'MM nUl^!!'!H;i;!l;!';: .'itih: !:t.!.;! lft;ii!i!i!i!p!iii:!i:i:.; 'TfUtHtJ'lIl •. ,lu., , . : :| i- w !;:i:;i;;iiv- tfi'!Mj|! l|:i}|<' i; :-' ';■'■; !lii!iliiil!;!;'ti!-L-f!,--',V liisiii':'.: .' t >:..- >: \m^- 7637167937 ��3732�97569 NATIONAL LIBRARY NLfl DDSblfllQ E NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service NLM005618102 THE & PRINCIPLES AND PRACTICE OF \ SURGERY. BY JOHN AgHHURST, Jr., M.D.. BARTON PROFESSOR OF SURGERY A*M) PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE PENNSYLVANIA HOSPITAL; 8ENIOR SURGEON TO THE CHILDREN'S HOSPITAL J CONSULTING SURGEON TO THE WOMAN'S HOSPITAL, TO ST. CHRISTOPHER'S HOSPITAL, TO THE HOSPITAL OF THE GOOD SHEPHERD, ETC. FIFTH EDITION ENLARGED AND THOROUGHLY REVISED. SIX HUNDRED AND FORTY-TWO ILLUSTRATIONS. PouJh PHILADELPHIA: LEA BROTHERS & CO. 1889. Entered according to Act of Congress, in the year 1889, by LEA BROTHERS & CO., in the Office of the Librarian of Congress. All rights reserved. COLLINS PRINTING HOUSE, 705 Jayne Street. 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 LIGHTENED, ftjjis Volume IS MOST GRATEFULLY DEDICATED BY THEIR FRIEND AND FELLOW-STUDENT, THE AUTHOR. DEDICATION TO THE FIRST EDITION. (3u iflemorium.) 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, %\p Mmt IS MOST CORDIALLY AND AFFECTIONATELY INSCRIBED, BY HIS FRIEND AND PUPIL, THE AUTHOR. PREFACE. The object of this work is, as its title indicates, to furnish, in as concise a manner as may be compatible with clearness, a condensed but comprehensive description of the Modes of Practice now generally employed in the treatment of Surgical Affections, with a plain exposi- tion 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 acknowl- edgment 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 fifth 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 im- provements ; and by making such changes as have been suggested to him by enlarged personal experience as a Clinical Teacher and Hospital Surgeon. The Chapters on Diseases of the Eye and of the Ear have been thoroughly revised, the first by Dr. George E. De Schweinitz, and the second by Dr. B. Alexander Randall, both former pupils of the author, who have executed the tasks entrusted to them in a manner which adds greatly to the value of the work, and which cannot fail to commend itself to the judicious reader. VI PREFACE. The general arrangement of the volume is the same as iu the previous editions ; all parts have been carefully revised, and, though by a cliange in the typographical arrangement of the book, much space has been gained, yet so large an amount of new material has been introduced as to require the addition of about thirty pages. The entire amount of new matter is estimated at fully one-eleventh of the whole. The number of illustrations has been considerably increased by the introduction of a large number of original cuts, chiefly from photo- graphs or drawings, and of electrotypes' showing new and improved forms of instruments, kindly furnished by Messrs. J. H. Gemrig and Son, the well-known cutlers. In the case of the selected illustrations, their original source has been indicated in everv 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, September, 1889. CONTENTS. Preface ........ List of Illustrations ...... Introductory Remarks ...... CHAPTER I. INFLAMMATION. Pathology of inflammation ..... Clinical view of inflammation ..... Ulceration ....... Granulation and cicatrization .... Gangrene ....... Inflammatory fever ..... CHAPTER II. TREATMENT OF INFLAMMATION. Prophylactic treatment . . . Curative treatment ...... Hygienic ....... Local . ...... Constitutional ...... CHAPTER III. OPERATIONS IN GENERAL ; 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 IT ail NOR SURGERY. Bandaging ....... Revulsion and counter-irritation .... Hypodermic injection ....-■ Vaccination ....... Bloodletting ....... Vlll CONTENTS. Transfusion of blood Aspiration CHAPTER V AMPU TATIONS. 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 PAOE 91 92 SURGICAL INJURIES. CHAPTER VII. EFFECTS OF INJURIES IN GENERAL : WOUNDS. Constitutional effects of injuries Shock Traumatic delirium Local effects of injuries Contusions Strangulation of parts Wounds Incised wounds Lacerated and contused wounds Antiseptic treatment of wounds Punctured wounds . Poisoned wounds CHAPTER VIII. GUNSHOT WOUNDS. Gunshot wounds ...... Amputation and excision in gunshot injuries 168 175 CONTENTS. ix CHAPTER IX INJURIES OF BLOODVESSELS. Injuries of veins .... Entrance of air into veins . Inj uries 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-venons wounds Lines of incision for ligation of special arteries CHAPTER X. INJURIES OF NERVES, MUSCLES AND TENDONS, LYMPHATICS, BURSE, BONES, AND JOINTS. Nerves Muscles and tendor 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 Sacrum and coccyx X CONTENTS.. 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 Cerebral localization 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 . Abdominal fistulse . Foreign bodies in stomach or bowels Injuries of pelvic organs . Injuries of male genitals . Injuries of female genitals PAGE 343 350 351 355 357 359 366 368 375 383 387 389 398 398 403 411 413 414 416 418 SURGICAL DISEASES. CHAPTER XX. DISEASES RESULTING FROM INFLAMMATION. Abscesses .... Ulcers .... Gangrene and gangrenous diseases CHAPTER XXI. ERYSIPELAS. Varieties and causes of erysipelas Symptoms Diagnosis and prognosis . Treatment 420 426 431 441 441 443 444 Xll CONTENTS. CHAPTER XXII. PYEMIA. PAGE Nomenclature of pyaemia Pathology . 448 449 Morbid anatomy . Causes 452 454 Symptoms . Diagnosis . 454 455 Prognosis and treatment 456 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 umbilicus Gonorrhoeal rheumatism . Chancroid .... Complications Treatment . Primary bubo or bubon d'emblee CHAPTER XXV. venereal diseases—continued. SYPHILIS. CHAPTER X X V I. TUMORS. Classification of tumors . Cystic tumors Simple or barren cysts Compound or proliferous cysts 458 459 460 462 465 469 472 472 473 475 475 476 477 478 482 History of syphilis 482 Causes of syphilis 482 Primary syphilis . 484 Secondary syphilis 488 Tertiary syphilis . 492 Hereditary syphilis 497 Diagnosis of syphilis 498 Treatment of syphilis 501 507 509 509 511 CONTENTS. xiii Non-malignant solid tumors and outgrowths Semi-malignant or recurrent tumors ; sarcomata Malignant tumors . Carcinoma . Epithelioma . . . . Excision of tumors .... CHAPTER XXVII PAOE 513 525 530 530 542 546 SURGICAL DISEASES OF THE SKIN, AREOLAR TISSUE, LYMPHATICS, MUSCLES, TENDONS, AND BURSE. Skin and appendages ..... . 548 Areolar tissue ...... 554 Lymphatic system ..... . 555 Muscles and tendons . . 556 Bursae ....... . 559 CHAPTER XXVIII. SURGICAL DISEASES OF THE NERVOUS SYSTEM. Neuritis Neuroma Neuralgia Tetanus CHAPTER XXIX. SURGICAL DISEASES OF THE VASCULAR SYSTEM. CHAPTER XXX. DISEASES OF BONE. Periostitis . Osteitis Osteo-myelitis Epiphysitis 562 562 563 566 Diseases of veins . 572 Vascular tumors or angeiomata . . 576 Diseases of arteries 580 Aneurism .... 583 Treatment of aneurism in general 591 Treatment of particular aneurisms 602 Aortic 602 Innominate 604 Carotid 607 Vertebral and subclavian 609 Axillary 612 Brachial, etc. 612 Abdominal and inguinal 613 Gluteal and sciatic 615 Iliac and common femoral 616 Femoral and popliteal 617 618 620 621 624 XIV CONTENTS. Abscess in bone 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 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, ribs, and sternum Shoulder-joint Humerus Elbow-joint Radius and ulna Wrist-joint . Bones of hand Hip-joint Femur Knee-joint . Patella Bones of leg and ankle-joint Bones of foot CHAPTER XXXIII ORTHOPEDIC SURGERY. Wry-neck .... Lateral curvature of the spine Deformities of the upper extremity Deformities of the lower extremity Club-foot . CONTENTS. CHAPTER XXXIV. DISEASES OF THE HEAD AND SPINE. Diseases of the scalp and skull .... Diseases of the brain ..... Encephalocele and meningocele .... Paracentesis capitis ..... Spina bifida . . . . . Antero-posterior curvature of the spine . . . . Arthritis, necrosis, and anchylosis of the spine . Tumors of the spinal cord .... CHAPTER XXXV. DISEASES OF THE EYE. Diseases of the conjunctiva Diseases of the cornea Diseases of the sclera and ciliary body Diseases of the iris Operations on the iris Cataract .... Operations for cataract Diseases of the vitreous humor, choroid, Functional disturbances of vision 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 cavity of the tympanum . Nervous deafness, etc. ..... CHAPTER XXXVII. DISEASES OF THE FACE AND NECK. Diseases of the nose ..... Rhinoplasty ...... Diseases of the frontal sinuses .... Diseases of the cheeks . Diseases of the lips ..... Diseases of the neck ..... retina, and optic papilla XVI CONTENTS. 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 CHAPTER XXXIX DISEASES OF THE BREAST. Hypertrophy of the breast Supernumerary nipples or mamma 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 hernia Strangulated hernia The taxis . Herniotomy CHAPTER XLI SPECIAL HERNIE. Classification of hernise . Diaphragmatic, epigastric, and ventral hernia; Umbilical hernia . Lumbar and inguinal hernise Femoral hernia Obturator hernia . Perineal and pudendal hernise . Vaginal and ischiatic hernise CONTENTS. XV11 CHAPTER XLII. DISEASES OF INTESTINAL CANAL. Intestinal obstruction Malformations of the anus and rectum Stricture and tumors of the rectum and Rectal fistulse Fistula in ano Fissures and ulcers of the anus Hemorrhoids Prolapsus of the rectum . Inflammation of the rectal pouches Neuralgia and pruritus of the anus PAGE 903 913 917 922 923 926 927 934 936 937 CHAPTER XLIII. DISEASES OF ABDOMINAL ORGANS, AND VARIOUS OPERATIONS ON THE ABDOMEN. Umbilical tumors and fistulse ....... 937 937 Paracentesis abdominis Ovarian tumors Csesarean section, etc. Operations on the kidneys Operations on the spleen Operations on the stomach and bowels Pancreatectomy and pancreatotomy Hepatectomy and hepatotomy ; hepatic phlebotomy Operations on the gall-bladder Treatment of abdominal abscesses Treatment of abdominal hydatids, etc. CHAPTER XLIV URINARY CALCULUS. CHAPTER XLV. DISEASES OF THE BLADDER AND PROSTATE. Malformations and malpositions of the bladder . Cystitis ...... 2 939 947 948 951 953 955 955 956 957 959 Varieties of calculus ..... . 960 Renal calculus . . 963 Vesical calculus ...... . 964 Litholysis, or solvent treatment of stone 971 Lithotrity ...... 971 Rapid lithotrity with evacuation, or litholapaxy 975 Lithotomy . . . . . . 981 Recurrent calculus ..... 997 Urethral calculus . . . 998 Prostatic calculus ...... 998 Calculus in women ...... 999 Extra-pelvic vesical calculus .... 1000 1001 1006 xvm CONTENTS. 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 XL VI. DISEASES OF THE URETHRA AND URINARY FISTULA. Exploration of the urethra Malformations of the urethra . . ■ Prolapsus of the urethra, urethrocele, and urethritis Spasm of the urethra Stricture of the urethra Urethral fever Treatment of stricture Tumors and fissures of the urethra Urinary fistula in the male Urinary fistula in the female PAOE 1009 1012 1013 1016 1017 1022 1024 1025 1030 1032 1033 1034 1037 1038 1050 1051 1054 CHAPTER XL VII. diseases of the generative organs. Male Genitals. Diseases of the penis and scrotum Diseases of the testis ..... Hydrocele and hseinatocele Varicocele ..... Sarcocele and tumors of the testis Functional disorders of the male generative apparatus . 1060 1068 1070 1076 1078 1082 Female Genitals. Malformations Surgical diseases of the vulva Surgical diseases of the vagina Surgical diseases of the uterus 1085 1087 1088 1090 Index 1095 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 the 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. Allis's ether inhaler . 12. Clover's chloroform apparatus (Erichsen) 13. Reversed spiral bandage 14. Figure-of-8 bandage . 15. Spica bandage 16. Four-tailed bandage . 17. Bandage of Scultetus IS. Hunter's saw for removing plaster bandages 19. Seutiu's pliers 20. Corrigan's button cautery 21. Porte-moxa .... 22. Different forms of cautery iron 23. Marshall's galvanic cautery . 24. Paquelin's cautery 25. Mechanical leech 26. Apparatus for transfusion of blood . 27. Aspirator . 28. Esmarch's apparatus for bloodless operations 29. Petit's tourniquet 30. Spanish windlass 31. Signoroni's tourniquet 32. Skey's tourniquet 33. Lister's aorta-compressor (Erichsen) 34. Amputating knife ... 35. Double-edged catlin . 36. Bistoury .... 37. Scalpel .... 38. Amputating saw 39. Small amputating saw 40. Bone nippers .... 41. Legouest's periosteotome 42. Artery forceps 43. Tenaculum .... 44. Reef-knot .... 45. Surgeon's knot and reef-knot combined 46. Surgical needles 47. Amputation of the arm ; circular method (Druitt) 48. Amputation of the thigh ; antero-posterior flap method (Bryant) 49. Amputation of the thigh ; modified circular method (Skey) 50. Amputation of the leg ; Teale's method (Bryant) 51. Simultaneous quadruple amputation 52. Synchronous triple amputation 53. Result of synchronous amputation of hip and leg XX LIST OF ILLUSTRATIONS. FIG. 54. Simultaneous triple amputation 55. Thigh stump, with splint for extension (Bryant) . 56. Aneurismal varix in stump (Erichsen) 57. Neuromata of stump (Miller) 58. Necrosis after amputation (Lister) . 59. Amputation of a finger (Erichsen) . 60. Amputation at metacarpophalangeal joint (Skey) 61. Amputation of the thumb (Erichsen) 62. Result of partial amputation of the hand . 63. Amputation of the wrist (Erichsen) 64. Amputation of the forearm (Bryant) 65. Amputation of the shoulder-joint; Larrey's method 66. Result of Larrey's amputation 67. Amputation at shoulder-joint: Dupuytren's method (Bryant) 68. Result of Dupuytren's amputation . 69. Amputation of great toe with metatarsal bone (Erichsen) 70. Amputation of metatarsus ; Lisfranc's and Hey's method (Skey) 71. Chopart's amputation (Bryant) 72. Pirogoff's amputation (Erichsen) . 73. Bony union after Pirogoff's amputation (Hewson) . 74. Syme's amputation (Skey) . 75. Result of Mikulicz's operation (Stephen Smith) 76. Flap amputation of the leg (Erichsen) 77. Amputation of the knee-joint (Erichsen) 78. Amputation of the hip-joint (Holmes) 79. Result of hip-joint amputation 80. Abdominal tourniquet .... 81. Mounted needle, with ligature 82. Interrupted suture ..... 83. Continued or glover's suture 84, 85. Quilt suture ..... 86. Twisted suture ..... 87. India-rubber suture ..... 88. Quilled suture ..... 89. Serre-fine ...... 90. Cicatrices following shark-bite 91. Steam spray-apparatus .... 92. Nelaton's probe ..... 93. Bullet forceps ..... 94. Screw-extractor ..... 95. Gunshot fracture of hip .... 96. Partial excision of radius for gunshot injury 97. Rupture of external iliac artery 98. Hewson's torsion forceps .... 99. Speir's artery-constrictor .... 100. Aneurismal needle ..... 101. Grooved director ..... 102. Ligation of an artery in its continuity (Bryant) 103. Acupressure ; first method ; raw surface (Erichsen) 104. Acupressure ; first method ; cutaneous surface (Erichsen) 105. Acupressure ; second method (Erichsen) . 106. Acupressure; third method (Erichsen) 107. Acupressure ; fifth method (Erichsen) 108. Arterio-venous aneurisms (Bryant) 109. Ligation of innominate artery (Skey) 110. Ligation of carotid and facial arteries (Bryant) 111. Ligation of occipital artery (Skey) . 112. Ligation of temporal artery (Skey) . 113. Ligation of subclavian and lingual arteries (Bryant) 114. Ligation of brachial, radial, and ulnar arteries (Miller) 115. Ligation of common iliac artery (Liston) 116. Ligation of external iliac and femoral arteries (Bryant) 117. Ligation of popliteal artery (Miller) 118. Ligation of anterior tibial artery (Miller) . 119. Ligation of posterior tibial artery (Miller) . LIST OF ILLUSTRATIONS. XXI FIG. 120. Trophic lesions following wound of median nerve 121. Wallerian degeneration of nerve (Bertolet) 122. Partial fracture .... 123. Comminuted fracture of patella 124. Impacted fracture through trochanters of femur 125. Deformity from injury of epiphysis 126. Gangrene from tight bandaging (Bell) 127. Bavarian immovable splint (Bryant) 128. Improved drill for ununited fracture 129. Gaillard's instrument for ununited fracture 130. Barton's bandage for fractured jaw . 131. Attachments of outer end of clavicle ; showing branches of coraco-clavic ular ligament (Gray) .... 132. Oblique fracture of clavicle (Gray) 133. Sayre's dressing for fractured clavicle 134. Velpeau's bandage . . . 135. Separation of upper epiphysis of humerus . 136. Fracture of the surgical neck of the humerus (Gray) 137. Dressing for fracture of the surgical neck of the humerus (Fergusson) 138. Fracture at the base of the condyles of the humerus (Gray) 139. Fracture at the base of, and between, the condyles of the humerus (Erichsen) .... 