inequality in the length of the lower limbs is, according to Barwell, a frequent cause of lateral curvature. Symptoms.—The symptom of lateral curvature which first attracts atten- tion is commonly a projection or "growing out" of the right scapula, often attended with pain in the shoulder and back; this is usually worse while sitting, or upon first lying down, so that a patient who has made no com- plaint during the day may lie awake in pain for several hours upon going 644 ORTHOPEDIC SURGERY. to bed at night. Upon making an examination, the surgeon will readily perceive the wing-like projection of the scapula, and may, even at this early stage, recognize a slight deviation in the line of the vertebra?, by tracing down the spinous processes and marking each with pen and ink. It must be, moreover, remembered that the deviation of these processes by no means represents the degree of distortion of the bodies of the bones, the displace- ment of the latter being, I believe, invariably greater than that of the for- mer. In the early stages of the affection, the deformity can be made to disappear by laying the patient on a bed in the prone position and making slight extension on the spine; but in ad- vanced cases the deformity will persist in all positions, while the whole chest and the pelvis may be likewise markedly distorted, and serious functional disturbance, or even organic disease, may result from the conse- quent compression of the thoracic, abdomi- nal, or pelvic viscera. Diagnosis.—Lateral curvature may be distinguished from the graver condition known as antero-posterior curvature, or Pott's disease of the spine (which will be described hereafter), by the fact that in the latter affection the displacement is commonly an- gular, rarely lateral, and unattended with axial rotation of the vertebra?. There are besides, usually, marked immobility, thick- ening, and tenderness of the affected portion of the spine. From the spinal distortion of rickets, lateral curvature may be distin- guished by observing the different ages at which the diseases respectively occur, and by noting that in rachitis the primary dis- placement is antero-posterior, the lateral deformity, if there be any, being a mere coincidence; while in the true lateral curvature the fact is exactly the reverse, cyphosis and lordosis being in these cases secondary phenomena. Treatment.—No matter how slight the deformity in any case may appear to be, it should not be neglected: in the early stages, before any structural alteration has occurred, it may be possible to effect a complete cure; but at \lat,er Penod tne most that can be done is to prevent further increase of the deformity. The treatment consists in the adoption of measures to im- prove the general health, the administration of tonics, especially iron and quinia, and the abandonment of any injurious habit or occupation. The pa- tient should take exercise in the open air, and may often derive great advan- tage from gymnastics, swinging by the hands from bars placed above the head, the use of light dumb-bells, etc. The object is to put in motion and thus to strengthen the various muscles attached to the spinal column, and much ingenuity may be exerted in devising various modes of accomplishing this purpose None of these exercises should, however, be persevered in to the extent of producing fatigue. During the intervals of exercise, the pa- tient should be encouraged to keep the recumbent posture, lying upon a firm mattress or sofa with a single pillow, so as to relieve the vertebral column Lateral curvature of spine. (Erichsen.) DEFORMITIES OF THE UPPER EXTREMITY. 645 ■ from pressure. If the curvature persist while lying down, a cushion may be placed under the projecting portion of the spine, so as gradually to press the bones into their normal position. Friction of the muscles on either side of the spine, either with the hand alone or with stimulating liniments, will often be of service, as will also the daily use of the cold salt douche. In severer cases it will probably be necessary to afford mechanical support by means of some form of apparatus. A great many instruments have been devised for this purpose, the general principle of action being to elevate the shoulders by means of crutch-heads under the axillae (connected with a well- padded pelvic collar), with side-pieces to support and gradually replace the projecting vertebra? by applying pressure to the corresponding portions of the chest-walls. Such an apparatus should be, as a rule, worn during the day only. Prof. Sayre has recommended the use of a plaster-of-Paris ban- dage, applied while the spine is made as straight as possible by suspending the patient by his head and arms. The suspension itself may also prove of service, as was pointed out by Glisson in the seventeenth century. My own judgment in regard to the plaster dressing in lateral curvature is that, while in some very bad cases it is capable of affording a certain measure of relief, it is ill adapted for the large majority of cases, as unnecessarily and even injuriously confining the chest and interfering with the action of the muscles; hence, for all ordinary cases of lateral curvature, I prefer a light metallic support to a plaster jacket. Even for the very bad cases, a moulded leather splint is in some respects better than the plaster bandage, or, which Mr. Adams prefers, a splint made of "poroplastic" felt. If a case of lateral curvature be recognized at an early period, and promptly and judiciously treated, it may be, if not cured, at least kept in check until the critical period of adolescence has passed by, when there will be com- paratively little tendency to increase of the deformity. It thus happens that, while a very large number of young girls suffer from incipient lateral curvature, its advanced stages are comparatively seldom seen — the disease being, as it were, " outgrown " in a great many instances. Myotomy, or subcutaneous division of the spinal muscles and aponeuroses, for a long time almost entirely abandoned in the treatment of lateral curva- ture, has been revived by Prof. Sayre, of New York, who has in several cases divided the latissimus dorsi with alleged immediate benefit. I confess that the operation seems to me unnecessarily heroic, and, indeed, as the disease is mainly dependent upon ligamentous and muscular relaxation, not contrac- tion, I do not understand why such a procedure should be expected to prove ultimately successful. Deformities of the Upper Extremity. Contraction of the Shoulder.—Duplay has described, under the name of scapulo-humeral periarthritis (see page 611), an affection which consists in inflammatory thickening of the sub-acromial bursa and sub-deltoid areolar tissue, with the formation of adhesions which interfere with the motions of the humerus. The extra-articular character of the affection can be recog- nized by observing the localization of the pain and swelling in the sub-acro- mial region. The treatment consists in forcibly rupturing the adhesions while the patient is under the influence of an anaesthetic, and in the subsequent employment of passive motion, friction, galvanism, and the cold douche. Gosselin has described a similar condition as occurring in the knee. 646 ORTHOPEDIC SURGERY. Contraction of the Elbow, apart from disease of that joint, may be owing to the retraction of the cicatrix of a burn, or to a contracted state of the biceps muscle—which latter condition may itself be variously due to hysteria, to rheumatism, or to constitutional syphilis (see pp. 461, 519). In hysterical cases, the proper constitutional treatment for that condition should be em- ployed, the arm being, if necessary, extended while the patient is in a state of anaesthesia, and then kept in a straight position for a few days._ In the rheumatic form, Avhen the contraction is permanent and accompanied with organic change, tenotomy may be required. The operation is performed by slipping a tenotome flatwise beneath the tendon of the biceps from within outwards, so as to avoid the artery, and then, turning the edge of the knife forwards and upwards, effecting the section by cutting with a slight sawing motion while the arm is forcibly extended. The wound should then be closed and the arm placed in a sling, extension being applied after a few days by means of a screw-splint or weight. Contraction of the Forearm and Hand is occasionally met with as the result of excessive use of certain muscles, with disuse of others: the treatment consists in a change of occupation, with the employment of a straight splint, friction, galvanism, etc. Club-Hand is a rare affection, analogous to club-foot. It is usually com- plicated with a deformed condition of the lower end of the radius, and sometimes of the carpal bones. Two forms of club-hand are met with, in one of which the part is in a state of extreme flexion, and in the other of extension. The affection is sometimes congenital, but usually results from infantile paralysis, and is, according to Holmes, always accompanied by other deformities. The treatment consists in supplementing the action of the paralyzed muscles by means of India-rubber bands, attached