140. Physick's elbow splints 141. Hartshorne's elbow splint 142. Fracture of the radius near its lower end (Liston) 143. Bond's splint for fracture of the radius 144. Gordon's splints for fracture of the radius . 145. Coover's splints for fractured radius 146. Agnew's splint for fracture of metacarpus . 147. Fracture of neck of femur (Fergusson) 148. Adhesive-plaster stirrup for making extension in fracture of lower extremity .... 149. Weight-extension with long splints for treatment of fractured till 150. N. R. Smith's anterior splint for fractured thigh 151. Compound fracture of thigh; treatment by bracketed long splin (Erichsen) .... 152. Fracture of patella .... 153, 154. Separation of upper epiphysis of tibia 155. Fracture-box, with movable sides 156. Salter's cradle .... 157. Wire rack for fracture of the leg 158. Clove-hitch ..... 159. Congenital dislocation of both hips (Holmes) 160. Dislocation of lower jaw 161. Unreduced dislocation of lower jaw . 162. Dislocation of sternal end of clavicle (Bryant) 163. Dislocation of clavicle on acromion (Bryant) 164. Dislocation of humerus into axilla (Pirrie) 165. Subcoracoid luxation of humerus (Pirrie) . 166. Reduction of dislocated shoulder by heel in axilla 167. Reduction of dislocated shoulder by White's and Mothe's method 168. Forward dislocation of head of radius (Liston) 169. Dislocation of elbow backwards (Liston) 170. Reduction of dislocated elbow .... 171. Unreduced dislocation of thumb 172. Levis's instrument for reducing dislocation of thumb and finger 173. Anatomy of the hip-joint; the Y ligament (Bigelow) 174. Backward dislocation of hip .... 175. Reduction of backward dislocation by manipulation (Bigelow) 176. Downward dislocation of hip 177. Reduction of downward dislocation by manipulation (Bigelow) 178. Application of rope windlass for backward dislocation of hip 179. Bloxam's dislocation tourniquet applied for downward dislocation (Erichsen) .... 180. Pulleys applied for upward dislocation of hip 2* XXII LIST OF ILLUSTRATIONS. FIG. 1^1. Angular extension in old dislocation of hip (Bigelow) 182. Contraction of arm following burn . 183. Result of plastic operation for contraction following burn 1M. Teale's operation for contraction of lower lip (Erichsen) 185, l^ij. Severe scalp wound .... 1 s7. Fracture of skull with loss of substance 188. Hey's saw ...... 189. Cerebral localization ; application of flexible square 190. Common trephine ..... 191. Different forms of elevator .... '192. Hopkins's trephining forceps 193. Conical trephine ..... 194. Bilateral dislocation of cervical vertebra (Ayres) 195. Bony union of fractured vertebrae . 196, 197. Fracture of vertebral body and unilateral dislocation of a lumbar vertebra ..... 198. Schell's spud for removing foreign bodies from cornea 199. Oblique illumination (Wells) 200. Eversion of upper lid for detection of foreign bodies (Erichsen) 201. Dislocation of crystalline lens 2<>2. Tracheal stricture (Cohen) 203, 204. Fracture of larnyx (Roe) 205. Application of laryngoscope (Erichsen) 2(i6. Throat-mirror used in laryngoscopy 207. Gross's tracheal forceps .... 2o>. Cohen's tracheal forceps .... 209. Fibrinous cast from trachea .... 210. Brass shawl-pin removed from trachea 211. O'Dwyer's instruments for intubation of larynx 212. Operation of tracheotomy (Liston) 213. Golding-Bird's tracheal dilator 214. Tracheal tube ..... 215. Trousseau's tracheal forceps 216. Elsberg's tracheal forceps .... 217. Cohen's tracheal tube .... 21s. Trousseau's elbow forceps .... 219. Tracheal tube with ball-valve 220. Wire retraction for tracheotomy . . . 221. Burge's oesophageal forceps .... 222. Swivel probang ..... 223. Horsehair probang, or ramoneur 224. Ventral hernia following rupture of abdominal muscles 225. Lembert's suture ..... 226. Gely's suture ..... 227. Appolito's suture ..... 22s. Dupuytren's enterotome .... 229. Enterotome applied (Erichsen) 23H. Luer's forceps for removal of foreign bodies from bladder 231. Urethral scoop of Le Roy d'Etiolles 232. disco's urethral forceps .... 233. Operation for ruptured perineum (Thomas) 234. Drainage-tube and forked probe 235. Volkmann's sharp spoon or curette 236. Strapping an ulcer (Liston) .... 237. Scissors for skin-grafting . . 238. Incurable ulcer with scleroderma 239. Diagram illustrating processes of thrombosis and embolism (Callender) 24o. Scrofulous ulcer of leg (Erichsen) 241. Gonorrhoeal epididymitis (Liston) . 242, 243. Ophthalmic gonorrhoea (Dalrymple) . 244. Multiple chancres inoculated by tattooing . 245. Mucous patches (Miller) .... 246. Syphilitic ulceration of face .... 247. Syphilitic rupia (Druitt) .... 248. Syphilitic panaris ..... LIST OF ILLUSTRATIONS. xxiii FIG. 249. Syphilitic permanent teeth (Hutchinson) 250. Bone-disease in hereditary syphilis 251. Maury's fumigating apparatus 252. Sebaceous tumors and horn (Bryant) 253. Structure of a fatty tumor (Bennett) 254. Fatty tumor showing lobated appearance (Miller) 255. Fibro lipoma of twenty-five years' standing 256. Fibro-cellular tumor of labium (Holmes) 257. Structure of myxoma (Holmes) 258. Structure of fibrous tumor (Erichsen) 259. Structure of fibro-muscular tumor (Bennett) 260. Structure of enchondroma (Erichsen) 261. Large enchondroma of scapula 262. Multiple enchondromata of hand (Druitt) 263. Cancellous exostosis of femur (Druitt) 264. Ivory-like exostoses of skull (Miller) 265. Multiple osteomata of head and face 266. Adenoma of mamma (Rindfleisch) . 267. Lymphoma (Green) . 268. Painful subcutaneous tubercle (Smith) 269. Recurrent fibroid tumor (Green) 270. Recurrent fibroid tumor of thigh 271. Myeloid tumor (Billroth) 272. Several varieties of sarcoma (Bryant) 273. Alveolar sarcoma (Billroth) . 274. Sarcoma of arm and shoulder 275. Section of scirrhous breast (Liston) 276. Scirrhus of breast, in stage of ulceration 277. Carcinoma of both breasts 278. Secondary growths of scirrhus (Miller) 279. Cells from a scirrhus of the mamma (Green) 280. Microscopic appearances of scirrhus (Green) 281. Medullary cancer in stage of ulceration (Druitt) 282. Microscopic appearances of medullary cancer (Green) 283. Melanoid cancer (Bryant) 284. Hsematoid cancer of breast (Miller) 285. Microscopic appearances of colloid cancer (Rindfleisch) 286. Epithelioma of lower lip 287. Concentric globes of epithelioma (Green) 288. Ecraseur .... 289. Wire ecraseur 290. Elliptical incision for removal of tumors 291. Double S incision for removal of tumors 292. Pean's haemostatic forceps . 293. Nunneley's clips 294. Warts around the anus (Ashton) 295. Malignant onychia (Druitt) 296. Toe-nail ulcer (Liston) 297. Rodent ulcer 298. Phagedsenic lupous ulcer (Druitt) . 299. Elephantiasis Arabum in lower extremity (Smith) 300. Felon (Liston) 301. Compound ganglion . 302. Enlarged bursa over the patella ; housemaid's knee (Liston) 303. Formation of seton with trocar and canula (Erichsen) 304. Apparatus for treatment of bunion 305. Section of a neuroma (Smith) 306. Application of pins to varicose veins (Miller) 307. Aneurism by anastomosis (Fergusson) 308. Nsevus ; application of quadruple ligature (Liston) 309. Subcutaneous ligature of nsevus (Holmes) . 310. Diagram of ligature of flat and elongated na^vus (Erichsen) 311. Diagram of tied flat and elongated nsevus (Erichsen) 312. Fatty degeneration in inner coat of aorta (Green) 313. Atheroma of aorta (Green) .... XXIV LIST OF ILLUSTRATIONS. FIG. 314. Atheromatous ulcer of aorta (Liston) .... 315. Large fusiform aneurism of aorta bursting into pericardium (Erichsen) 316. Sacculated aneurism of aorta (Erichsen) . 317. Perforation of ribs by aortic aneurism (Pirrie) 318. Aneurism of innominate artery (Erichsen) 319. Stellate rupture of aortic aneurism into pericardium (Erichsen) 320. Diagram of Anel's operation 321. Diagram of Hunter's operation 322. Diagram of Brasdor's operation 323. Diagram of Wardrop's operation 324. Carte's compressor for the groin 325. Gibbons's modification of Charriere's compressor . 326. Result of simultaneous ligation of carotid and subclavian arteries 327. Carotid aneurism . 328. Osteoporosis of femur (Druitt) 329. Sclerosis and eburnation of femur (Liston) 330, 331. Osteitis deformans .... 332. Abscess in tibia (Holmes) .... 333. Caries (Druitt) ..... 334. Gouge forceps . . . 335. Burr-head drill ..... 336. Central necrosis; new bone with cloacae (Erichsen) 337. Sequestrum forceps ..... 338. Necrosis of femur, following gunshot fracture 339. Senile atrophy of neck of thigh-bone (Liston) 340. Scrofulous osteitis (Erichsen) 341. Osteo-sarcoma of forearm .... 342. Enchondroma of femur .... 343. Gelatinous arthritis of elbow 344. Arthritis of knee-joint in advanced stage . 345. Barwell's splint for continuous extension . 346. Deformity in second stage of hip-disease 347. Deformity in third stage of hip-disease 348. Excised head and neck of femur, showing change in shape of bone in third stage of hip-disease 349. Deformity from double hip-disease (Hodge) 350. Sayre's short splint for hip-disease . 351. Sayre's long splint for hip-disease . 352. Agnew's splint for hip-disease 353. Head of femur in rheumatoid arthritis (Druitt) 354. Synostosis of hip-joint (Pirrie) 355. Consecutive dislocation following arthritis of knee-joint 356. Anchylosis of knee-joint in position of over-extension 357. Chronic arthritis of knee-joint, with partial anchylosis in bad position 358. Barwell's splint for continuous extension in anchylosis of the knee 359. Bigg's apparatus for contraction of knee 360. Adams's saw for subcutaneous osteotomy . 361, 362. Subcutaneous osteotomy of both thigh-bones 363, 364. Anchylosis of both hips ; osteotomy below trochanter 365, 366. Bony union after subcutaneous osteotomy of femur 367. Trochlea of humerus, with loose cartilages 368. Fergusson's lion-jawed forceps 369. Butcher's saw ..... 370. Chain saw ...... 371. Butcher's knife-bladed forceps 372. Excision of shoulder-joint (Erichsen) 373. Result of excision of shoulder-joint 374. Excision of elbow-joint (Bryant) 375, 376. Excised extremities of humerus and ulna 377. Result of excision of elbow-joint 378. Deformity following excision of radius 379. Diagram of Lister's method of excising wrist-joint 380. Diagram of Heyfelder's method of excising hip-joint 381. Excised head and neck of femur 382. Sayre's cuirass for hip-joint excision LIST OF ILLUSTRATION S. XXV 383. Result of hip-joint excision . 384. Excision of both hip-joints . 385, 386. Excised extremities of femur and tibia 387. Price's splint for excision of knee-joint 388. Wire splint for excision of knee-joint 389, 390. Result of excision of knee-joint 391. Bracketed wire splint for ankle 392. Tenotome .... 393. Lateral curvature of spine (Erichsen) 394, 395. Dupuytren's finger contraction 396. Apparatus for knock-knee . 397. Macewen's osteotome 398, 399. Macewen's operation for knock-knee 400, 401. Osteotomy for bow-legs 402, 403. Osteotomy for anterior curvature of leg bones 404. Talipes equinus (Pirrie) 405. Talipes varus (Fergusson) . 406. Varus shoe, with jointed sole-plate 407. Cuneiform excision for varus 408. Inveterate varus 409. Talipes calcaneus (Bryant) . 410. Talipes valgus (Pirrie) 411. Chronic hydrocephalus 412. Spina bifida (Druitt) 413. Antero-posterior curvature of spine (Liston) 414. Caries of the vertebrae (Liston) 415. Sayre's suspension apparatus 416. Sayre's jury-mast 417. Diphtheritic conjunctivitis . 418. Granular lids (Jones) 419. Pterygium (Stellwag von Carion) . 420. Sarcoma of conjunctiva 421. Pannus (Jones) 422. Paracentesis corne33 (Erichsen) 423. Prolapse of the iris (Miller) 424. Abscission of staphyloma (Stellwag von Carion) 425. Critchett's operation for staphyloma (Lawson) 426. Iritis ; showing ciliary zone of sub-conjunctival injection (Pirrie 427. Lance-shaped iridectomy knife 428. Curved iris forceps .... 429. Liebreich's bandage (Lawson) 430. Tyrrell's hook .... 431. Spatula-hook .... 432. Flap extraction of cataract (Wells) 433. Cystotomy and curette 434. Traction spoons .... 435. Von Graefe's cataract knife 436. Diagram of Von Graefe's operation for cataract 437. Von Graefe's hook .... 438. Bowman's stop-needle 439. Hays's knife-needle .... 440. Canula scissors .... 441. Loring's smaller ophthalmoscope . 442. Use of the ophthalmoscope (after Loring) . 443. Galezowski's strabismometer 444. Strabismus hook . 445. Snellen's clamp .... 446. Entropion forceps .... 447, 448. Adams's operation for ectropion (Lawson) 449. Symblepharon (Mackenzie) 450. Bowman's canaliculus knife 451. Vertical section of external auditory canal, membrana tympani, and tym panic cavity (after Politzer) 452. Toynbee's ear speculum 453. Wilde's snare for aural polypus XXV1 LIST OF ILLUSTRATIONS. FIG. 454. 455. 456. 457. 458. 459. 460. 461. 462. 463. 464. 465. 466. 467. 468. 469. 470. 471, 473. 474. 476, 478. 479, 481, 483. 4*4. 485. 486. 4S7. 488. 489. 490. 491. 492. 493. 494. 495. 496. 497. 498. 499. 500. 501. 502. 503. 504. 505. 506. 507. 508. 509. 510. 511. 512. 513, 515. 516. 517. 518. 519. 520. 521. 522. 523. 524. Forceps for aural polypus .... Enlarged representation of normal membrana tympani Siegle's pneumatic speculum Politzer's method of inflating the tympanum Toynbee's artificial membrana tympani Application of the otoscope (Toynbee) Catheter for Eustachian tube " . Lipoma (Liston) ..... Plugging the nostril with Bellocq's sound (Fergusson) Posterior nasal syringe .... Gooch's double canula .... Fibrous polypus of the nose producing frog-face . Rhinoplasty by Indian method (Fergusson) Pancoast's tongue and groove suture Result of rhinoplasty by Indian method Diagram of Syme's rhinoplastic operation . Diagram of Burow's plastic operation 472. Operation for epithelioma of lip and neck Formation of prolabium by Serres's method 475. Serres's cheiloplastic operation, modified (Erichsen) 477. Buchanan's cheiloplastic operation (Erichsen) Result of Syme's cheiloplastic operation 480. Operation for restoration of upper lip and angle of mouth 482. Restoration of upper lip (Sedillot) Diagram of single harelip (Holmes) Cheek-compressor for harelip (Fergusson) Malgaigne's operation for harelip . Double harelip with projecting intermaxillary portion (Holmes) Macrostoma .... Bronchocele (Green) Tumor of parotid region (Fergusson) Ranula, between floor of mouth and mylo-hyoid muscles (Fergusson) Wood's gag for operations on the tongue Regnoli's mode of exposing tongue (Erichsen) Removal of tongue by division of lower jaw and ecraseur (Erichsen) Fibrous epulis (Bryant) Encephaloid of antrum (Liston) Osteoma of upper jaw Excision of upper jaw (Fergusson) Disarticulation of lower jaw (Fergusson) Mason's gag .... Sedillot's operation for staphylorraphy Forceps-scissors for cutting uvula . Fahnestock's tonsillotome Stricture of the oesophagus (Druitt) Epithelioma of larynx (Erichsen) . Gibb's laryngeal ecraseur Simple hypertrophy of breasts (Bryant) Paget's disease of nipple Strapping the breast Brodie's sero-cystic sarcoma of breast (Druitt) Mammary sarcoma with large cysts Excision of the breast (Fergusson) . Scrotal hernia in a child 514. Johnson's probe-knife for subcutaneous herniotomy Strangulated hernia ; stricture in neck of sac (Erichsen) Strangulated hernia; gangrene of intestine (Liston) Herniotomy ; searching for seat of stricture (Liston) Hernia-knife ..... Oblique and direct inguinal hernise Hernia into vaginal process of peritoneum (Pirrie) Hernia into funicular portion of vaginal process Common inguino-scrotal hernia (Pirrie) Encysted hernia (Liston) .... Wutzer's apparatus for radical cure of hernia LIST OF ILLUSTRATIONS. xxvii FIG. 525. Agnew's instrument for radical cure of hernia 526. Wood's operation for radical cure of hernia 527. Incision for strangulated inguinal hernia (Fergusson) 528. Femoral hernia (Erichsen) . . . . 529. Incision for strangulated femoral hernia (Fergusson) 530. Internal strangulation by a diverticulum (Pirrie) . 531. Lumbar colotomy (Bryant) . 532. Imperforate anus (Ashton) . 533. Imperforate rectum (Ashton) 534. Fibrous stricture of rectum (Ashton) 535. Malignant stricture of rectum (Ashton) 536. Rectal speculum 537. Protruding hemorrhoids (Ashton) . 538. Smith's clamp for piles 539. Ring-forceps for piles 540. Bushels needle and needle-carrier . 541. Partial prolapsus of rectum (Bryant) 542. Section of complete prolapsus of the rectum (Druitt) 543. Anal truss .... 544. Tapping the abdomen (Fergusson) . 545. Sims's uterine probe 546. Siphon trocar 547. Fitch's trocar and canula 548. Atlee's clamp 549. Sims's catheter 550. Uric acid deposits (Holmes) 551. Uric acid calculus (Gross) . 552. Oxalate of lime deposits (Holmes) . 553. Mulberry calculus (Miller) . 554. Phosphate of lime (Holmes) 555. Triple phosphate (Holmes) . 556. Cystine calculus (Roberts) . 557. Alternating calculus (Erichsen) 558. Sound for examining bladder 559. Thompson's hollow sound, with slide and scale 560. Sounding for stone behind prostate (Erichsen) 561. Sounding for stone above pubis (Erichsen) 562. Sounding for encysted calculus (Erichsen) 563. Weiss and Thompson's improved lithotrite 564. Fergusson's lithotrite 565. Introduction of the lithotrite (Erichsen) 566. Position of lithotrite in crushing the stone (Liston) 567. Handle of Bigelow's lithotrite 568. Blades of Bigelow's lithotrite 569. Clover's evacuating apparatus 570. Bigelow's evacuator 571. Bigelow's catheters for evacuating fragments after litholapaxy 572. Urethral forceps 573. Lithotomy staff 574. Lithotomy forceps 575. Lithotomy scoop 576. Tube for plugging wound in lithotomy 577. Position of patient and incision in lateral lithotomy (Erichsen) 578. Deep incision in lithotomy (Fergusson) 579. Position of finger and scoop in extracting stone (Erichsen) 580. Physick's cutting gorget 581. Frere Corne's lithotome cache" 582. Dupuytren's lithotome cache 583. Bilateral lithotomy ., 584. Urethral dilator 585. Female staff 586, 587, 588. Plastic operation for extroversion of bladder 589. Keyes's apparatus for washing out the bladder 590. Polypoid tumors of the bladder (Civiale) . 591. Enlarged median lobe of prostate (Erichsen) XXV111 LIST OF ILLUSTRATIONS. FIG. 592. Hypertrophied bladder and prostate (Thompson) 593. Mercier's elbowed catheter 594. Prostatic catheters 595. Squire's vertebrated prostatic catheter 596. Catheterization in enlarged prostate (Erichsen) 597. Puncture of bladder through rectum, and above pubis (Phillips) 598. French flexible bougie and catheter 599. Bougies a boule ..... 600. Introduction of the catheter (Voillemier) . 601. Desormeaux's endoscope .... 602. Epispadia ; Duplay's operation 603. Hypospadia ; Duplay's operation . 604. Stricture of urethra at sub-pubic curvature (Thompson) 605. Stricture of urethra near orifice (Thompson) 606. False passages (Druitt) .... 607. Thompson's stricture expander 608. Holt's instrument for splitting stricture 609. Civiale's urethrotome .... 610. Syme's staff for external division of stricture 611. Tapping the urethra in the perineum (Bryant) 612. Papillary tumor of female urethra (Boivin) 613. Urinary fistulse in the male (Liston) 614. Dieffenbach's lace suture .... 615. Urethroplasty by Dieffenbach's method (Erichsen) 616. Urethroplasty by Le Gros Clark's method (Erichsen) 617. Duck-billed speculum for the vagina 618. Emmet's vaginal speculum 619. Knife for vesico-vaginal fistula 620. Operation for vesico-vaginal fistula ; sutures in position (Simon) 621. Coghill's wire twister 622. Bozeman's button-suture 623. Operation for vesico-uterine fistula (Thomas) 624. Transverse obliteration of the vagina (Simon) 625. Circumcision (Erichsen) 626. Reduction of paraphimosis (Phillips) 627. Hypertrophy or elephantiasis of scrotum (Titley) 62s. Epithelioma of the penis 629. Epithelioma of the scrotum (Curling) 630. Strapping the testicle (Velpeau) 631. Hernia of the testicle (Curling) 632. Tapping for hydrocele (Erichsen) . 633. Wood's instrument for varicocele 634. Royes Bell's instrument for varicocele 635. Cystic sarcocele (Bryant) 636. Division of spermatic cord in castration (Erichsen) 637. Cylindrical speculum for the vagina 638. disco's vaginal speculum . 639. Thomas's clamp for elytrorrhaphy . 640. Fibro-cellular uterine polypus protruding from vulva (Boivin and 641. Interstitial uterine fibroid (Barnes) 642. Amputation of the cervix uteri with the ecraseur (Chassaignac) Duges) PAGE 1018 1020 1020 1021 1022 1023 1025 1026 1028 1030 1031 1031 1035 1035 1040 1041 1042 1043 1044 1047 1051 1051 1052 1053 1053 1054 1055 1056 1057 1058 1058 1058 1059 1062 1063 1065 1066 1067 1069 1070 1072 1078 1078 1080 1082 1089 1089 1089 1091 1092 1094 THE PRINCIPLES AND PRACTICE OF SURGERY. The word Surgery, or Chirurgery, as it was formerly written, is derived from the two Greek words zeip (the hand) and spyoi> (a work). In its ear- liest and narrowest signification, it was therefore limited to certain manual operations, which we accordingly find that the surgeon was formerly in the habit of executing under the direction and guidance of the physician, who was considered as occupying a higher grade in the profession, and who took entire charge of, and was responsible for, the management of the consti- tutional 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 prefer- able 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 scarce^ 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 different lesions and morbid conditions, as to entitle them to be looked upon rather as a part of general than of special surgery. CHAPTER I. INFLAMMATION. Inflammation, or the Inflammatory Process, may be considered from two points of view: the Pathological and the Clinical. In discussing it clinicallv, 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 some- thing superadded to the natural condition of the part. This view is now almost universally abandoned, and authors, though differing as to the proper explanation to be given of many of the phenomena of inflammation, are, I think, generally agreed that those phenomena are mere modifica- tions of the phenomena 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 in the direction of excess. Changes of Function__Thus, as regards function, the first effect of an irritant upon muscular fibre is to produce contraction (an increased 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 increased 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 discussion. That the quantity of blood in an inflamed part is increased, and that the size of its bloodvessels is greater than in corresponding unin- flamed structures, was so patent as to have been the subject of early obser- vation; and hence it is not surprising that, in the absence of more accurate investigations, all the phenomena of inflammation should have been attrib- uted (as was the case for many years) to what was called an "altered activity of the bloodvessels." Modern pathology has, however, shown that nutrition and formation are due to cell-action, and that the office of the bloodvessels is purely that of a servant, to bring new material, and.to remove that which is effete and useless. Hypersemia.—While, as has been said, the quantity of blood is increased in a part which is inflamed, or in which the inflammatory process is in pro- gress, this increase, or Hypersemia, is not necessarily a part of, nor in anv way connected with inflammation. A simple reference to anv of the erec- tile tissues of the body will suffice to illustrate this point. Again, there may be a true hypersemia, 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 elas- ticity of the walls of the bloodvessels themselves, not an unfrequent coin- cidence of the general loss of tone which usually attends advancing a»e. These forms of hypersemia, which are always police and due to mechani- cal causes, are properly designated by the "term Conyesfion, which ini-ht well be reserved for these conditions; the form of hypersemia which manv writers have called Active Congestion being more conveniently distin- guished by the name Fluxion (a term used by Billroth), or fJrtmnination. Determination is essentially an active condition. It is, as we shall here- after see, clinically speaking, the first stage of Inflammation. A familiar CHANGES OF NUTRITION. 35 example is the active hypersemia 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 con- traction. As a matter of observation, it is found that the condition varies according to the nature of the irritant employed, and, as F. Darwin sug- gests, 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 capil- laries 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 be- come elongated and tortuous; they have also been observed to become pouched at points, presenting 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, drawing blood from both arms of a patient who had a whitlow on one hand and not on the other. With regard to the immediate cause of the hypersemia of inflammation, it would appear to be due to an increased attraction exerted by the tissues of the inflamed part upon the blood circu- lating within its minute vessels. This theory, the germ of which may be found in the writings 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.—Besides the changes which are observed in the blood- vessels, in the course of inflammation, the blood itself undergoes certain alterations. The red corpuscles adhere together by their flat surfaces, 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 inflammation, the number of red corpuscles falls considerably below the normal standard. The white corpuscles appear to be increased in number in the blood of an inflamed part. It is, however, doubtful whether this increase be absolute or only relative, the number of red corpuscles, as has been seen, rapidly diminishing as the inflammation continues. The white corpuscles adhere to the sides of the vessels, and thus further increase the tendency to stag- nation of the circulating fluid. 36 INFLAMMATION. The proportion of fibrin in the blood is notably increased in inflamma- tion. It is estimated by Andral and (Javarret that its proportion may rise from 2\ in 1000 parts to 10 per 1000. The albumen and salts of the blood are somewhat reduced in amount, and the proportion of water somewhat increased by the inflammatory process. Owing to the changes in the constitution of the blood in inflammation, its mode of coagulation differs from that of blood in the normal state. The crassamentum or clot forms more slowly than in health, and is smaller and firmer in consistence. The slowness of coagulation and the increased 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 huffy 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 clipped. Other nutritive changes.—The modifications of the phenomena of nutri- tion due to inflammation are not confined to the blood and bloodvessels. Important changes take place in the parenchymatous tissues, and it is in- deed 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, accord- ing to Tirehqw, due to the fact that the cells of the part become enlarged, through the absorption of new material; this power of taking up an in- creased quantity of material is, according to the doctrines of the cellular pathology, inherent in the cells themselves, and not dependent upon any previously established modification in the vascular or nervous state of the part. According to Billroth, however, the first step is a distention and increased pressure in the capillaries, a larger quantity of blood plasma than in the normal state thus passing into the surrounding tissues, the swelling of which is therefore only a secondary phenomenon. The nervous tissues, likewise, doubtless undergo modification in the inflammatory process, and by a form of reflex action, which it would be foreign to the scope of this work to consider, react in time upon both bloodvessels and parenchyma. The swelling of the parenchymatous tissue, which is, according to Yir- chow, at first scarcely distinguishable from a true hypertrophy, and which may be conveniently designated as temporary hypertrophy, together with the accompanying vascular and nervous changes, correspond to what will be hereafter spoken of as the first stage of inflammation. Formative Changes : Lxjmph and pus.—The third series of changes to be noticed as due to inflammation, are Xhe formative, consisting in the formation of the substances known to surgeons as lymph and pits'. A mi- croscopic examination of inflamed tissue, made at a period varvin"- 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 -^^ of an inch in diameter, spherical or nearly so, pellucid, and colorless, or grayish- white. The origin of these cells, which are commonly called lymph cells or corpuscles, and which form the corpuscular clement of what is known as inflammatory 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 sub- stance exuded from the bloodvessels in a fluid condition and subsequently coagulated, is now almost universally abandoned ; and the three theories which at present chiefly divide the suffrages of pathologists are, (1) Yir- chow's, which looks upon the new cellular elements as the result of prolifer- FORMATIVE CHANGES. 37 ation1 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 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 condition ; the basis substance itself, as well as the previously ex- isting cells, thus taking a share in the new production.3 Inflammatory lymph, as ordi- narily observed by the surgeon, is a yellowish or grayish-white, semi-solid substance, which is somewhat elastic and semi-transparent, re- sembling a good deal the buffy coat of an in- flammatory clot. Chemically, it consists of fibrin with an admixture of oily and saline matters,4 while when examined microscopi- cally it is found to contain fibrils5 and cor- puscles (which have already been referred to) in varying proportion. The fibrillous, or, as Paget calls it, fibrinous element of lymph, is, according to that author, probably exuded from the capillary bloodves- sels in a fluid state, and subsequently coagulated; that there is in inflam- mation an exudation from the capillaries into the surrounding tissue, is, as we have already seen, in accordance with the doctrines of Billroth, and 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- 1.—Corpuscles and filaments in recent lymph. (Benxett ) 1 It would appear from the observations of Virohow 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 itself, undergoes similar changes, and thus from one, two or more new cells are devel- oped. 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 (Kcilliker), 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 amceba- form; they probably originate in the lymphatic system, from which they pass into the bloodvessels, wandering thence into the surrounding tissue, where they may be- come fixed, or whence they may wander back a^ain 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 Encyclopaedia of Surgery, vol. i. p. 35.) 4 According to Hoppe-Seyler, the lymph corpuscle contains glycogen while its power of movement continues, but npon 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 Roki- tansky into fibrinous and croupous lymph. Inflammatory lymph is, however, essentially the same under all circumstances, though the relative proportion of its constituents may vary in different cases. 38 INFLAMMATION. wandering which has been described as taking place in an inflamed part, the filamentary intercellular substance of the connective tissue itself gradu- ally 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 connec- tive-tissue cells, or from both sources, as well as from a return of basis substance to an embryonic condition, and the fibrinous element also from a transformation of the intercellular substance. Lymph is said to be absorbed, to be developed into new tissue, or to un- dergo various forms of degeneration. In some cases where absorption of lymph is supposed to have taken place, it is probable that the true patho- logical condition 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 y fj jf J *f h / actually disappear by a process which may f .-■/■,, 1/ ^'ho*^ tf l;\i be properly called absorption, as is not un- n y '^■■*°vfs^°**'? -/H *A frequently seen in cases of iritis. When f,'j ^ .-;1k""s /£°-'^'f k "'a lymph is absorbed, the lymph corpuscles !:f%c,^."" J^S??^ ,:'0y% maybe gradually utilized in the normal ivk C^^>-' -<--—-""'i^?*' Ji nutrition of the part, being converted into "" ^=-. r^^".^^ ' /'/' ordinary connective-tissue corpuscles, or --^£X^i-;'^ . ■:•".*•'■ *-^r-3^ niay possibly resume their migratory habits -■ - e=^r>:iirv&C°^'i"°'' and re-enter the circulation. In the devel- Fig. 2—Fibro-plastic and fusiform cells Opmetlt of lymph into IieVV tissue, it passes from recent lymph on the pericardium, through the fibro-cellular condition, be- Simllar ell. are found in granulations. d whjt>h jndee(l jt frequently does not (Bennett.) •' , T' . ., . ' \ . .•'. , advance. It is this material which consti- tutes the adhesions, bands, etc., which are so frequently met with after the inflammatory process has subsided. Lymph that undergoes development becomes vascular; new vessels appear in it, apparently originating from those in the surrounding tissues, and form a capillary network through which the circulation is carried on. It is somewhat doubtful as yet whether any production of nerve-fibres takes place in lymph that has become de- veloped into new tissue. The lymph corpuscles during the process of de- velopment pass through the forms which have been variously designated as plastic cells, fibro-cells, fibro-plastic or caudate cells, etc. (set; Fig. 2). Lymph may undergo various forms of degeneration, as the calcareous, fatty, or granular (the degenerated lymph cells forming the so called gran- ule 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 (lumphi- zation, lymphogenesis), then passing into the third stage, or that of pus formation (pyogenesis). Pu.