to a light metal frame, and passing beneath a ring at the wrist. In inveterate cases, te- notomy may be required, followed, after the healing of the wound, by passive motion, aided by the use of friction and galvanism. Contraction of the Fingers into the palm of the hand is not unfrequently met with, usually in old persons, as the result of an indurated state of the palmar and digital fascia, due apparently to a gouty condition or to one analogous to that of rheumatoid arthritis. The exciting cause of the affec- tion (which was first well described by Dupuytren) is often the habitual pressure of the head of a cane, or of the handles of various kinds of tools. A similar contraction may be due to burns or other traumatic causes (in which case a scar would be perceptible), or to certain forms of eczema—an important point to be remembered, as the operation about to be described would not of course be applicable to that affection. The best treatment of the deformity now under consideration consists in the cautious subcutaneous division of the contracted fascia, which may be effected by slipping a very small flat-edged tenotome beneath the skin—between it and the fascia—and cutting downwards; the part should then be immediately extended, and kept in the straight position by means of a light splint worn continuously for three weeks, and afterwards, only at night, for several weeks longer. This plan, which is that advised by Mr. Adams, I myself resorted to with most gratify- ing success in a case from which the annexed illustrations are taken (Figs. 325, 326). Busch and Madelung advise that a triangular flap of skin should be dissected up, and the palmar fascia notched at every point at which it DEFORMITIES OF THE LOWER EXTREMITY. 647 seems tense; the flap is then to be replaced, and, when the wound has united, mechanical extension resorted to. Post divides the contracted fascia by Fig. 325. Fig. 326. Dupuytren's finger contraction. The same hand after operation. direct incision, and, like Adams, lays stress upon the importance of making immediate extension. Webbed Fingers. — This annoying deformity may be remedied by per- forating the base of the web and allowing the parts to cicatrize around a metal ring, when the rest of the web can be divided without risk of read- herence; by a plastic operation, as employed by Barwell (who transplanted flaps for the purpose from the patient's buttock), by Harris, of New Jersey (who utilized for the purpose a strip of skin taken from the web itself), and by A. T. Norton (who loosens a tongue of skin from between the knuckles, and another from the palm, and, after dividing the web, brings these together with sutures); or by the use of the elastic ligature, as recommended and successfully employed by Vogel, of Eisleben. Deformities of the Lower Extremity. Contraction of the Hip.—Contraction of the muscles surrounding the hip may occasionally require tenotomy or myotomy, in cases of spasmodic rigidity of the lower extremities, of congenital luxation, or of chronic hip disease. The tendon which most often requires division is that of the adductor longus, though the operation is also sometimes performed upon the adductor brevis, pectineus, tensor vaginae femoris, and rectus. Division of these muscles is performed in accordance with the principles of tenotomy in general, the 648 ORTHOPEDIC SURGERY. Fig. 327. knife being introduced behind the part to be divided, and the section then cautiously effected by cutting from behind forwards. Knock-knee or Genu-valgum is a not uncommon deformity, consisting of a relaxation of the ligamentous and muscular structures of the knee-joint, allowing the articulation to yield in a direction inwards and backwards. The internal lateral ligament is elongated, while the external lateral liga- ment is rendered tense, together with the vastus externus and outer ham- string tendon. The inner condyle of the femur is, as compared with the outer, disproportionately large and prominent, while the popliteal space is somewhat obliterated. The affection is probably never congenital, but comes on during childhood, and is apparently connected in many instances with a rachitic tendency. Both knees are usually simultaneously affected, though the disease may be more marked in one than in the other. The treatment consists in the adaptation of an apparatus such as is shown in Fig. 327. An iron rod, hinged at the hip, knee, and ankle, extends from a pelvic band to the sole of the shoe, and is provided with pads, straps, and buckles, by which the knee may be drawn outwards: in severe cases, motion should be permitted at the hip and ankle only, the knee being fixed, and its displacement grad- ually rectified by means of the adjusting straps or a ratchet-screw. Division of the external hamstring tendon is occasionally resorted to as a preliminary measure, but, according to Little, does not appreciably hasten recovery, and is therefore not to be recommended. Forcible straightening of the limbs is a favorite mode of treatment with French and German surgeons, but, ac- cording to De Santi, should only be em- ployed in rachitic cases, and never at a later period of life than 14 years. Little, Schede, and Annandale have, in aggravated cases, straightened the limbs by excising wedge- shaped pieces of bone, the two former from the tibia, and the latter from the condyles of the femur. Schede also divided the fibula with a chisel. Exision of the knee-joint has in a similar case been successfully resorted to by Mr. Howse. Ogston simply saws through the projecting condyle and forcibly straightens the limb, while a similar operation with the chisel and with antiseptic precautions is practised by Barwell. Beeves and Chiene employ operations of like character, but avoid opening the joint, and thus make the section extra-articular. The first-named surgeon simply divides the condyle, or, as he has latterly recommended, the shaft of the femur itself, just below its middle, while the latter removes from the condyle a wedge-shaped portion of bone. McEwen, of Glasgow, divides with a chisel or osteotome the inner two-thirds of the femoral diaphysis, just above the condyles, and then straightens the limb by bending or breaking the remainder. None of these operations can be considered entirely free from risk, though their results have been upon the whole very satisfactory, 256 cases operated on by one or other method having furnished, according to Poore, of New York, only 4 deaths, while McEwen alone Apparatus for knock-knee. CLUB-FOOT. 649 reports 367 operations on 220 patients, with only 3 deaths, and these from independent causes. Outward Bowing of the Knee or Genu-Extrorsum is a condition which is the reverse of Genu- Valgum; the external lateral ligaments are relaxed, and the tibia? themselves are commonly curved, giving the appearance known as " bow-legs." This deformity is sometimes traceable to premature attempts at walking, and is usually connected with a rachitic vice of constitution. The treatment consists in the application of padded splints, so as to overcome the outward bending of the limbs, and, at a later period, in the adaptation of suitable supports, so as to prevent a recurrence of the deformity. Mr. Marsh recommends forcible straightening of the curved tibia?, or even partial division of these bones, with a narrow saw, and fracture of the remaining fibres and of the fibula?, and reports several cases in which this apparently severe operation was resorted to with good results. A similar mode of treat- ment has been successfully resorted to by Billroth, McEwen, and Poore, who, however, employ a chisel instead of a saw. McEwen has performed ten osteotomies on the same patient, both femora, and both tibia? and fibula? (the latter at both upper and lower ends), being divided at one operation. Contraction of the Knee, dependent upon shortening of the hamstrings, may occur in connection with anchylosis of the joint, or independently: the treatment consists in division of the hamstring tendons, followed by gradual extension, with passive motion, friction, etc. Division of the Hamstring Tendons is thus performed: the patient being m the prone position, an assistant renders the parts tense by fully extending the limb, and the surgeon then introduces the tenotome flatwise on the inner side of the outer hamstring, or biceps tendon (which is to be first divided), through a puncture which in the adult should be an inch above the point at which the tendon joins the fibula. By keeping the knife close to the tendon, the risk of wounding the peroneal nerve is avoided, and the section is then effected by cautiously cutting towards the skin. The semi-tendinosus, being superficial and prominent, is readily divided, but the semi-membranosus re- quires a freer use of the knife: it, however, comparatively seldom needs to be cut. In operating on the inner hamstrings, the tenotome should be introduced close to the outer (popliteal) side of the semi-tendinosus, as there is thus less risk of wounding the important structures in the popliteal space. After the operation, the wounds should be instantly closed with a firm com- press (to prevent extravasation, or the entrance of air), and no attempt at extension should be made until the parts are entirely healed, which usually requires a delay of four or five days. Neglect of this precaution may give rise to wide-spread suppuration in the tissues of the ham. When cicatrization has occurred, gradual extension may be made by means of a weight, elastic bands, or screw apparatus, or in some few cases forcible extension may be preferably employed, the patient being, of course, in a state of anaesthesia. Recovery may be further promoted by the assiduous practice of passive motion, aided by friction, douches, etc. Club-Foot.