< is a creamy, whitish-yellow fluid, sometimes having a o-reenish tin«-e thick, opaque, smooth, and slightly glutinous to the touch, with a fa?nt odor and slightly sweetish taste. It is of variable gravity, ran^ino- from 1.021 to 1.042, and is neutral or slightly alkaline in its "reaction.0 This description is to be understood as applying to what is called healthy or i 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 laudable pus, derived from an ordinary suppurating wound in a person of good constitution. Beside this form, surgeons speak of sanious pus (mixed or tinged with blood), ichorous pus (when it is thin and acrid), and curdy pus (when it contains cheesy-looking flakes). Muco-pus and sero-pus are of course pus mixed respectively with mucus and serum. Che- mically, pus contains water, albumen, pyine (which appears to be almost identical with fibrin), fatty matters, and salts. When formed in connection with diseased bone, pus has been found to contain 2^ per cent. of the granular phosphate of lime, and Mr. Coote, in Holmes's System of Surgery, quotes from a paper by I)r. Gibb, of Canada, ten cases in which pus presented a blue1 color fromcontainingthecyanuretofiron. Orange- colored pus has been observed by Delore, Broca, Verneuil, and other surgeons.2 Under the microscope, pus is fmind to consist of corpuscles floating in a homogeneous liquid (liquor puris). These corpuscles, which are variably termed pus corpuscles, pus globules, or pus cells, have a diameter ranging from uoV^n to ^V^th of an inch. They usually contain several nuclei, which become apparent upon the addition of acetic acid. With these pus corpuscles there are commonly found granular matter, shreds of fibrin, and disintegrated lymph corpuscles. The above description applies to what must be called dead pus cells,3 the living cells possessing the power of active amoeboid movement, and corresponding in every respect with the wandering cells already referred to. It is even more difficult to speak positively of the origin of the pus cell than 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 Fin. 3.—Pus corpuscles, a. From a healthily granulating wound. 6. From an abscess in the areolar tissue. e. The same treated with dilute acetic acid. d. From a sinus in bone (ne- crosis), e. Migratory pus corpuscles. (Kl.VDFLEISCH.) 1 Billroth and others speak of blue suppuration, resulting from the development of small vegetable organisms in the pus of a wound, but the coloring matter (which, according to Sedillot, pertains not to the pus-cells but to the liquor puris, and may also be found in the serum of the blood) has been isolated in a crystalline form by Fados, who calls it pyocyanine; it is believed by Roucher and Jacquin to be qf vegetable 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 de- velopment 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. According to Ledderhose, who gives for pyocyanine the formula CUHUN20, this substance is produced by a bacillus, not from pus, but probably from the secre- tion of the sweat-glands in the neighboring skin. Pfliige and Fraenkel doubt the pathogenic character of this bacillus, but Ledderhose has killed rabbits and guinea- pigs by injection of its cultures. 2 The color of orange pus is, according to Robin, due to the presence of hematine or crystals of hematoidine ; it is often, though not exclusively, met with in pyaemic cases, and is believed by Verneuil to indicate the existence of some grave constitutional condition, such as alcoholism, diabetes, phosphaturia, etc. I have myself, however, seen it so often in wounds of patients who were doing and continued to do perfectly well, that I have ceased to attach to it any prognostic significance. 3 The absence of glycogen may, according to Hoppe-Seyler, serve to distinguish the pus-cell from the lymph-corpuscle. (See note 4, p. 37.) 40 INFLAMMATION. rapid proliferation (luxuriation) of connective-tissue and other nucleated cells, while Cohnheim,1 on the other hand, maintains that the sole origin of the pus corpuscle is the migration bv amceboid movement of the white blood- corpuscles through the vascular walls.2 Prof. Strieker, 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-network, 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. It is the prevailing view with modern pathologists that the formation of pus is due to the presence of special organisms or microbes, of which Ernst enumerates more than a dozen varieties; this subject is full of in- terest, but it belongs rather to the domain of general pathology than to that of practical surgery, and I shall therefore not enter upon it here. Destructive Changes due to Inflammation___We have now traced inflammation through its nutritive and formative changes, eonsider- ing in succession the temporary hypertrophy from cellular enlargement, and the development of lymph and of pus, both forms of new material de- rived from pre-existing elements in the part inflamed. We have next to consider the inflammatory process as affecting already formed tissue in another way, namely, by degeneration or liquefaction. The application of an irritant, such as a blister, excites the inflammatory process, causing the formative changes which have been described, to occur beneath the cuticle. But the cuticle itself undergoes a change, and is thrown off as effete material, leaving a raw surface or abrasion. If the irritant act with greater intensity (as in the case of a burn), the destructive effect will be greater, the super- ficial 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, which may therefore be defined as the molecular death of a part. Ulceration and gangrene cannot be looked upon as essential parts of the inflammatory proress; thev 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 t<> the degree of irritation present, modifies the phenomena of natural textural life as regards function, nutrition, and formation; in each case the modifica- i Mr. William Addison, nearly half a century ago, maintained " that pus corpus- cles 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. P,ov. Med. and Sura. .■!,■«,.., vol. xi. pp. 247-253.) Dr. Augustus Waller, also, in 1*4 maybe considered as proved, but whether there is an absolute in- crease over the temperature of the central organs, is still uncertain. The sensations of the patient are of course unreliable in determining the amount of increased heat, and, it must be confessed, the impression conveyed to the hand of the surgeon cannot be implicitly trusted. Prof. S. D. Gross, however, by actuaf observation, repeatedly found the temperature of in- flamed parts to be above 100° Fahr., and in some instances saw the mer- cury in the thermometer rise to 105°, 106°, and even 107°. The cause of the change of temperature in an inflamed part is involved in some obscurity, and, as this question is rather physiological than surgi- cal, I shall not enter upon it further than to say that the chemical processes involved in nutrition may be supposed to cause the normal heat, and there- fore, when nutrition is disturbed in inflammation, the abnormal heat which accompanies the process; besides which, I see nothing unreasonable in the notion that nervous action may be more or less directly converted into heat—both being now recognized, in the language of the day, as correla- tive " modes of motion." The degree of elevation of temperature varies in different instances; it generally becomes less as the inflammation progresses, the thermometer falling to or near the natural standard when suppuration is established. It is scarcely necessary to add that in cases of gangrene the temperature of the dead part falls below the normal standard. The fourth symptom of the inflammatory process which demands atten- tion is modification of sensation, generally manifested as pain. The pain of inflammation varies with the nature of the part affected; thus in the mucous membranes it is of a scalding or itching character (as in conjunc- tivitis or in hemorrhoids), in the serous and synovial tissues it is sharp and lancinating (as in pleurisy or in inflamed joints), in the fibrous tissues it is dull, aching, or boring, and often worse at night (as in inflammation of bone or periosteum). A most distressing burning pain accompanies certain inflammatory lesions of the nervous system. The form of pain varies also with the stage of inflammation ; thus, on the approach of suppuration, it assumes a marked throbbing or pulsatile character, while a peculiar burn- ing pain sometimes heralds the approach of mortification. The pain is usually most severe when the inflammatory process is at its stage of greatest intensity ; but a sudden cessation of the pain of inflammation is always to be dreaded, as often indicating the occurrence of gangrene, as in the case of a strangulated hernia. The pain is usually greatest at the part where inflammation is highest, but this rule has notable exceptions. A whitlow may cause great pain in the axillary glands, while the pain of hepatitis is frequently referred to the right shoulder, and that of hip-disease to the knee. The nervous connections of the parts are usually concerned in this misplaced pain, though in some cases (as in whitlow) it is directly referable to irritation transmitted by the lymphatics. If there is not much pain in any case of inflammation, there is often great tenderness to pressure; as instances may be mentioned certain cases of inflamed joints, of mammitis, and of swelled testicle. The cause of inflammatory pain is doubtless due, in some measure to pressure on the nerves of the part due to the inflammatory swelling: but this cannot be admitted to be the sole or even the chief agent in producing the pain of inflammation, for there may be quite as much swellino- and course. 45 nervous compression from congestion or other causes, with comparatively little suffering; at the same time, compression has its effect, for it is found that the pain is usually greatest in those tissues and organs that admit of least external swelling. The principal cause, however, I cannot doubt, of the pain which attends inflammation, is to be found in a direct alteration of the condition of the nerve-fibres themselves. The pain of inflammation sometimes serves a good purpose in warning the patient to guard the affected part from external violence; it is increased or diminished by position and other circumstances which will be referred to again under the head of treatment. The fifth local symptom of inflammation is modification of function. This has been already mentioned in discussing the pathological division of the subject, and I trust that it was then made clear that altered function is an essential part of the inflammatory process. The functional disturbances due to inflammation are perhaps most evident in the case of the organs of special sense; thus deep-seated inflammation of the eyeball is commonly attended by frequent scintillations and flashes of light, at the same time that the power of vision may be impaired or entirely abolished. Again, in the case of an inflamed gland, the function of the organ is invariably affected, not only the amount secreted, but the properties of the secretion itself, being materially different from what they are in the normal condition. A slight degree of irritation, as has been already said, stimulates the function of secretion. In absolute inflammation it is temporarily suspended, and, when restored, the nature of the secreted material is usually markedly altered. The power of using an inflamed organ is much impaired or altogether lost. It is well that this is the case, as, were it possible to read with a seriously inflamed eye, or to walk with a knee affected with acute arthritis, it is evident that the prospect of recovery of the diseased part would often be materially lessened. Lastly, a prominent symptom of inflammation, and one which is always present, is modification of n utrition. In the first place, as has been already seen, there is a positive hypertrophy of the affected part. This may persist after recovery, or the part may resume its natural size, or may even con- tract and become as it were atrophied. Inflammation may be attended with induration (as in the so-called phlegmonous inflammation of the sub- cutaneous tissues), or it may be attended with softening, as in the case of bone ; or there may be a slow wasting from a kind of interstitial absorp- tion, without any softening or production of new material. Course—Inflammation is often spoken of as acute, subacute, or chronic. This classification may be, and doubtless is, convenient for certain purposes, but must, I think, be deemed incorrect. The inflammatory process is the same, no matter what duration of time it occupies, and no matter with what intensity its phenomena are displayed. It may, however, be properly re- garded as having three principal stages, through all of which it frequently passes, though it may be arrested at any period of its course. The first stage of inflammation embraces all the phenomena of the process from determination, or simple active hypersemia, to the temporary hypertrophy which has been so often referred to; the second stage is characterized by the appearance of lymph, and the third by the occurrence of suppuration. Besides these we may recognize certain subordinate stages, as that of serous effusion, that of ulceration, and that of gangrene. The effusive may be considered a modification of the ordinary second stage of inflammation, and is most marked in certain tissues, particularly the serous and synovial membranes. The ulcerative and gangrenous stages are very closely con- nected together, the former being met with on the surface of organs merely, 46 INFLAMMATION. while the latter may involve the entire thickness of the part in which it occurs. Many authors describe these, which I have called stages of inflam- mation, as separate forms of inflammation ; it seems to me, however, that the inflammatory process must be considered as essentially the same under all circumstances; and hence that it is more correct, and equally conve- nient, to look upon effusion, suppuration, ulceration, etc., as various stages of one process, their occurrence being dependent on extraneous circum- stances, such as the nature of the part affected, the intensity of the original irritating cause, or the general state of health of the patient in whom the pro- cess is going on, rather than on any essential diversity in the process itself. First stage.—The symptoms of the first stage are those which have already been considered, viz: changes of color, size, temperature, sensi- bility, function, and nutrition. Second stage.—The development of lymph is attended with certain modi- fications of these symptoms. Thus, the swelling may become harder, or there may be an cedematous condition of the subcutaneous tissue from the concomitant effusion of serum. The period at which the development of lymph (or, as the late Prof. Gross termed it, lymphization) occurs, varies with the tissue affected. In inflammation of the serous membranes, such as the pleura, arachnoid, or peritoneum, it occurs early ; in those of the mucous membranes seldom at all, and, when it does occur, at a compara- tively late period of the disease. Third stage.—The approach of the third or suppurative stage of inflam- mation is usually attended with marked changes. The redness becomes more dusky, and the swelling softens in a certain part of its area, the sur- rounding tissue being hard and infiltrated from the presence of lymph. The pain becomes pulsatile and throbbing. The cuticle over the softened por- tion may desquamate. If the part which is about to suppurate be of suffi- cient size, the presence of fluid beneath the skin may be detected by the touch recognizing fluctuation or undulation. Under other circumstances, pus may form in large quantities with very little warning, and without the occurrence of the symptoms -which have been described. In suppuration of mucous membranes, pus makes its appearance in the natural mucous coating of the part at an early period. The process of pointing of pus in the deeper- seated tissues will be considered when we come to speak of abscess. Ulceration.—The ulcerative stage of inflammation is that in which, in addition to the nutritive and formative changes that have been con- sidered, there is a destruction of previously existing tissue, which is thrown off by the process of ulceration. Ulceration may be defined as that part of the inflammatory process in which portions of inflamed tissue, degene- rate or liquefied, are thrown off in solution, or as very minute particles from the surface of the inflamed part (molecular death of a part). Some writers speak of ulceration with absorption of the degenerated material and thus consider that the process may occur in the deep-seated tissues of the body. I think, however, with Sir James Paget, that it is better to give this the name of interstitial absorption, which has been already re- ferred to as one of the nutritive changes of inflammation, and to restrict the term ulceration to the process as met with on free surfaces, where there is an absolute casting off of the degenerate and effete material. During the process of uloeration, or while an ulcer is spreading the affected tissue is surrounded by a circle which is inflamed, and which pre- sents the ordinary symptoms of the inflammatory process. The ed"es of the ulcer are more or less sharply cut, and often have a jagged or eroded an pearance. The destructive action may affect the subcutaneous tissue more than the skin itself, so that the latter may be undermined for a consider- GRANULATION AND CICATRIZATION. 47 able space around the ulcer. The surface of the ulcer itself, during its period of spreading, is covered with a gray or yellowish layer of dead material (a slough, in fact), which may be very thin, consisting of mere shreds and patches, or may be thick, soft, pultaceous, and elevated. The discharge is very slight, and more serous or sanious than purulent, though I doubt if there be any true ulceration without the existence of pus. When an ulcer ceases to spread, the symptoms of surrounding inflamma- tion subside, and the appearance of the ulcer itself undergoes corresponding changes. Its edges become firm from the infiltration of lymph, and are frequently hard and elevated. The face of the ulcer becomes clean, and the superincumbent slough comes away in flakes, or is apparently dissolved in the discharge, which, though still in very limited amount, approaches more closely to the character of normal pus. Granulation and Cicatrization.—The repair of an ulcer is a very interesting process. The ulcer contracts, while its surface becomes elevated above the edges, and presents a vascular appearance, seeming as if studded with numerous papillae ; the discharge becomes more profuse, and presents the Characters of healthy or laudable pus, while a faint blue line along the edge of the ulcer marks the gradual advance of the healing process. The papilla; which have been spoken of above are called granulations, and an ulcer is said to heal by granulation and cicatrization. Granulations ap'pear to consist of Pymph which has become organized into new tissue, and their peculiar conical shape corresponds with the loops or arches of new vessels1 which give them their great vascularity. Healthy or normal granulations are small, closely set, of a bright red color,- and covered with healthy pus ; they may, under various circumstances, be irritable, and bleed on the slightest touch, or they may be indolent and flabby, oedematous, as it were, from serous effusion, and may become detached in large masses as if they had not enough vitality to preserve their nutrition. The process of cicatrization does not begin until that of granulation is so far advanced that the edges of the ulcer appear depressed as regards its sur- face, the granulations themselves being healthy and covered with a layer of laudable pus. In the process of cicatrization, the granulations become smooth and flat, and become covered with a thin bluish-white pellicle, which is the new skin. Cicatrization almost always proceeds from the surface to the centre, though occasionally islets of new skin are apparently formed in the middle of a granulating surface. Within the faint-blue line of new-formed skin, may be traced a line of deeper red than the ordinary color of the ulcer, consisting of granulation tissue in the transition stage of epithelium. The closure of the ulcer is promoted also by the contraction of the newly-formed tissue, probably owing to the transformation of the lymph or granulation cells into fibrils, which occupy less space, and therefore occasion the shrink- ing which is characteristic of all cicatricial tissues. In some instances con- traction of the ulcer appears to precede the development of granulations. The healing of an ulcer leaves a permanent scar, which undergoes various changes subsequent to its formation. Thus the scar of a burn may continue to contract for many months after the process of healing is complete, giving rise in this way to marked and sometimes very distressing deformity; there would appear indeed in some cases to be an actual development of elastic tissue in a scar, so persistent and irresistible is its contractile tendency. A scar, when first formed, is usually redder than the surrounding skin, or it may be bluish if deeply congested ; in the course of time its color fades, 1 This is denied hy Hamilton, of Edinburgh. See foot-note in Chapter vii. (Repair of Wounds). 48 INFLAMMATION. so that an old scar is commonly of a dead-white color. Cicatrices gra ally assume the appearances of the surrounding textures, and at the sa time their deep attachments become stretched and loose, so that the niobil of the part is after a time measurably restored. A scar, however, ne Fio.4.—Vertical section through the edge of a granulating surface in process of repair, a. Secretion of pus. b. Granulation tissue lembryonic tissue) with capillary loops. whos« walls consist of a layer of cells longitudinally disposed ; their thickness decreases as we approach the surface, c. Cicatri- zation beginning at the base (spindle-cell tissue), d. Cicatricial tissue, e. Fully formed cuticle, its middle layer consisting of grooved cells. /. Young epithelial cells, g. Zone of differentiation. (Rindfleisch.) entirely gains the characters of the tissues around it, and is always more susceptible to injury, and more likely to give way and again become the seat of the ulcerative process, than the tissue in its immediate neighborhood which has never been affected. It has been pointed out by Mr. W. Adams that cicatrices formed in childhood grow with the part in which t hey are placed. Gangrene.—As abrasion (see page 40) is like but less than ulceration, so may gangrene or sloughing be considered as ulceration on a larger scale, and the gangrenous as closely allied to, and, indeed, but a modification of, the ulcerative stage of inflammation. Where an irritant has acted with great intensity, so large an amount of tissue may be deprived of vitality that mor- tification, gangrene, or sphacelus is said to have occurred. The'term spha- celus is sometimes limited to gangrene of the soft tissues ; that of the bones is called necrosis. A mortified, gangrenous, or sphacelated part of the body can only be removed by the process of granulation, and when isolated by that process is said to be a slough, wThile the part affected is spoken of as sloughing. Gangrene may occur at a late stage of the inflammatory process, »»r it may be primary, from the intensity with which the original irritant has INFLAMMATORY FEVER. 49 acted. The onset of gangrene is marked by a peculiar dusky redness of the inflamed tissues, by the formation of bullae, filled with a dark fluid, and by the part, from being hard and tense, becoming doughy to the touch ; the pain becomes burn- ing, and the temperature of the part falls. When mortification has actually occurred, the skin becomes mottled, purple, greenish, or even black; sensibility and motion are lost; the part may seem shrunken ; it becomes colder than the surrounding tissue; and a peculiar odor is emitted, due to gaseous exhalations from the gangrenous mass. This description is to be understood as ap- plying to what is known as moist gangrene; there is another form of mortification, which results principally from arterial obstruction, and to which the name of mummification or dry gangrene is applied ; this presents some- what different characters, and will be con- sidered in its proper place.1 When the spread of gangrene has been arrested, whether from the irritant which caused it having, as it were, spent its power. or from having reached tissues which have more vitality, and are therefore more capable of resisting the gangrenous process, what is called the line of demarcation is formed. This appears as a line of more or less vivid redness (sometimes preceded by a circle of minute vesicles), which immediately surrounds the morti- fied part. This line of demarcation is soon replaced by a line of granulations called the line of separation, and the slough is gradually pushed off, as it were, by the formation of new tissue beneath it, a healthy surface remaining when the dead part is finally removed. It is usually said that the separation of a slough is effected by ulceration ; but, as justly re- marked by Mr. Coote, it is rather by the process of granulation ; there is no destruction of living tissues beyond the slough, but the spread of the gan- grene is immediately succeeded by the reparative process of granulation. Inflammatory Fever.—We have now considered the local manifes- tations of the inflammatory process in its ordinary stages, those of deter- mination, lymph development, and suppuration, as well as in its subordi- nate stages or varieties, those of effusion, ulceration, and mortification. The next subject for discussion is the effect of the inflammatory process on the general condition of the patient, or, in other words, the constitutional symp- toms of inflammation, which may be grouped together under the name of inflammatory, sympathetic, or symptomatic fever. Traumatic fever is another name which has been used, but which is objectionable, because the condition signified may accompany inflammation which is entirely inde- pendent of traumatic causes. Surgical fever would be a good name, but for the confusion which might arise from the term having been applied (by Fio. 5.—Complete sphacelus of foot and ankle. The sloping line of separation well shown ; studded with granulations. (Miller.) 1 If a part dies quickly, while full of blood and other fluid matters, the gangrene which ensues is of the moist variety ; when the death is slower, the gangrene is dry. The occurrence of moist gangrene is chiefly determined by the existence of venous congestion. 4 50 INFLAMMATION. Sir J. Y. Simpson) to an entirely different affection, viz., pyaemia.1 It is probable that no inflammation, however slight, is altogether unattended with symptomatic fever, though the course of the latter may be so mild as not to excite attention. An ordinary attack of inflammatory fever comes on usually within twenty-four hours of the first development of the inflam- matory process. Air. Pick, of St. George's Hospital, found that in seventy- three cases of inflammatory fever following wounds, the first symptoms were usually manifested about the second or third day, sometimes later, but never after the fifth day, and occasionally within the first twenty-four hours. As the inflammatory process itself usually does not commence until about twenty-four hours after the reception of a wound, it will be observed that this statement corresponds pretty closely with that above given as to the commencement of the symptomatic fever. The onset of the fever may be heralded by various abnormal sensations; there may be an absolute rigor, or merely chilliness, alternating with flushes of heat. The pulse rises in frequency, varying from seventy or eighty, to even one hundred or one hundred and twenty beats in the minute. It may be full but compressible, or hard and tense though small, as in cases of peritonitis. The respiration is usually hurried and somewhat oppressed, and there may be evidences of positive congestion of the pulmonary structures. The tongue may be red, dry, and clean, or coated with a white fur : the mouth feels clammy, and the patient suffers from thirst. The bowels are usually confined, and the secretions vitiated. The urine is scanty and high-colored. There may be frequent micturition, or, on the other hand, retention of urine, requiring the use of the catheter. The skin is hot and dry, the temperature having been found to rise as hi rupted, and in fatal cases death may be preceded by hiccough, subsultus tendinum, and coma. In what is called the irritative, form of inflamma- tory fever, the nervous system is especially implicated. The ordinarv sthenic, inflammatory fever may pass into the asthenic, or the latter may be present from the first. It is somewhat remarkable that the violence of an attack of inflammatory fever seems to bear no relation to the severity of the wound to which it may be due ; a compound fracture may cause less According to Kocher and Ogston. however, pyaemia and simple acute inflammation are identical affections, differing only in intensity. EXTENSION OF INFLAMMATION. 51 constitutional disturbance than a slight flesh wound. There appears, how- ever, to be a general correspondence between the intensity of the local symptoms of inflammation and the severity of the symptomatic fever. An attack of inflammatory fever usually reaches its height in about two days from the time of its commencement. Its whole course occupies from two to six days. If the inflammation be arrested in its first or second stage, the symptomatic fever subsides gradually; the occurrence of suppuration is usually marked by a rapid diminution of constitutional disturbance. Thus a case is given by Mr. Pick, in which, on the evening of the third day after a primary amputation for injury, the temperature was 104.6° Fahr., the pulse 110 and throbbing, the tongue furred, the face flushed, and the wound dry and glazed; the next day the temperature had gone down to 100°, the pulse was 84, soft and compressible, and the wound was discharging healthy pus. * Prof. Billroth has described a secondary fever, which begins on or after the eighth day, and he believes that this may occur without any pri- mary fever having existed. It would appear, however, from the observa- tions of Mr. Pick, that there has in these cases always been a primary attack, though it may have been so slight as easily to elude observation. The primary may run into the secondary fever, the temperature not sink- ing to the normal standard during the interval; and in any case, if the fever last beyond the eighth day, it is to be considered as secondary. The occurrence of secondary fever, which appears to be due to the absorption of septic material, is always to be looked upon with apprehension, as indi- cating a grave change in the local or constitutional condition. It may be followed by deep-seated or widespread inflammation of the connective tissues, or may herald the approach of serious surgical diseases, such as erysipelas, hospital gangrene, or pyaemia. Genzmer and Volkmann de- scribe an "aseptic" form of traumatic fever, met with in cases of subcu- taneous injury, etc., in which the increase of temperature is the only symptom which can be recognized. Inflammatory fever, as has been said, usually subsides with the occur- rence of suppuration. The formation of pus is, however, often attended with marked perturbations of the nervous system, consisting in repeated and sometimes prolonged rigors, alternating with flushes of heat. In cases where suppuration is unduly prolonged, and the patient in consequence weakened, an irritative type of fever is developed which is called hectic. In this form of fever the pulse is more rapid than in health, small, and compressible; the eyes are abnormally brilliant, and the cheeks flushed. The patient emaciates and becomes very feeble. The symptoms are usually most marked in the evening, when the skin is hot and dry, a condition which is often succeeded in the course of the night by colliquative sweating. The "cold sweat" of hectic often alternates or coexists with profuse diar- rhoea, both tending to exhaust the patient. I believe that hectic is never established in cases of suppuration until the pus finds a vent externally: as long as an abscess is unopened, hectic will not occur. Extension of Inflammation__Inflammation may extend from one part of the body to another \>\ continuity or by contiguity of structure. An instance of the former mode of extension may be found in the spread of tracheitis to the larynx or to the bronchi; an instance of the latter, in the extension of inflammation from the pleura to the lung, or from the bones of the skull to the membranes of the brain. Extension by metastasis is prob- ably rarer than is commonly supposed; the example usually given, viz : the occurrence of epididymitis in the course of gonorrhoea, is, I