—Talipes or Club-foot is a common deformity, which may affect one or both extremities, and may occur in either sex, though more frequently in boys than in girls. It may be congenital or acquired. There are four primary and as many secondary varieties of the deformity. The primary forms of club-foot are Talipes Equinus, Talipes Calcaneus, Talipes Varus, and Talipes Valgus, while the secondary forms are combinations of these, receiving the names of Equino-Varus, Equino-Valgus, Calcaneo-Varus, and 650 ORTHOPEDIC SURGERY. Calcaneo- Valgus. All forms of club-foot depend upon contraction of various muscles and tendons, which may result from spasm of the contracted parts themselves, or from paralysis of the antagonistic muscles; in most cases the bones of the foot are not altered in structure, but in inveterate cases of varus (which is the most common form of congenital talipes), the astragalus, sca- phoid, and cuboid will all be found more or less atrophied and twisted, the ligaments correspondingly altered in length, the tendons distorted, and the muscles of the whole limb wasted. Adams, indeed, maintains that, in cases of varus, the astragalus is malformed from the moment of birth, the malfor- mation probably being due to the pressure of the adjacent bones during intra-uterine life. In non-congenital club-foot, the muscles commonly undergo fatty degeneration, rendering prognosis in these cases less favorable than in those which are congenital. The first application of tenotomy to the cure of club-foot was an operation performed by Lorenz, in 1784, on the recommendation of Thilenius, of Frankford. The operation consisted in a simple incision, involving the skin and subjacent tissues as well as the contracted tendon, and a perfect cure is said to have been obtained. Delpech, in 1816, transfixed the limb beneath the tendo Achillis, and cut towards the skin, which was, however, carefully protected from injury. To Stromeyer, of Hanover, in 1831, is due the credit of first resorting to subcutaneous tenotomy as it is now practised, while to Guerin and Bonnet, in France, to Little, Tamplin, and Adams, in England, and to Detmold and Mutter, in this country, are in a great measure owing the general introduction and perfection of the procedure. The process of repair after division of tendons consists, as shown by Adams, in the development, between the retracted ends, of a new material, which does not, as was formerly supposed, subsequently contract and bring down the shortened muscle, but remains permanently, though gradually assimilating itself in struc- ture and appearance to the original tendon. 1. Talipes Equinus.—This is very seldom, if ever, a congenital affection, but is, on the other hand, the most common non-congenital form of club-foot, occurring, according to Tamplin, in forty per cent, of cases originat- ing after birth, and in twenty-two and a half per cent, (or according to Lonsdale and Adams, thirty-four per cent.) of all cases taken indiscriminately. The deformity in talipes equinus consists simply in an elevation of the heel, which may be so slight as merely to prevent the foot from being flexed beyond a right angle, or may be so marked as to force the patient to walk upon the toes and ex- tremities of the metatarsal bones, as seen in Fig. 328. The cause of this deformity (in children) is very often disturbance of the nervous system during dentition, or from the irritation of intestinal worms, though some cases depend upon general infantile paralysis; in adults, this form of club- foot may result from paralysis, from abscess or injury of the calf of the leg, or from habitually keeping the foot in a bad position (during the treatment of fractures, etc.), by which the patient acquires a " pointed toe." The treatment consists in the subcutaneous division of the tendo Achillis, Fig. 328. Talipes equinus. (Pirrie.) CLUB-FOOT. 651 about an inch above its point of insertion. The patient being prone, and the tendon rendered tense by depressing the foot, the tenotome is introduced flat- wise (on either side, as most convenient), and carried across in close contact with the tendon, so as to avoid wounding the posterior tibial artery; the edge of the knife being then turned backwards, the tendon is forcibly brought against it by still further depressing the foot, while the blade is given a slight sawing motion. An audible snap usually marks the completion of the opera- tion, when the heel can be immediately brought down an inch or two further than before. Prof. J. Pancoast has in some cases advantageously substituted division of the lower portion of the soleus muscle for that of the tendo Achillis. In very severe cases of talipes equinus, it may be necessary to divide the plantar fascia, or even some of the tendons of the toes, as well: when the plantar fascia is to be divided, this should be done as a preliminary operation, the tendo Achillis being for the time untouched, so that its tense condition may fix the heel and facilitate the " unfolding " of the arch of the foot. After the operation, the punctures made by the tenotome should be immediately closed with a piece of lint dipped in the compound tincture of benzoin, and an adhesive strip. Mechanical extension may be begun from the third to the fifth day (not before the former1), and may be conveniently effected by Adams's modification of Scarpa's shoe, which differs from those in ordinary use, chiefly in having a transverse division of the sole-plate, corresponding to the transverse tarsal joint. In using this, as with all other forms of ortho- paedic apparatus, care must be taken to guard against excoriation, by fre- quently removing the instrument and bathing the skin with some stimulating lotion. The extension must be effected very gradually, the maxim "festina lente " being in no cases more important than in these. 2. Talipes Varus is the most frequent variety of congenital club-foot, being met with, according to Tamplin, in ninety per cent, of such cases. The deformity of varus is twofold, consisting in an in- version of the anterior two-thirds of the foot, which rotates upon a centre of motion constituted by the astragalo- SCaphoid and Calcaneo-Cuboid joints, with Talipes varus. (Fergusson.) an elevation of the posterior third by the contraction of the muscles of the calf. When the latter displacement is particularly marked, the affection receives the name of equino-varus. The inversion of the front part of the foot is due to contraction of the tibialis anticus, tibialis posticus, flexor longus digitorum, and occasionally the flexor and extensor longus pollicis, the plantar fascia and flexor brevis digitorum being also sometimes more tense than in the normal state. The treatment of this form of club-foot is best divided into two stages, the inversion of the front of the foot being remedied during the first, and the elevation of the heel during the second, stage; in other words, the case is first to be converted into one of simple talipes equinus, and then treated as was 1 I believe this to be the best plan when the surgeon can watch the application of the apparatus during the whole course of after-treatment; but when this is impossible, I have of late years found it more satisfactory to restore the foot at once to the nor- mal position, and then apply a plaster-of-Paris bandage. The shoe can be adjusted a week or ten days subsequently, when there will be but little tendency to recon- traction. 