believe, no metastasis at all, but a simple extension by continuity of structure. Inflam- 52 TREATMENT OF INFLAMMATION. mation may spread by means of the lymphatics, as in adenitis of the axillary glands following upon a whitlow. The blood may indirectly be concerned in the spread of inflammation ; as in cases of embolism, where the detached fragment or clot is carried along in the circulation, and acts as a foreign body. With regard to the agency of the nervous system in the spread of inflammation, it is proved that, by a form of reflex action, a part may be rendered more susceptible to the influence of external irritants, and may thus be predisposed to the occurrence of the inflammatory process; but any more direct agency of the nervous system is still a matter of doubt (see p. 41). Terminations of Inflammation__What I have called the stages of inflammation are often spoken of as terminations of the inflammatory process; thus it is said to end in the formation of lymph, in suppuration, in ulceration, in gangrene, etc. But I think it will appear from what has been already said, that these cannot strictly be looked upon as terminations, for the reason that in each case the inflammation must go on in the sur- rounding parts until the whole process of ulceration, of mortification, etc., has been completed. Strictly speaking, inflammation can only end in reso- lution (a gradual return to the healthy state), or in the death of the patient, when of course inflammation must cease with the termination of other vital processes. Even metastasis, which is often called a termination of inflammation, is, as far as the part originally inflamed is concerned, really an instance of resolution. The other so-called terminations do not end the process, but are mere events in its course. In resolution the symptoms of inflammation more or less quickly disap- pear. The pain and heat diminish, the swelling subsides, and the redness slowly fades away. The function of the part is gradually restored, and its nutrition slowly returns to the normal state. The dilated bloodvessels contract, the stagnant blood-corpuscles are pushed on, and absorption, which has been to a great extent suspended, begins again with renewed activity, helping to remove the adventitious, newly-formed material. Re- solution may be complete, or only partial; in the latter case the part that has been inflamed remains permanently altered in structure. Thus inflam- mation of the eye may cause permanent opacity of the cornea, and gonor- rhoea a troublesome form of urethral stricture. CHAPTER II. TREATMENT OF INFLAMMATION. Before entering upon the subject of the treatment of inflammation, it may be well to reiterate what was said in the opening of the first chapter, that this process is not to be looked upon as a disease, to be met with lancet and calomel on the one hand, or with brandy and opium on the other but is to be viewed as a modification of natural processes, which may often be conducted to a favorable termination by judicious management on the part of the surgeon, or by bad treatment may easily be made to end in destruc- tion of the part affected, if not in the death of the patient. In dealing with any individual case of inflammation, the surgeon should bear in mind the nature of the pathological changes which are in progress and administer or withhold his remedies with due regard to both the^local and the general condition of his patient. HYGIENIC TREATMENT. 53 Prophylactic Treatment.—The first object of the surgeon, in every case, should be, if possible, to remove the cause of inflammation; and in many instances, if this, which constitutes the prophylactic treatment can be accomplished, nothing more will be requisite. Thus the extraction of a speck of dust from the eye, or of a splinter of wood from the hand, will often prevent the development of inflammation, or at least allow its subsidence if already present. In any case the removal of the cause (if this can be ascertained) must be first effected, even if the inflammation continue and require further attention : the first step in the cure of cystitis dependent on vesical calculus, is to remove the stone ; a strangulated hernia cannot possibly be relieved while the constriction remains. Curative Treatment__When the cause of inflammation cannot be detected, or after its removal, when that can be effected, what may be called the curative treatment comes into play. This may be divided into ■—I. The Hygienic treatment; II. The Local Remedial treatment; and III. The General or Constitutional Remedial treatment. I. The Hygienic Treatment of inflammation is first to be considered. It is, I think, often more important than either of the others. Rest is frequently all that is necessary in the management of even severe injuries (as in many cases of fracture), and by itself will often suffice to prevent the unavoidable and needful inflammation from passing beyond the stage which is required for the repair of the lesion. No severe inflammation, whether from injury or from disease, can be successfully treated without the en- forcement of rest, and even in slight cases it will be of great use in pro- moting and hastening a satisfactory issue. If an important organ (as the brain or lung) be inflamed, the patient should invariably be confined to bed ; the same rule should be adopted for severe inflammations of less vital parts. In many cases local rest will be sufficient; thus a patient with an inflamed hand or elbow may walk about with the part supported by a sling, when a similar affection of the foot or knee would necessitate confinement to bed. Functional rest of the inflamed part is very important. No one should attempt to read with an inflamed eye, to talk with an inflamed larynx, or to write with an inflamed hand. Subsidiary to rest is position: this is a point which should be carefully attended to in the treatment of inflammation. All the symptoms of in- flammation, and especially pain, are aggravated by a dependent position; hence an inflamed leg or arm should be supported on, or even elevated above, the level of the rest of the body. Even in cases which do not re- quire confinement to bed, great comparative ease and comfort may be afforded by supporting the affected part with a suitable splint or sling. An apparent exception is to be noted in cases of inflammation about the head. Every one who has had a headache may know from his own ex- perience that it is relieved by lying down, and it is a mistake to suppose that the impulse of blood to the head is diminished (as in the case of the foot for instance) by elevating the organ; the reason is obvious—the brain must have a certain supply of blood, and if the force of gravity be brought into play by elevating the head, the heart compensates for it by increased rapidity of action; hence in inflammation about the head, the recumbent should be adopted in preference to any other posture. The diet of a patient suffering from inflammation is a matter of great importance. Until within a comparatively recent period, surgeons united in recommending what was called " absolute diet" in cases of inflammation, and this was usually pretty much equivalent to no diet at all. As regards this matter, I cannot but think that medicine is more advanced than surgery ; very few physicians at the present day, I imagine, try to starve 54 TREATMENT OF INFLAMMATION. out pneumonias, and I cannot see why the principles which are now almost universally adopted in the management of internal inflammations should not be equally applicable in the case of the external, or of the internal when produced by traumatic causes. Up to a certain point, the inclinations of the patient* may be looked upon as a pretty safe guide ; no man suffering from a violent inflammation, whether external or internal, has an appetite for heavy meat meals or for stimulating sauces, and it may reasonably be concluded that this is a prompting of nature to avoid such condiments. But we must be cautious not to run into the other extreme. It has been, I think, clearly shown by the researches of modern investigators, that in addition to the waste of tissue which accompanies the inflammatory process, there is a large expenditure of force (as evidenced by the great elevation of temperature),1 and it is but rational to suppose that this waste and expendi- ture ought to be compensated by a supply of easily assimilable food. As to to the results met with in practice, it of course becomes any one sur- geon to speak with great modesty and hesitation ; I can, however, honestly aver that I have met with better success in the treatment of inflammation upon this plan, than I did when I habitually directed low diet, according to the rules still laid down in many surgical works. I do not doubt but that a patient suddenly attacked with inflammation may subsist for a short time— perhaps a day or two—upon barley-water or water-arrowroot, and proba- bly this meagre diet may be more suitable than the heavy meals which he has been in the habit of consuming; but I believe that he will do better still by taking in small quantities and at frequent intervals some light and easily digestible but nutritious article of food. The diet which I myself am in the habit of ordering for patients suffering from severe inflammation, is milk, in quantities varying according to the age of the individual, and at longer or shorter intervals according to the facility with which the process of diges- tion is accomplished. I have supported adult men for weeks at a time upon milk given by the teacupful (f^iv) every hour, and I know of no single article of food which is adapted to so great a variety of cases as is this. In the more advanced stages of inflammation, beef-essence and different forms of strong broth may be appropriately made to alternate with milk in the patient's diet. As a ireneral rule, once in two or three hours is often enough to give food in cases of inflammation, though when only small quantities can be taken at a time, the interval of course must be shorter. With regard to the administration of alcoholic stimulants no positive rule can be given. In the early stages of inflammation they are usually not required, and should not be given in any case unless the state of the pulse or other circumstances indicate that they are needed. The onset of delirium (unless the brain itself be involved in the inflammation) is almost always an indication for stimulation. The quantity to be given should not commonly exceed three or four fluidounces of brandy or whiskey, or half a pint of wine, in the course of twenty-four hours; I have, how- ever, in the later stages of inflammation (as in some cases of severe burn), occasionally increased the amount to as much as a pint and a half of brandy in twenty-four hours, and am sure that I have saved life by doing so. In many of the milder cases of inflammation, or what clini- cally might be called chronic inflammation, malt liquors may be advanta»-e- ousiv substituted for the stronger forms of stimulant. Other hygienic measures, which will suggest themselves to the intelli- gent practitioner, should likewise be adopted. Thus, the room which the i See, in relation to this point, Rev. Dr. Haughton's " Address on the Relation of Food to Work done hy the Body," etc. {Brit. Med. Journ., Aug. 1868.) LOCAL TREATMENT. 55 patient inhabits should be well ventilated, and well warmed in winter. The patient's skin should lie kept in a good condition by bathing, or, when this is not practicable from the severity of the attack, by frequent spong- ing. The body-linen and bedclothes should be kept clean, and all excreta and other sources of pollution removed as quickly as possible. The patient should not be exposed to a glare of light, nor, on the other hand, should the room be kept so dark as to be gloomy. All sources of annoyance, as from noise, etc., should be removed, and while no fatigue, either mental or bodily, should be permitted, the patient, if the nature of his case allow it, should be entertained by light literature (being read to, in preference to reading himself), or by cheerful conversation. I have dwelt at some length on these topics, from a conviction that they are too often neglected. The duty of the surgeon is not ended when he has dressed a wound and prescribed a dose of medicine. The hygienic management of a patient is of equal, and, in many cases, of even greater importance than the mere surgical and medical treatment, which yet, too often, exclusively engrosses the practitioner's care and attention. II. The Local Remedial Treatment of inflammation is next to be described. The applications to be considered under this heading may be classified as cold, heat, moisture, local narcotics, stimulants, astringents, antiseptics, alteratives, counter-irritants, cauterization, local bleeding, in- cisions, operations, compression, and friction. 1. Cold.—There can be no question as to the efficiency of cold as a local remedy for inflammation. It is indeed spoken of by Mr. Erichsen as a means of preventing inflammation. Its utility is, perhaps, most obvious in cases of wounds or sprains, though it is likewise of great service in many cases of inflamed joints, and other in- flammatory affections not dependent on traumatic causes. It may be ap- plied in the form of dry cold, or in con- nection with moisture. The use of dry cold has been especially recom- mended by Esmarch, and is particu- larly useful where the skin is un- broken, and where it is desirable to avoid the maceration and other dis- comforts Unavoidable with Wet appli- Fl(J 6._Mediatelrl.igation. con prepared for use. cations. Ice may be applied in India- (After petitgand.) rubber bags of various shapes, or in thin metallic boxes, which Esmarch considers preferable for hospital use. The intensity of the cold may be modified by interposing a folded towel or handkerchief between the bag or box and the skin. This is an admi- rable way of applying dry cold, but it must be carefully watched, lest it produce gangrene (as I have seen in one case, through the neglect of the attendant), or, on the other hand, lest the the ice melt, and the application be no longer a cold one. A safer and an equally efficient method of apply- ing dry cold is that described by M. Petitgand under the name of Mediate Irrigation. This surgeon makes use of a flexible tube of vulcanized India- rubber, sixteen or twenty feet long, and about half an inch thick, the tube- wall being only about a line in thickness. This tube he applies to a limb like a simple spiral bandage, holding it in place by a few turns of a roller, or he makes a coil of the tube, adapting it to the head, to a joint, to the female breast, or to any other part as required, keeping it in 56 TREATMENT OF INFLAMMATION. Fio. 7.—Coil applied to head (After Petitgand.) position by a few strips of bandage passing alternately above and below the contiguous spiral coils. Through this tube water is made to flow from a reservoir above the patient's level, of anv temperature that may be desired, and by testing the tem- perature of the water as it leaves the tube, the surgeon can easily ascertain to what degree he has succeeded in reducing the tempera- ture of the inflamed part itself. The application of cold to the head, by this method, is recommended by Sir Spencer Wells, in all cases of trau- matic fever, as a means of reducing the temperature of the whole body. " Leiter's coil" acts in the same manner as Petitgand's apparatus, the only difference being that the tubes are make of flexible metal. In cases where there is an open wound, the relaxing properties of moisture are often advantageously combined with cold, and here the ordinary form of irrigation by means of a funnel-shaped reservoir with a stop-cock, or even a skein of thread or a piece of lamp-wick acting as a siphon, may be conveniently employed. (Fig. 9.) In other cases, simply covering the part with a cloth, which is wetted from time to time with cold water or an evaporating lotion, will be sufficient. Cold is useful in the early stages of inflammation, when it will greatly assist in promoting resolution, or in the latter stages, when the parts are flabby and relaxed, and when, especially in the form of a cold douche, it is often extremely useful. Cold is not generally desirable when suppura- tion is impending, though I have in at least two instances succeeded in causing the absorption of an abscess by the use of dry cold. Cold is rarely useful when suppuration has actually occurred, and should always be avoided in cases of impending or present gangrene. 