652 ORTHOPEDIC SURGERY. directed in speaking of that form of the affection. In some very slight cases of congenital varus, the deformity can be remedied by simple manipulation and friction repeated several times a day, but in cases of ordinary severity, tenotomy should be resorted to, the best age for the operation being probably between the second and third months of life. The tendons to be divided in Fig. 330. FIG. 331. Acquired Cozgrenital ^Talifies Calcaneus (Bryant.) the first stage of treatment, are those of the tibialis anticus and posticus, with sometimes that of the flexor longus digitorum, and the plantar fascia. Buchanan of Glasgow, advo- cates division of the muscular substance of the abductor pollicis. The tibialis anticus tendon deviates from its normal direction, curving downwards and backwards across the inner malleolus, while the posterior tibial tendon passes from behind the inner ankle directly Varus shoe, with jointed soie-piate. downwards, or even with a slight backward ., . . , obliquity. In dividing the latter tendon, there is some risk of wounding the posterior tibial artery; hence it is well to adopt Tamphn's suggestion of making a preliminary puncture, and then using a blunt-pointed tenotome. Should the vessel be wounded, it should be cut completely across, and a firm compress and bandage then instantly ap- plied. If a traumatic aneurism form, it may be treated by compression by injection of the perchloride of iron, or by the "old operation." Similar treatment would be required if the internal plantar artery should be wounded in dividing the plantar fascia. After tenotomy, the inversion of varus may be slowly overcome by bandaging the limb to a straight external splint, or by the use of a "varus shoe," provided with a joint in the sole-plate for effecting eversion (Fig. 330). The second stage of treatment consists in dividing the tendo Achillis, and in subsequently bringing down the heel, as in a case of simple talipes equinus. The time required for the cure of talipes varus varies from two months to a year, according to the age of the patient and the severity of the affection. Excision of the cuboid bone, suggested by Dr. Little and first practised by Mr ,soily m a case of talipes varus in an adult, has been lately revived with good result in several cases by Mr. R. Davy, and the same surgeon as well as Bryant, J. F. West, W. H. Bennett, and Konig have further extended the operation to removal of a wedge-shaped portion of the tarsus.1 Davies- bolley has, m a case of varus, excised the cuboid, with portions of the astragalus, calcis, scaphoid, cuneiforms, and outer metatarsals; while Lund, ol Manchester has in a similar case successfully excised the astragalus on both sides. Mason, of New York, has excised the astragalus and external 1 Davy reports 17 operations of this kind upon 14 patients, with only one death. CLUB-FOOT. 653 Fig. 332. malleolus for equino-varus, but sloughing and hemorrhage followed, and amputation was performed with a fatal result. The astragalus has also been excised for club-foot (successfully) by Verebelyi, and the cuboid (also successfully) by Poinset. 3. Talipes Calcaneus (Fig. 331) is very rare as a congenital affection, though as a non-congenital disease, resulting from infantile paralysis (particularly in combination with talipes valgus), it is, according to Adams, comparatively common. This form of club-foot depends upon contraction of the muscles of the front and outer part of the leg, the deformity, which is the reverse of talipes equinus, causing the patient to walk on the heel. In slight cases of the congenital variety, a spontaneous cure may be effected by the simple process of walking, but in most instances, tenotomy will be required, the tendons to be divided being those of the tibialis anticus, extensor-communis digitorum, extensor proprius pollicis, and peroneus tertius. The after- treatment consists in the application of an apparatus provided with an elastic spiral spring at the heel, to supplement the action of the tendo Achillis. Willett recommends re- section and "splicing" of the latter tendon, and records three cases in which this operation was advan- tageously resorted to. This form of talipes is occasionally combined with varus, constituting calaneo- varus. 4. Talipes Valgus, or fiat or splay- foot, is rare as a congenital, but suffi- ciently common as an acquired, affec- tion. The deformity is here the re- verse of that seen in varus, the sole being flattened, the arch of the instep obliterated, and the foot everted. In severe cases, the heel is commonly depressed as well, constituting calca- neo-valgus; or, on the other hand, the heel may be elevated, consti- tuting equino-valgus. Congenital cases of talipes valgus may often be cured by simple manipulation, or by bandaging the foot to an inside splint with a wedge-shaped pad, as in Dupuytren's mode of treating fractured fibula. In other instances, tenotomy will be required, the parts to be divided being the tendons of the peroneus longus and brevis, extensor longus digitorum, and peroneus tertius, with sometimes the tendo Achillis, or even the tendons of the tibialis anticus and extensor pollicis. The first-named tendons may be divided about an inch above the external malleolus, and the flexors in front of the ankle-joint. The after-treatment consists in applying an apparatus to produce gradual inversion, with a pad to restore the arch of the foot. Weak Ankles, which often precede the development of acquired talipes valgus, should be treated by attention to the hygienic surroundings of the patient, and by the use of friction and the salt douche, with, if necessary, an elastic bandage, or light metallic lateral supports. On the Treatment of Club-foot without Dividing Tendons.—Mr. Barwell opposes the practice of tenotomy, in the treatment of talipes, on the ground that the affection is always the result of paralysis, and that divided tendons seldom reunite. He recommends instead, the employment of an apparatus Talipes valgus. (Pirrie.) 654 DISEASES OF THE HEAD AND SPINE. in which elastic cords supplement the paralyzed muscles, and counteract the action of those which are contracted. Without entering into any discussion of Mr. Barwell's theoretic views (which are opposed to those of the leading authorities on the subject of club-foot), it will be sufficient to say that, while the ingenious mode of treatment which he advocates may undoubtedly effect a cure in mild cases, it will, as undoubtedly, fail in many of those which are more severe; and even in the slight cases, tenotomy (which has not been proved to do any harm) certainly abbreviates the time required for treatment. Indeed, we may safely say, in the words of Mr. Adams, that the successful treatment of club-foot demands, in most cases, " a judicious combination of operative, mechanical, and physiological means." The chief advocate of Mr. Barwell's views, in this country, is Prof. Sayre, of New York, who is how- ever too judicious a surgeon to recommend Barwell's plan as an exclusive mode of treatment. Prof. Sayre's rule for determining whether or not a tendon should be divided, is to anaesthetize the patient and then, having put the parts on the stretch, to press with the finger or thumb on the stretched tendon; if this pressure produce reflex contractions, tenotomy is required. Dr. Newton M. Shaffer, of New York, has devised an ingenious appa- ratus for applying traction to the anterior part of the foot, and thus aiding in unfolding the tarsal arch; Dr. J. C. Hutchison and Mr. H. A. Reeves recommend the use of plaster-of-Paris bandages in the after-treatment of club-foot, and I have myself frequently followed this plan with good results in cases in which the patients were not going to remain under my constant supervision. (See note, page 651.) Contraction of a Toe, usually the second, is commonly due to a tense state of the digital prolongation of the plantar fascia, and requires division of the offending structure; the operation should be done subcutaneously, opposite the base of the second phalanx, the toe being then straightened, and secured to a small pasteboard or wooden splint. According to Nunn, some cases of contracted toe (hammer toe) are of spinal origin. Contraction of the great toe, sometimes called Hallux valgus, has already been referred to in speaking of bunion (p. 524). CHAPTER XXXIV. DISEASES OF THE HEAD AND SPINE. Diseases of the Head. Tumors of the Scalp.—The most common forms of tumor met with in the scalp are the cutaneous proliferous cyst and the vascular or erectile tumor, though fatty and fibrous growths have also been occasionally seen in this situation. The treatment of these affections has been sufficiently discussed in other parts of the volume. Tumors of the Skull.—Bony, cartilaginous, myeloid, and cancerous growths are met with in the cranial walls, the latter form of disease constituting the affection sometimes described as Fungus of the Skull. Surgical interference is rarely admissible in this serious condition, though a case is referred to by Erichsen, in which such a growth was successfully removed by B. Phillips. ENCEPHALOCELE, MENINGOCELE, ETC. 655 Fungus of the Dura Mater. — Under this name is commonly described a tumor which, beginning without any obvious cause, makes its appearance on the top or side of the head, or in the temporal region, forming a semi- fluctuating mass, sometimes crackling on pressure, pulsating, attended with much pain, and accompanied with various cerebral symptoms, such as double- vision, deafness, convulsions, and, in the latter stages, coma and paralysis. The tumor, as it increases, becomes softer and more prominent, a distinct margin of bone being often felt surrounding the morbid growth, indicating the occurrence of erosion of the skull. The pathology of this serious affection, which was first clearly described by Louis, has been recently investigated by Mr. Lawson Tait, who concludes, from the dissection of a case which came under his own observation, as well as from the recorded histories of other instances of the disease, that the so-called fungus of the dura mater is really an affection of the skull, originating in the layers of osteal cells, and, clini- cally speaking, of a malignant character. The disease may originate either beneath the pericranium (outside the skull), or between the cranial wall and the dura mater, or, as happened in Mr. Tait's OAvn case, in both situations simultaneously, the skull thus undergoing erosion on both sides, until the masses meet and amalgamate, when pulsation is developed. The Diagnosis from vascular tumor of the scalp, which is the only disease with which the affection is likely to be confounded, may be made by observ- ing that the growth cannot be moved laterally upon the skull, and (in cases in which the bone is perforated) can be often partially reduced within the cranial cavity. A fungus of the dura mater has been punctured under the impression that it was an abscess, but such a mistake could scarcely arise except through carelessness. The Treatment of this affection is extremely unsatisfactory: Louis recom- mends that the growth should be excised, or otherwise extirpated, after re- moving as much of the skull as may be necessary with the trephine; but the case which he gives of recovery after this severe treatment, seems, as justly remarked by Holmes, to have been really one of simple caries with under- lying exuberant granulations. Any partial operation, in view of the malig- nant character of the affection, would be worse than useless, while complete extirpation would, in all probability, but hasten the fatal issue. Fungus of the Brain, or Hernia Cerebri, has been sufficiently alluded to in a previous portion of the work. (See page 323.) Encephalocele, Meningocele, etc. — These are the names given to con- genital tumors, consisting of a protrusion through a suture, or part of the skull which in foetal life is membranous, of portions of the cranial contents. The meningocele contains merely a bag of cerebral membranes with sub- arachnoid fluid, while the encephalocele contains a portion of brain-substance as well. Hydrencephalocele, as the term is used by Prescott Hewett, is an encephalocele complicated by the protrusion of one of the ventricles filled with fluid. These malformations usually, but not invariably, occupy the occipital region, protruding a little behind the situation of the foramen magnum; they are usually solitary, but occasionally multiple, varying in size from that of a pea to that of the head itself, and complicated with internal hydrocephalus. The sac of a meningocele may be single or multilocular, and the contained fluid may be clear like that of a hydrocele, or may be dark from the admixture of blood. If the tumor be sessile, it may be wholly or partially reducible by pressure, such reduction being followed by symp- toms of cerebral compression; the tumor swells up and becomes tense when the child cries, and sometimes partakes of the motions of the brain. The 656 DISEASES OF THE HEAD AND SPINE. affection is occasionally complicated with na?vus, and not unfrequently with other congenital malformations. The Diagnosis from congenital cystic tumor, when the meningocele is sessile, is sometimes very difficult; but in most cases may be made by observing the situation of the malformation, its variations of tension, and the fact that it is not movable upon the skull; if, however, the communication with the cranial cavity be very small, the diagnosis may be quite impossible. The affection is also liable to be confounded with erectile tumors of the scalp, and, indeed, as already mentioned, the two diseases may coexist. The Prognosis is unfavorable, the large majority of these cases terminating fatally during infancy, though occasionally patients thus affected have sur- vived to adult life. Death is usually preceded by convulsions, due to cerebral pressure, but in some cases ulceration or rupture occurs, when inflammation of the sac and general spinal meningitis are the immediate precursors of the fatal issue. The Treatment in most cases should (according to Holmes, who has devoted special attention to the subject) be limited to affording support and making gentle pressure, by means of a gutta-percha cap lined with cotton wadding; and in cases evidently complicated with general hydrocephalus, nothing fur- ther is admissible; compression with a plate of sheet-lead proved successful in a case recorded by Dr. W. S. Hill, of Maine. If the tumor be rapidly increasing, without general symptoms, repeated tappings may be resorted to, with precautions against the entrance of air; the aspirator has been thus successfully employed by J. F. West. In cases of meningocele, if peduncu- lated, iodine injections may be tried with some hope of benefit. Finally, if there be reason to believe that, as sometimes happens, the communication with the cranial cavity has become obliterated, the tumor may be excised; or even if a communication persist, the operation might be occasionally justifiable, the pedicle of the tumor in such a case being first compressed by means of a clamp, which should be allowed to remain for twenty-four hours. A very remarkable case was reported a few years ago by Dr. Daniel Leasure, of Allegheny City, Pa., in which a meningocele (or, as the author termed it, hydrencephalocele) was said to have been radically and perma- nently cured by evacuating the contents of the sac, and invaginating its integuments, so as to plug the cranial aperture—very much as is done with the scrotal tissues in Wutzer's operation for the radical cure of hernia. Paracentesis Capitis.—The operation of tapping the head is occasionally required in cases of acute, or even of chronic, hydrocephalus, when death seems imminent from the intra-cranial pressure exercised by the accumu- lated fluid. The relief afforded by paracentesis, under these circumstances, can scarcely be expected to be permanent, particularly in congenital cases, in which there is usually malformation of the brain. Still the operation is not, even in these instances, likely to add much to the gravity of the situa- tion, while in the non-congenital cases it has unquestionably been occasion- ally productive of much benefit. An aspirating tube or very delicate trocar is to be employed, being introduced through the anterior fontanelle, as far as possible from the median line (so as to avoid wounding the longitudinal sinus), or, in cases of internal hydrocephalus, through the coronal suture on either side, midway between the anterior and sphenoid fontanelles, the point being then directed inwards and backwards so as to penetrate the lateral ventricle. A small quantity only (about two fluidounces) of fluid should be evacuated, the sides of the skull being compressed during the operation by the hands of an assistant. As soon as the instrument has been withdrawn, the puncture should be closed with an adhesive strip, and an elastic, per- DISEASES OF THE SPINE. 657 forated, India-rubber cap (as advised by Holmes) tightly drawn over the head, so as to support the skull and prevent syncope. If no bad results follow the operation, it may be repeated at another point, after a few weeks' interval. Injections of iodine have been practised in these cases, and in some instances with alleged benefit, but the only case in which I have seen this mode of treatment tried terminated fatally in less than forty-eight hours. Diseases of the Spine. Fig. 333. Spina Bifida (Hydrorachis).—This is a congenital malformation, which consists in a deficiency of the spinous processes and laminae of one or more vertebrae, allowing the protrusion of the spinal membranes, which form a tumor containing cerebro-spinal fluid and usually some of the spinal nerves, or even it is said a part of the spinal cord itself. Spina bifida in the cervico-dorsal region, however, according to Giraldes, contains no nervous filaments, and I was told by Dr. J. B. S. Jackson, of Boston, that in numerous dis- sections of spina? bifidae, he had invariably found the cord itself to terminate above the upper margin of the tumor. Hydrorachis may occupy any portion of the vertebral column, though most frequent in the lum- bar and sacral regions; may be single or multiple; is usually of an oval shape ; and varies in size from that of a walnut to that of a child's head. It may be sessile or pedunculated, sometimes lobulated, and is usually covered by skin of a more or less normal character, though in some instances there is no cutaneous investment, the sac- wall being constituted of the spinal dura mater itself, in which case ulceration is apt to occur. The tumor is tense and elastic when the child is in the upright position and during the action of expiration, becoming softer during inspiration and when the child is laid on its face. Fluctuation is sometimes observed, and partial reduction may be often effected by pressure—the bony aperture through which the protrusion has taken place being then perceptible to the touch. Spina bifida often coexists with other deformities, and is frequently complicated with hydrocephalus. Death usually occurs within a short time of birth, from convulsions or spinal meningitis, though occasionally life is prolonged to adult age (74 years in a case observed by Callender), and in some rare instances it would appear that a spontaneous cure has been effected by the channel of communication with the cavity of the spinal membranes becoming obliterated. The treatment of this affection is usually not very satisfactory; if the tumor be not rapidly increasing in size, the surgeon should content himself with applying equable support, with perhaps slight pressure, by means of a well- padded leather or gutta-percha cap, or an air pad; if the skin be not irri- table, the tumor may be painted with collodion, thus taking advantage of the contractile properties of that substance. If the child be otherwise healthy, and life seem to be endangered by the rapid growth of the tumor (threaten- 42 Spina bifida. (Druitt.) 