2. Heat is seldom employed in cases of inflammation, except in conjunc- tion with moisture. If dry heat should be desired, it may conveniently be applied by M. Petitgand's method of "mediate irrigation," by merely substituting warm water for cold. 3. Moisture, in connection with warmth, is a very valuable remedy in inflammation. Heat and moisture may be applied in a variety of ways. Warm-water dressing is very useful in cases of suppurating wounds; the water may be applied unmixed, or it may be medicated by the addition of laudanum, lead-water, muriate of ammonium, alcohol, carbolic acid, corro- sive sublimate, etc. An excellent dressing may be made by diluting alcohol with an equal quantity of water. In applying any form of warm- water dressing, the lint or other material which is saturated with the water sho ild be covered with oiled silk, or with waxed paper, so as to prevent evaporation. Hot fomentations are often very useful in the early stages of inflammation ; they are commonly directed to be made by dipping flannel in hot water, and applying it to the affected part, renewing it from time to time. This is very apt to cause maceration and desquamation of the cuticle, and hence the application, when repeated several times, becomes extremely painful; to obviate this, I am in the habit of using warm olive LOCAL TREATMENT. 57 oil instead of hot water, a substitution which does not impair the efficiency of the remedy, while it renders it much more agreeable to the patient Moisture may, in some cases, be advantage- ously employed by the process of steaming; this may be done by means of an ordinary funnel, inverted over the hot liquid and di- rected towards the affected part, or by means of the atomizer, now so much used in affections of the throat and air-passages; in employing the latter apparatus, the tem- perature of the vapor can readily be regu- lated by varying the distance of the instru- ment from the part to which the current is applied. One of the most common, and certainly one of the most efficient, modes of applying heat and moisture is by means of a poul- tice. I cannot unite in the crusade against this most useful remedy in which some surgeons have en- gaged : there can be no doubt that poultices have often been abused, and that in certain stages of inflammation they are capable of effecting much harm, but the same objection might lie against any other remedy, and cannot justly de- tract from their real merit under suitable circumstances. The best materials for making poultices are flaxseed-meal and the powdered bark of the Ul- musfulva, or slippery elm; in an emergency, however, a very good substitute may be found in corn-meal or bread crumbs.1 The poultice should be mixed with hot water, and should be of an even consistence, so as to admit of being spread smoothly. Flaxseed or elm poultices should not be more than two or three lines in thickness, and should receive a thin coating of olive oil before being applied ; this is to prevent their adhering to the surface of the body, and breaking in removal. Corn- Fig. 8.—Mediate irrigation: a. Supply-tube acting as a siphon ; b. Coil applied to lower extremity ; c.Waste pipe with stop-cock. (After Petitgand.) -Irrigating apparatus 1 Thin sheets of cotton wadding, saturated with a decoction of. carrageen, or Irish moss, have been recommended as a substitute for poultices by M. Lelievre, a French pharmaceutist, and may often be employed with Satisfaction. 58 TREATMENT OF INFLAMMATION. meal or bread poultices must be made about half an inch thick, and maybe kept from the surface by the interposition of a piece of thin and soft muslin. Poultices should be made freshly, immediately before application, and should invariably be covered with oiled silk or waxed paper, to prevent evapora- tion. It"is well for the surgeon to give his pergonal attention to the making and application of poultices, as the patient's comfort greatly depends on the care and neatness with which this is done, and very few nurses will be found to do it properly, unless constantly watched by the medical attend- ant. The fermenting poultice, which is an excellent application to slough- ing sores, mnv be made by mixing wheat or corn flour with half its weight of yeast, and" gently warming it until it begins to swell. A convenient substitute is the porter poultice, made by incorporating common porter with the ordinary flaxseed poultice. Warmth and moisture, in whatever form used, are especially to be recommended in the second stage of inflam- mation, and when suppuration is impending. When the discharge of pus is fully established, poultices are, as a rule, not desirable, while in the gan- grenous stage, as already said, a fermenting or porter poultice is often the best application that can be made. 4. The local use of narcotics is often advisable in cases of inflammation : thus laudanum mav be applied with advantage to inflamed wounds and irritable ulcers, while a belladonna plaster is often of great service as an application to inflamed lymphatic glands. Anodynes may be used in connection with cold (as in the common mixture of Goulard's extract and laudanum), or with heat, as in the form of a hop poultice, often employed in cases of peritonitis. 5. Stimulants and astringents may be used with advantage in the local treatment of inflammation ; as instances, I need only refer to the constant employment of nitrate of silver in inflammations of the mucous membranes, conjunctivitis, gonorrhoea, etc. ti. Antiseptics have lately acquired great importance in the treatment of inflammation, especially when resulting from wounds. I have for many years made use of the antiseptic properties of alcohol and of the perman- ganate of potassium in the local treatment of surgical affections, but the articles which are most valued at the present time are the bichloride of mercury and carbolic or phenic acid, the merit of introducing which into common use is undoubtedly due to Sir Joseph Lister, of London, though its properties were previously familiar to chemists, and though it had occasionally been employed in surgery before he directed general attention to the subject. Prof. Lister's mode of applying this antiseptic agent will be described when speaking of the treatment of wounds. 7. Alteratives, particularly the preparations of mercury and iodine, are of great value in many subacute and chronic inflammations. I constantly apply equal parts of mercurial and belladonna ointments to inflamed glands and joints. 8. < 'ounter-irrHants are sometimes advantageously employed in the local treatment of inflammation. This is denied by some modern writers of hi"-h authority, but, for my own part, I cannot doubt that great benefit is occa- sionally derived from the practice. I have seen a bubo disappear without suppuration, under the application of blisters, or of tincture of iodine (ap- plied, as advised by Furneaux Jordan, around, but not over, the inflamed part) and even if this desirable consummation be not attained, the use of the counter-irritant may serve to hasten the formation of pus, and thus shorten the time required for treatment. The advantages derived from the use of sinapisms and turpentine stupes, employed as derivatives like- CONSTITUTIONAL TREATMENT. 59 wise seem to me unquestionable. The principal counter-irritants employed by surgeons are blisters, issues, setons, and moxa. 9. Cauterization is a remedy which may prove serviceable in certain cases of inflammation. The actual cautery may be advantageously applied to serpiginous chancroids, while caustic in some form is frequently employed by the surgeon in the treatment of ordinary ulceration. 10. Local bleeding, by cupping or leeching, is now much less often resorted to than formerly. The general question of the abstraction of blood in in- flammation will be considered under the head of constitutional treatment, but I may say here that I cannot doubt that local bleeding is sometimes of use, and may prevent fatal disorganization in an important organ ; I firmly believe that I have seen it do good in cases of traumatic peritonitis. 11. Incisions, to relieve tension, are often of great use in cases of inflam- mation ; after incising the tunica albuginea in cases of swelled testicle, I have observed the pain to disappear almost instantly, and the duration of the affection to be very materially shortened. In diffuse inflammation of the subcutaneous areolar tissue, and in phlegmonous erysipelas, numerous incisions are often absolutely essential to check the spread of the morbid process, or even to save life. 12. Surgical operations of more or less gravity are frequently required in the treatment of inflammation. Sequestra must be extracted, and gan- grenous parts cut away, before the attending inflammation can be expected to subside. In this place I may refer to'an old suggestion which has been recently revived, to treat or to attempt to prevent inflammation of joints by ligating the main artery of the limb above the part affected. If inflamma- tion were solely dependent upon the condition of the blood and bloodvessels, this might seem reasonable enough ; but when we consider that the function of the vessels in inflammation is merely ministerial, and that the increased quantity of blood in an inflamed part is not the cause of, but is itself caused by, the inflammation (see page 35), it will appear, I think, that this plan of treatment is as incorrect in theory as it is in fact dangerous in practice. 13. Compression is often of great use in the treatment of inflammation. It is especially in the later stages, when the parts are left flabby and relaxed (as in indolent ulcers), that pressure is of service, thought it is occasionally useful at a much earlier period. I know of no better treatment for car- buncle than methodical pressure by the concentric application of strips of adhesive plaster. 14. Finally, friction is frequently a valuable remedy in cases of inflam- mation. The French have systematized the use of friction, under the name of massage, to a much greater extent than has been done in England or in this country. Slow and gentle rubbing with warm olive oil, or even with the hand alone, is often very soothing in the early stages of inflammation, and may be of positive benefit in assisting to promote resolution : I have found it of great use in the treatment of mammitis, and it may also be em- ployed in cases of sprain; in the later stages of inflammation, again, fric- tion may prove a valuable adjunct to the employment of the cold douche. III. Constitutional Treatment.—We have next to consider the General or Constitutional Remedial treatment, which, except in very slight cases, is not less important than the local measures adopted. Depletion.—Until within a comparatively recent period, any surgeon, be- ing asked what was the most important remedy in the treatment of inflam- mation, would have answered unhesitatingly that it was bleeding ; and the expression was constantly used that venesection was the surgeon's " sheet- anchor", in dealing with inflammatory affections. Xow I suppose that there is no fact better established in the whole circle of therapeutic observation, 60 TREATMENT OF INFLAMMATION. than that certain of the symptoms of inflammation (especially pain) can be relieved by the abstraction of blood; and hence, when the prevailing doc- trines of pathology taught that the essence of inflammation was an altered action of the vessels, accompanied bv a morbid richness or " inflammatory" state of the blood itself, we cannot wonder that our predecessors thought that reason and experience united in showing that loss of blood was the surest way of curing inflammation. More careful observation, and more just views of pathology, have, however, now shown that, in the words of Mr. Simon, alreadv quoted, "A part does not inflame because it receives more blood. It receives more blood because it is inflamed." Hence, bleeding does not remove a cause of inflammation ; it merely obviates one effect of the inflammatory process. Here, as in the matter of diet, the practice of physicians has, it must be confessed, being more enlightened than that of surgeons. Few would indeed, at the present day, bleed for the inflamma- tion attending a compound fracture, but it is still taught in many of our surgical text-books that venesection is absolutely required in the treatment of injuries of the head, and of wounds of the chest. Now it seems to me but reasonable that we should adopt the same principles in the management of traumatic inflammations that we do in dealing with those of idiopathic ori- gin, and hence that venesection should not be resorted to in the treatment of surgical affections, except for its immediate mechanical effect in relieving a vital part, the functional or structural integrity of which is in imminent danger. For example, bleeding may be necessary in a case of traumatic as in a case of ordinary apoplexy, when the darkly congested face, turgid lips, distended veins, and laboring pulse, give warning that the brain is op- pressed, and unless speedily relieved, will cease to act; or when a wound of the lung is followed by great dyspnoea, pain, and oppression, the loss of a little blood may be of benefit, just as it would at the outset of an ordinary pneumonia presenting similar conditions. Even under these circumstances, I believe that local bleeding, by cupping or leeching, will be usually better than venesection ; and it should always be considered that the loss of blood is an evil, which may indeed be preferable to a greater evil, but which is never a positive good. The experience of any individual surgeon should of course be referred to with great modesty, but I may say that in twenty- eight years of hospital practice, I have never had occasion to employ vene- section, and have directed local bleeding in but very few cases. If general bleeding be ever resorted to, it should be done in such a way as to produce the greatest effect with the least loss of blood ; hence the patient should be in a sitting posture, and the blood drawn in a full stream from a free open- ing in a large vein, generally the median-cephalic. Arterial sedatives are often useful in the treatment of inflammation, either after the abstraction of blood or as a substitute for it. I am sure that I have derived advantage from the Veratrum virile in eases of traumatic peritonitis, given in the form of the tincture in doses of three or four drops every three hours. It is a powerful remedy, and its use should be stopped, or at least suspended, when a decided impression is made in reducing the frequency of the pulse. Aconite has been similarly used with advantage. The preparations of antimony were formerly much used in the management of inflammation. They are best adapted to the first stage, and seem to have a decided effect in preventing the further progress of the inflammatory process. This property of antimony has been called the " anticipatory an- aplastic" effect of the remedy. Tartar emetic, which is perhaps the best form in which the drug can be given, may be employed in doses of one- sixteenth to one-twelfth of a grain, repeated every two or three hours. It may be conveniently combined with opium and diaphoretics. In anv form, CONSTITUTIONAL TREATMENT. 61 antimony is a remedy which should be used with great caution and watch- fulness. It should never be given for a trivial inflammation, and should be avoided in cases of children or old persons, or in patients of feeble consti- tution. Purgatives have been much employed in the treatment of inflammation. As there is very often a loaded state of the bowels at the beginning of the inflammatory process, a brisk cathartic may be of service, and will often act in some degree as a derivative, thus being additionally beneficial. I usually, however, prefer those purgatives which are milder in their action, such as rhubarb, colocynth, etc. If the tongue be much furred, as is often the case, a blue bill, followed in twelve hours by a dose of castor-oil, will often answer as well as any other prescription. The bowels should not be allowed to become constipated during the progress of an inflammation, but should be relieved from time to time by the aid of enemata, or of small doses of magnesia, rhubarb, or other laxative. There can be no necessity, however, for violent purgation, especially as the articles of food usually given in inflammation produce comparatively little fecal matter. Diaphoretics and Diuretics are of undoubted utility in cases of inflam- mation. They promote secretion, diminish the violence of the attending inflammatory fever, and perhaps act in some degree as derivatives as well. The spirit of nitrous ether may be used as a diuretic, in combination with the neutral mixture or the solution of acetate of ammonium. Digitalis also may be used in the same way. Opium is an invaluable remedy in the treatment of inflammation. It is a direct promoter of what we have seen to be an important condition of recovery, viz: physiological and functional rest.1 Of all single remedies it is probably the most useful. It may be given in the form of Dover's powder, or in a diaphoretic mixture. Some such combination as the fol- lowing will be found well adapted to a great many cases:— R. Morphiae acetatis gr. j ; Spirit, aetheris nitrosi f5ij; Sacchari albi 3ij ; Aquas camphorae f§iijss; Liq. ammonii acetatis f^iv. M. R. Morphiae acetatis gr. j ; Spirit, aetheris nitrosi 15ij : Syrupi acaciae i3v.i : Aquae aurantii riorum fjiij ; Mist, potassii citratis f'iv. M. A tablespoonful of either of these mixtures may be given every two or three hours, during the height of the inflammatory fever, and either will be found to unite very satisfactorily the properties of an anodyne, febri- fuge, and antispasmodic. Alteratives.