658 DISEASES OF THE HEAD AND SPINE. ing ulceration and rupture, or inducing convulsions or paralysis), paracen- tesis may be tried; the sac is tapped with an aspirator or a small trocar at a distance from the median line (in which position the nerve-structures are most likely to be placed), an ounce or two of fluid being evacuated, and the wound then instantly closed, and pressure reapplied. If these means fail, and the tumor be pedunculated, a small quantity of a solution of iodine may be cautiously injected, a plan which, with various modifications, has been successfully "employed by Brainard, of Chicago, Velpeau, J. Morton, Watt, Eate, Ewart, and other surgeons. According to Morton, however, the iodine treatment is not applicable in cases accompanied by paralysis. The formula recommended by this surgeon is iodine, 10 grains; iodide of potassium, 30 grains ; glycerine, 1 fluidounce. Of 18 cases treated in this way, 15 are said to have terminated successfully. Ligation and excision have been occasion- ally resorted to, and each has proved successful in at least one instance, but, in most cases, has but served to hasten death. The use of the elastic ligature, with or without paracentesis, has been employed by Laroyenne, Ball, Colog- nese, Baldossare, and Mouchet, 6 cases collected by the last-named surgeon having given 3 recoveries and 3 deaths. It is best adapted to cases in the cervical and dorsal regions, as in these no nerve-elements are involved. False Spina Bifida.—Under this name are included three distinct condi- tions, viz.: (1) a true spina bifida, the connection of which with the spinal membranes has become obliterated; (2) a congenital tumor, cystic or fatty, which originates within the spinal canal and protrudes through an aperture due to a deficiency in the vertebral laminae; and (3) a tumor containing fcetal remains, constituting the malformation properly described as included fcetation. If the surgeon can satisfy himself by careful and repeated exami- nation, that, in a case of this kind, there is really no communication with either the cavity of the spinal meninges, or with the pelvic or other internal viscera, an operation for the relief of the deformity may be properly re- sorted to; if the tumor be evidently cystic, iodine injection would be the proper remedy, but under other circumstances excision would be preferable.1 Congenital Cystic Tumors, unconnected with the spine, but occupying the median line of the back, may closely simulate cases of spina bifida, but as pointed out by T. Smith, can sometimes be distinguished by feeling the line of spinous processes beneath the cyst; the diagnosis might further be aided by an analysis of the contained fluid, which in some cases of spina bifida has been found to contain a substance resembling grape-sugar. Antero-posterior Curvature of the Spine (Disease of the Spine, Pott's Dis- ease).—This affection usually originates in osteitis of the bodies of the verte- brae, though occasionally it would appear that the disease began in the intervertebral fibro-cartilages. In some instances—and in these the prog- nosis is least unfavorable—the case is one of ordinary osteitis; but in most cases there is evidence of the existence of scrofula, or even of the deposit of tubercle. Spine disease occurs chiefly in children and in young adults, and is perhaps rather more frequent in boys than in girls. Occasionally a fall or a blow is referred to as the exciting cause of the affection, but in most instances no explanation of its origin can be given. Any part of the verte- bral column may be the seat of the disease, which is, however, most common in the dorsal region. The bodies of several vertebra? are usually simultane- 1 See, upon this subject, Holmes's Surgical Treatment of Children's Diseases, pp. ANTERO-POSTERIOR CURVATURE OF THE SPINE. 659 ously affected, becoming softened and disintegrated, and leading to disor- ganization of the intervertebral fibro-cartilages—the superincumbent weight of the head and upper part of the body eventually giving rise to the posterior angular deformity which is characteristic of the fully developed affection. In most cases the osseous change runs on to caries (whence the disease is frequently spoken of as caries of the vertebrce), abscess forming as a conse- quence, and the pus usually making its way to the surface, either in the loin or by descending in the course of the psoas muscle; in other cases, however, the pus, for a time at least, becomes concrete and obsolete, rendering the spine a favorite situation of the residual abscess (see p. 393). In a few in- stances the disease runs its course without any evidence of pus-formation Fig. 334. Fig. 335. Anteroposterior curvature ot spine. (Liston.) Caries of the vertebra. (Liston.) whatever, the pathological change in these cases, therefore, being more properly designated as interstitial absorption than as caries (see p. 584). Although, in the course of the disease, the spinal canal may be bent to a right angle, it is very seldom that the spinal cord is pressed upon or other- wise injured. This is evidently owing to the gradual nature of the change, which allows the cord to accommodate itself to its altered circumstances; and to the occurrence of anchylosis, which prevents injurious motion. An- chylosis is indeed the process by which nature effects a cure in these cases. It frequently goes on pari passu with the disintegrating changes, arches of new bone being thrown across from one vertebra to another, and the same specimen exhibiting at once caries, medullization, and eburnation in differ- ent parts. In cases in which anchylosis is deficient (as may happen when the angular projection is not marked, the diseased vertebral bodies being then separated and prevented from coalescing), spinal meningitis may occur, leading to secondary changes in the cord, and to consequent paralysis; while in the cervical region, where the vertebral column has a considerable range of motion, consecutive fracture or dislocation may take place, and, by com- pressing or bruising the cord, lead to a rapidly fatal issue. 660 DISEASES OF THE HEAD AND SPTNE. Symptoms.—The early symptoms of spine-disease, particularly in children are somewhat equivocal, consisting chiefly in evidences of spinal irritation, such as weakness, numbness, and tingling of the lower extremities, a diffi- culty in standing or walking, with a tottering gait, and a tendency to fall forwards. The spinal column is somewhat stiffened, the patient moving it as a whole, and thus being unable readily to raise or turn himself in bed with- out assistance. Examination may reveal an undue prominence of some of the dorsal spines, with perhaps thickening of the surrounding tissues, and tenderness on pressure. Pain may be elicited by pressing on the head, or by making the patient jump from a stool to the floor, thus approximating the extremities of the vertebral column. In adults, pain is a more constant symptom, being usually of a dull, rheumatic character. Spasmodic pain in the abdomen is, according to Dr. B. Lee, an early and characteristic symp- tom of this affection. As the disease advances, paralysis may be developed, involving the lower or upper extremities, according to the part of the spine affected. Incontinence of feces and retention of urine sometimes form fur- ther disagreeable complications. Abscess sometimes occurs quite early in the course of the disease, and not unfrequently before the development of angular deformity. According to Dr. C. S. Bull, Pott's disease is usually accompanied with dilatation of the pupils, and with passive engorgement of the vessels of the retina and optic disk. Diagnosis.—The diagnosis in the early stages is often very difficult; in- deed it is sometimes quite impossible to distinguish spine-disease, particularly in children, from inflammation of the surrounding ligamentous structures, until the milder course of the latter affection reveals its true nature. From neu- ralgia of the spine, an affection analogous to the hysterical knee-joint, the diagnosis may be made by observing the absence, in the neuralgic affection, of rigidity or other physical evidence of disease, even in cases of long dura- tion. The wincing of the patient, upon the application of a sponge wrung out of hot water to the suspected part of the spine, is looked upon by many surgeons as a sure proof of the existence of caries. According to my experi- ence, this test is not to be implicitly relied upon; at least, I have known it to fail in cases in which the deformity and other symptoms left no doubt as to the nature of the case. The diagnosis from morbus coxarius, and from sacro-iliac disease, has already been referred to. (See pp. 605 and 608.) When the characteristic deformity appears, there is little difficulty in recog- nizing the nature of the affection. This deformity consists, as already men- tioned, in a posterior angular projection of the diseased vertebrae, due to the absorption or disappearance of their bodies, and the consequent subsidence of the upper portion of the column. It is distinguished from the antero- posterior curvature of simple debility, by its persistence in the prone posi- tion—and from that of rickets, by its angular character. This angular de- formity is accompanied, after the occurrence of anchylosis, with compensatory forward curvatures above and below; the gibbosity of the spine is thus thrown into a plane behind that of the pelvis, while the head is directed upwards and backwards, giving the peculiar but involuntary strut and air of pride which are so often seen in hunchbacks. Occasionally the displacement is at first somewhat lateral, and a hasty examination might then give the impres- sion that the case was one of lateral curvature; the diagnosis may be made by observing that in true spine-disease there is no axial rotation of the verte- bra?, such as always exists in the other affection (see p. 644). When the vertebra? involved are those of the cervical region, particularly the atlas and axis, the case may be mistaken for one of wry-neck. The sterno-mastoid mus- cles are, under these circumstances, tense and prominent, and the neck stiff; while the patient often involuntarily supports the head with both hands, so as ANTERO-POSTERIOR CURVATURE OF THE SPINE. 661 to guard against sudden movements. The diagnosis from wry-neck may be made by noting the localized tenderness and thickening of the spine, and the increase of pain by tapping or pressing on the head. The diagnosis of Abscess arising from Spine-disease requires some attention. The situation of the abscess, in these cases, varies with the part of the verte- bral column which is involved. Thus, in disease of the cervical vertebrae, the pus may present itself at the back of the pharynx, at the side of the neck (beneath the sterno-mastoid muscle), or more rarely in the axilla; it may even pass downwards into the thoracic cavity. Abscess from disease of the upper dorsal vertebrae commonly makes its way downwards, along the course of the aorta and iliac arteries, presenting itself in the iliac fossa above Poupart's ligament, but may gravitate to the back of the pelvis, passing out through the sacro-sciatic notch into the gluteal region, may pass forwards along the ribs, opening at the side of the trunk, or may go directly back- wards, forming a dorsal or lumbar abscess; finally, it may, in some rare cases, burst into the air-passages or gullet. When the lumbar and lower dorsal vertebrae are affected (the most common situation of the disease), the abscess usually descends in the sheath of the psoas muscle, on one or both sides, con- stituting the condition known as psoas abscess.1 This generally points in the front of the thigh beneath Poupart's ligament, but may burrow downwards to the ham or even to the ankle. In other cases the pus may present itself in the lumbar region, in the perineum, on the outer side of the hip, in the iliac fossa, or in the inguinal canal; or it may even burst into the bowel or bladder. By care and attention it is usually possible to determine whether an abscess, occurring in any of these situations, be or be not dependent upon disease of the spine. It is, however, sometimes a matter of great difficulty to distinguish between psoas and iliac abscess—the former commonly arising, as we have seen, from caries of the dorsal or lumbar vertebra?, while the latter originates in the areolar tissue of the iliac fossa, and may or may not be connected with disease of the bony pelvis. This difficulty is further in- creased by the circumstance that, while spinal abscess occasionally presents itself, as we have seen, in the iliac region, an iliac abscess may, on the other hand, make its way into the sheath of the psoas muscle. Psoas abscess is, however, commonly a disease of early life, points below Poupart's ligament, is usually attended with irritation and rigidity of the psoas muscle, and often makes its appearance suddenly; while iliac abscess, on the other hand, occurs almost exclusively in adults, points above Poupart's ligament, and is gradu- ally developed. Psoas and iliac abscesses must also be distinguished from inguinal aneu- rism which has become suddenly diffused, from femoral hernia, and from fatty, serous, or hydatid tumors. The diagnosis from aneurism may be made by investigating the history of the case, and by observing the presence of fluctuation and the absence of any bruit or other stethoscopic signs. From hernia, the affection may be distinguished by noting the fluctuating character of the swelling, the absence of gurgling (in both diseases the swelling is re- ducible, and there may be an impulse transmitted by coughing), and the situation of the femoral vessels, which in hernia are to the outside, and in abscess usually to the inside, of the tumor. Fatty and other tumors may be recognized by their not being reducible within the abdomen, and, if neces- sary, by the use of the exploring needle. Prognosis.—The prognosis of antero-posterior curvature of the spine is 1 Psoas abscess, however, according to Stanley, Bryant, and others, sometimes originates independently of spinal disease. 662 DISEASES OF THE HEAD AND SPINE. Fig. 336. never favorable; the best that can be hoped for is the occurrence of anchy- losis, with a permanent angular deformity. If the spine retain its straight position, fatal inflammation of the membranes is apt to occur, while if abscess forms, the pa- tient almost always perishes from exhaustion or from secondary visceral disease. In a case at the Episcopal Hospital, some years ago, a psoas abscess caused ulceration of a branch of the internal iliac artery, leading to rapid death from hemorrhage. Treatment.—In the treatment of disease of the spine, rest of the part is of the utmost im- portance: if the cervical vertebrae be affected, the head must be carefully supported with sand-bags or other mechanical contrivance, so as to prevent any sudden movement which might cause death by producing dislocation. In ordinary cases, the patient may be con- fined to the horizontal position on a suitable couch, the prone being more desirable than the supine posture. No attempt should as a rule be made either to extend the spine or to remove any existing backward projection, for such attempts are liable to do harm by inter- fering with the occurrence of anchylosis; if, however, the part were very painful, it might be proper to give a cautious trial to continu- ous double extension, as recommended by J. Wood. The horizontal position must be rigidly maintained for many months, until the surgeon can satisfy himself indeed that bony union of the diseased vertebra? is well advanced. Tonics, especially cod-liver oil, may be exhibited with advantage, and the patient, if a child, should be daily carried into the open air on a couch or in a suitable coach. Counter-irritation (by means of setons, is- sues, or the actual cautery) was highly com- mended by Pott, who first accurately investi- gated the nature of this disease—and is still , .. m much repute with many surgeons. I am not myself very enthusiastic with regard to these severe applications, believ- ing with Shaw and Holmes that, in most cases, the milder remedy of paint- ing the tincture of iodine on either side of the affected vertebra? will be quite sufficient If there be much pain, tenderness, and other evidence of inflammation, there can be no better local remedy than dry cold applied in the form of an ice-bag. r m In most cases, it will be desirable to combine mechanical support with rest m the prone position, and this may be conveniently done by the use of a moulded gutta-percha, leather, felt, or pasteboard splint, or a corset-like bandage stiffened with whalebones, or a plaster-of-Paris bandage, applied while the patient is partially suspended by the head and shoulders, as rec- ommended by Prof. Sayre, or lying prone in a canvas hammock (which is Sayre's suspension apparatus for the application of the plaster-of-Paris bandage. ARTHRITIS AND NECROSIS OF THE SPINE. 663 Fig. 33^ itself included by the bandage), as advised by R. Davy. Mr. Adams, and J. C. Hutcbison, of Brooklyn, apply a "poro-plastic felt" jacket, while the patient is suspended, and consider this material, upon the whole, better than the plaster-of-Paris. Dr. Stillman and Dr. Wyeth, of New York, eraplov a double plaster jacket, with extending bars secured to perforated zinc plates placed between the layers of plaster. Dr. Vance, of the same city, employs a brace made of glue and paper. When anchylosis is well ad- vanced, the patient may be allowed to get up, wearing the leather, felt, or plaster jacket, or a well-fitting apparatus consisting of"a firm pelvic band with crutch-pieces to take off the weight of the upper portion of the trunk, and suitable pads and straps to immovably fix the portions of the spine above and below the seat of deformity. If the cervical vertebrae be involved, a firm but well-fitting leather collar, so arranged as to fix the neck and sup- port the head and chin, may be emploved, or an occipito-mental sling, sus- pended _ from Sayre's "jury mast" (Fig. 337), attached to the plaster or leather jacket, or to the ordinary "spinal appara- tus," as may be preferred. In some cases, Steele, of Bristol, adapts the jury mast and axillary sup- ports to the chair which the patient ordinarily uses, and finds this more convenient than any other form of apparatus. The treatment of spinal abscess is that of cold or chronic abscess in general (see page 393). Every effort should be made, in the first place, to induce absorption of the fluid, it being remembered that, even if a residual abscess follows at a later period, the prognosis will then, probably, be more favor- able than if the collection had been evacuated in the first instance. Even if the opening of a psoas abscess appear inevitable, it is better in most instances to leave the case to nature, rapid sinking not unfrequently following the use of the knife under these circumstances. If, however, it be determined to interfere, the aspirator may be used, or a valvular incision may be made, or the abscess cavity may be washed out with a solution of carbolic acid, or, finally, the surgeon may adopt the precautions recommended by Prof. Lister. Dr. S. W. Gross advises that after the abscess has been evacuated, its walls should be supported with adhesive strips and a flat sponge, and that opium should be freely administered. Fischer and Riedel have evacuated psoas and pelvic abscesses by trephining the ilium. Sayre's "jury mast" for disease of the cervical vertebrae. Arthritis occasionally attacks the articulations of the vertebrae, and, in the case of the occipito-atloid and atlo-axoid joints, is attended with risk of sudden death from the occurrence of dislocation. The most important points in the treatment are to fix the head and neck by suitable mechanical appli- ances, so as to prevent injurious movements, and to give free vent to any pus that may be formed, lest suffocation should result from pressure of the abscess upon, or its bursting into, the air-passages. Necrosis of the bodies of the cervical vertebrae is occasionally seen in cases of syphilitic ulceration, or as the result of gunshot or other injuries; and cases in which recovery has followed the discharge of large sequestra, 664 DISEASES OF THE EYE. under these circumstances, have been recorded by Wade, Keate, Syme, Mercogliano, Morehouse, Bayard, Mackenzie, Ogle, Beck, and Chatman. Anchylosis of the spine, as a result of Pott's disease, has already been referred to; it may also occur as a consequence of rheumatoid arthritis, as described by R. W. Smith, Von Studen, and Sturge, the latter of whom pro- poses for the affection the name of spondylitis deformans. CHAPTER XXXV. DISEASES OF THE EYE. It would be utterly impossible to give, within the narrow limits of this chapter, even a sketch of the present state of ophthalmic surgery, nor indeed would the attempt to do so be worth making, since the diseases of the eye have become, of late years, to a great degree, an object of especial study, and since numerous excellent manuals and treatises on the subject are accessible to any one who may desire to make himself familiar therewith. I shall, therefore, chiefly confine my attention, in the following pages, to a brief reference to those more common affections of the eye which every surgeon may be called upon to treat, and to a short description of the more impor- tant operations which are performed upon this organ. Diseases of the Conjunctiva. Acute Conjunctivitis (Catarrhal Ophthalmia).—An inflammation of the conjunctiva, usually caused by cold or other local irritation, but sometimes prevailing epidemically in certain localities, and apparently transmissible by contagion. Symptoms.—A sensation as of dust in the eye, with heat, smarting, and stiffness of the lids. The conjunctiva is brilliantly injected, the redness being quite superficial, and, at first, greatest at the circumference of the globe. Slight photophobia, with increased lachrymation, followed by muco-purulent discharge, which, becoming dry, causes the lids to adhere. Treatment.—Astringent lotions of alum, sulphate of zinc, or corrosive sub- limate (gr. i to f§j), with frequent ablutions ivith cold water,1 and, in severe cases, the application once or twice daily of a few drops of a solution of nitrate of silver (gr. j-ij to f^j). The lids may be smeared at night with simple ointment, to prevent their adhering together. The constitutional treatment consists in regulating the digestive functions, and in improving the general health by the use of tonics, especially iron and quinia. A shade may be worn if there is much photophobia. Chronic Conjunctivitis, or Chronic Ophthalmia, may occur as a sequel of the affection just described, or may originate from the irritation of inverted lashes, or from reading or sewing with an insufficient light. Treatment.—The cause must, if possible, be removed, by taking away any sources of local irritation, forbidding overuse of the eyes, etc. In addition to 1 L. Connor, however, advises douches of hot water in all inflammatory affections of the eyes. OPHTHALMIA NEONATORUM. 665 the measures above directed for the acute form of the affection, counter-irri- tation by means of a small blister or the vapor of bromine may be advanta- geously applied to the temples, or behind the ears. If complicated with granular lids, this condition must, of course, be remedied before the conjunc- tival inflammation can be cured. Phlyctenular Conjunctivitis (Pustular or Papular Ophthalmia.—This is a form of conjunctivitis characterized by the formation of little elevated vesicles, with increased vascularity of the conjunctiva in their immediate vicinity. The treatment, after any acute irritation has been subdued, con- sists in dusting into the eye with a camel's-hair brush a little finely powdered calomel, in the application to the inside of the lids of a weak red precipitate ointment (gr. iv-viij to ,?j), or in dropping into the eye, thrice daily, a weak solution of the bichloride of mercury.1 Purulent Conjunctivitis, or Purulent Ophthalmia, is a very high grade of conjunctival inflammation, attended with a profuse muco-purulent discharge which is fully developed within twenty-four to forty-eight hours after the first onset of the disease. There are three varieties, the purulent ophthalmia of new-born infants, the contagious or Egyptian ophthalmia of adults, and the gonorrhoeal ophthalmia, which has already been considered. (See page 439.) Ophthalmia Neonatorum.—This form of the disease usually begins a few days after birth, involving both eyes simultaneously or consecutively, and sometimes ending in total loss of vision. The affection often appears to originate during birth, from direct contact with a purulent vaginal discharge in the mother. Symptoms.—A whitish or yellow, muco-purulent or purulent discharge, rapidly increasing in quantity, with swelling of the lids and chemosis of the ocular conjunctiva. If the disease be not checked, opacity, ulceration, or even sloughing of the cornea will probably occur, with, of course, total loss of sight. Treatment.—The discharge should be removed as fast as it accumulates, by syringing the eye with a solution of alum (gr. v to f Jj), to which Power advises that permanganate of potassium should be added, every half hour, day and night, the lids being gently separated with the thumb and finger of the left hand, while the syringe is worked with the right; or, the lids being everted, a five-grain solution of nitrate of silver may be applied, with a camel's-hair brush, once a day, any excess of the caustic being immediately neutralized with a solution of common salt; the lids should be greased with simple ointment, to prevent their sticking together. Dor advises the appli- cation of solutions of tannin and benzoate of sodium, and Wolfe those of borax followed by atropia, and, in bad cases, cauterization with the lapis mitlgatus. (See page 667.) Diluted chlorine water is employed by Moore, of New York. If ulceration of the cornea occur, quinia should be given in doses of about half a grain, three times a day. As a prophylactic measure, Crede advises that the eyes of children exposed to the disease should be covered with a bandage wet with a solution of salicylic acid, and Olshausen recommends the application of carbolic acid, beginning his treatment even before the child has been completely born. 1 The following formula, which corresponds to the preparation known as Aqua Conradi, will be found satisfactory: R. Hydrarg. chlorid. corrosiv. gr. \; Mucilag. cydonii f^ss ; Vin. opii gtt. v ; Aquse destillat. f^ij. M. 666 DISEASES OF THE EYE. Purulent Ophthalmia of Adults, Contagious or Egyptian Ophthalmia (so called from its prevalence as an endemic in Egypt), in its mildest form re- sembles catarrhal ophthalmia, but often runs a course quite as severe as the affection which results from the contagion of gonorrh