—Certain substances, which are usually classed together as alteratives, have an undoubted efficacy in many cases of inflammation. Mercury is much less often prescribed now than formerly, and there can, I think, be no question that our ancestors used it too frequently and in too large doses. Still, I cannot but believe that it does exercise an influence, particularly over the second stage of inflammation, or that attended with the production of lymph. It is, however, like blood-letting and antimony, a dangerous remedy, and a positive evil, though it may on occasion do good. It should, I think, be reserved for cases in which an important organ is endangered, and should even then, be used with great caution and reserve. It is especially adapted for inflammation of fibrous and serous membranes, such as the meninges and the peritoneum. It should be given in small doses, as one-sixth to one-quarter of a grain of calomel, or half a grain of blue mass, and may be conveniently combined with opium and ipecacuanha, Iodide of p>otassium is a valuable remedy in certain forms of inflamma- 1 The action of opium in inflammation is physiologically explained by its property of arresting osmosis and cell-hypertrophy. 62 OPERATIONS IN GENERAL. tion, especially of the fibrous tissues, such as bone or periosteum. The usual dose is from five to ten grains, three times a day. Sarsaparilla was formerly much used as a remedy for inflammation, and has been highly recommended by so eminent an authority as Mr. Erich- sen. I cannot "say that I have ever seen any effect, good or bad, from the use of this drug, and I look upon it as almost, if not quite, inert. In the form of the compound syrup, it may, however, be used as an elegant menstruum for the exhibition of the iodide of potassium. Tonics are of great use, particularly in the later stages of inflammation. Among the best are cod-liver oil, iron,1 quinia, and the various prepara- tions of Peruvian bark. They are almost always required to support the system under the exhausting influences of profuse suppuration or the occur- rence of gangrene. The mode of treatment which I have endeavored to indicate as suitable in cases of surgical inflammation, is essentially similar to that which has been called the " restorative" in cases of pneumonia, etc. It may be neces- sary in any case to bleed, to give antimony or mercury, to make free inci- sions (entailing additional loss of blood), and to resort to other depressing modes of treatment; but, hand in hand with these measures, which, though for the time needful, are all in themselves evils, the surgeon must bring his restoratives as well; he must supply abundance of food, easily assimi- lable but nutritious, and must in some cases pour in alcoholic stimulus besides, even at the very time when he is applying leeches and administer- ing purges. Finally, in many chronic inflammatory conditions, the sur- geon must give up treating the disease, and devote himself to improving the state of the patient's general health; when it will often be found that, the constitutional condition having been amended, the inflammation itself will have spontaneously disappeared. CHAPTER III. OPERATIONS IN GENERAL; ANESTHETICS. In its widest sense, a surgical operation may be considered as embracing every manipulation which forms part of the surgeon's practice, from the application of a poultice or the introduction of a catheter, to the extraction of cataract or amputation at the hip-joint; and as the surgeon will have occasion to do many slight and trivial operations in proportion to the number of those which are more important, it is well for him to cultivate a habit of neatness and accuracy in matters which, though apparently trifling in themselves, are yet very influential in determining the comfort or discomfort of his patient. Qualifications of the Surgeon.—Every surgeon should aim to be, if not a brilliant, at least a neat and successful operator ; and vet the mere use of the knife and other instruments constitutes but a small part of the operative surgeon's duty. It is of much greater importance for him to be a careful and accurate diagnostician, and to have that knowledge of pathology and therapeutics which will enable him to decide whether° an operation i The muriated tincture of iron may be conveniently combined with the solution of acetate of ammonium, and in this form may sometime!- be given with advantage even in the earliest stages of inflammation. ° RESULTS OF OPERATIONS. 63 should or should not be performed, and, when the operation is over, to con- duct the after-treatment of the patient in a judicious manner, than merely to be able to do the operation in a given number of seconds, or to shape his incisions in peculiarly graceful curves; in other words, what is techni- cally called judgment is more essential to a surgeon than mere operative skill. The day is happily past when it was thought right for a surgeon to be a mere hand-worker under the direction of another, and it is becoming more and more established as a rule, that no one is justified in operating in any case, unles his own practical knowledge and judgment tell him that in that case the operation should indeed be performed. No one can hope to be a successful operator who is not thoroughly grounded in anatomy ; it is rather mortifying, after amputating a thigh, to be unable to find the femoral artery without loosening the tourniquet, or to dissect around the neck of the scapula in an attempt to cut into the shoulder-joint; yet the surgeon must not, in his zeal for the cultivation of anatomy, neglect the other branches of medical science. The importance, and even necessity, of a thorough knowledge of practical anatomy, can, indeed, scarcely be over- rated ; yet it is more essential for the surgeon to be well versed in pathology and therapeutics (or, in other words, to be an accomplished physician), than it is for him to know the attachments of every muscle in the body, or all the possible variations of arterial distribution. Circumstances Affecting Results of Operations.—The success of an operation does not, however, by any means depend altogether upon the skill of the surgeon. Every one must know, from his own experience, that during certain periods, or in certain classes of patients, the gravest operations have been followed by favorable results, while among a different set of patients, or at other times, death has seemed almost inevitably to follow even the slightest use of the knife. Various circumstances influence the results of operations. Age.— The age of a patient is a very important point for consideration ; children, beyond the earliest period of infancy, as a rule, bear operations well. This is doubtless owing, in some degree, to their freedom from con- stitutional diseases and from those depressing habits of life which are often acquired with approaching maturity, but is probably also due, in great measure, to the happy carelessness and freedom from anxiety which is characteristic of childhood. A child neither looks forward to an operation with dread, nor is oppressed with care for the future, when the operation is over. While an operation may and often must be performed without regard to the age of the patient, the surgeon should, as much as possible, avoid either extreme of life. The new-born infant has less power of recu- peration than the older child, while, on the other hand, an operation might be perfectly proper and suitable if performed on a strong and vigorous man in the prime of life, which would be little better than butchery if practised on one tottering on the verge of the grave. Especially as regards what are sometimes called operations of election or of complaisance, is the age of the patient to be considered ; in the case of a young and healthy woman whose beauty was marred by the contracted cicatrix of a burn, it might be not only permissible, but even imperative, for the surgeon to resort to a plastic operation for her relief, though perhaps that operation might entail long confinement, and might even seriously endanger life; but to practise such an operation on a withered crone, who could at best hope for but a few months or years of existence, would be supremely ridiculous, were it not absolutely improper. The general state of a patient1 s health exercises an important influence upon the success of an operation. Hence it is observed that those whose 64 OPKRATIONS IN GENERAL. occupation has been of an exhausting or otherwise unhealthy character, bear operations worse than those whose lives have been spent under more favorable circumstances. This is one reason why serious operations, such as amputations, are less successful among the inmates of our large city hospitals (for their patients are usually derived from the least healthy class of inhabitants), than among hearty agriculturists who bring to the operat- ing-table a constitution unimpaired by either the diseases or the vices of city life. Hence, too, if, before a battle, soldiers have been worn down by long marches and insufficient food, they will bear the operations which may be rendered needful by the conflict of the day, worse than if their general condition had been unimpaired by antecedent suffering. The condition of particular organs should be carefully inquired into in estimating the chances of success after any operation. No one would think of operating, unless for absolute necessity, upon a patient whose lung con- tained a large tuberculous cavity, or who suffered from serious organic dis- ease of the heart. Our army medical officers can testify to the unfavorable influence upon the results of operations exercised by the chronic diarrhoea and attendant ulceration of the bowels, from which so many of our soldiers perished during the late war, and every practical surgeon knows how slight are the chances of success, after even a comparatively slight operation, in a patient suffering from affections of the urinary organs, and especially from diabetes or the chronic forms of Bright's disease. The condition of pregnancy may be considered a contra-indication to any operation which can be properly postponed until after confinement. The temperament and idiosyncrasy of the patient exercise an influence upon the success of operations. Some races, as the Chinese, the individuals of which appear to be of a lymphatic temperament, seem to tolerate opera- tions which among other nations would be extremely fatal. An individual of a cheerful, light, and buoyant disposition, has, I think, a better chance of recovery from a given operation than either one who is gloomy and who fears the approach of death, or one who calmly and philosophically makes up his mind to either alternative. The hygienic conditions to which a patient is subjected before, at the time of, and after submitting to an operation, exercise a marked influence upon its success or failure. A man who is half starved is in no condition to undergo a serious operation, nor, on the other hand, is one who habitually overtaxes his digestive powers by too much indulgence in rich and stimulat- ing food, or who exhausts his nervous system by intoxication. Those who have long been exposed to a close and impure atmosphere, or who have con- stantly inhaled noxiousexhalations.whether of animal or of vegetable origin, are less able to undergo an operation than those who have lived in large and well-ventilated apartments, and in a healthy locality. The hygienic sur- roundings of the patient at the time of operation are also of great import- ance. Except in case of necessity, no operation should be done in very hot weather, or during the prevalence of an epidemic, especially of such diseases as erysipelas or hospital gangrene. The room in which an operation is done should be large, well-ventilated, and, in cold weather, well warmed- it should be kept scrupulously clean. The army surgeon must, indeed' practise his art in cold and rain, or under the full rays of the summer sun- his operations are eminently those of necessity, and must be done under circumstances which he cannot control. But in civil hospitals, and in most instances in private practice, the operator can secure such surroundings as are needful for his patient's welfare. In certain operations, as in those which involve extensive exposure of the abdominal cavity, these external RESULTS OF OPERATIONS. 65 conditions are of extreme importance; I should not consider any man justified in performing ovariotomy in a cold, a damp, or a foul room. After an operation a patient should be placed in the best possible hygienic conditions. As every operation (except, perhaps, the very slightest) is fol- lowed necessarily by inflammation, what has already been described as the hygienic treatment of the inflammatory process should be immediately adopted. While the digestive powers should not be burdened by the admin- istration of heavy or irritating food, the patient must not be starved, under the impression that such a course can prevent the development of inflamma- tion. I knowT of no food better adapted to the condition of a patient imme- diately after an operation than milk, and hence I commonly direct milk-diet under such circumstances. If it seem to oppress the stomach, or if there be any tendency to vomiting, the milk may be diluted with one-fourth or one- third its bulk of lime-water. The after-treatment of a patient who has sub- mitted to an operation should be conducted in a clean and well-ventilated room, sufficiently large to allow from 1500 to 2000 cubic feet of space for each bed which it may contain. In estimating the cubic capacity of a room, it is unfair to consider great height as compensating for limited dimensions in other respects; and the surgeon should not allow beds to be crowded close together, because a very lofty ceiling brings the cubic capacity of the apart- ment up to the standard. Too much stress cannot be laid upon the import- ance of free ventilation for a surgical ward; one of the greatest merits of the pavilion system of hospital construction, which was so largely adopted during the late war, was the almost impossibility of making pavilions, especially with ridge ventilation, close, as they would invariably have been had the patients and hospital attendants found it practicable to make them so. There is room for skepticism as to the practical utility of many of the plans for artificial ventilation which have been proposed of late years; it may be doubted whether any- thing can compensate for the ab- sence of large windows upon both sides of a ward. While the sur- geon would of course not wish to expose his patient to a draught, and would therefore take care not to place a bed immediately beneath an open window, yet it is always better to run the risk of having too much than by any chance to have too little fresh air. Not only should over-crowding be avoided in a hospital ward, but the surgeon should adopt means to avoid all sources of zymotic poisoning from contagious emana- tions, whether gaseous or otherwise. For this purpose, the ward should be kept scrupulously clean ; all excreta should be removed as soon as pos- sible, and if this cannot be at once done, disinfectants, and especially those containing chlorine or carbolic acid, should be freely used. The ward should contain no unnecessary furniture; there should be no pictures or engravings hung about the walls, and bed-curtains should be strictly for- bidden ; these all serve as nests to collect any noxious exhalations which may permeate the atmosphere. If any case of erysipelas, pyaemia, tetanus, or hospital gangrene occur in a ward, the affected person should be at 5 66 OPERATIONS IN GENERAL. once removed to an isolated apartment, or at least separated as widely as possible from other wounded patients; the>e diseases, if not directly con- tagious, at least do harm by impairing the quality of the surrounding air. Great care should be exercised in dressing wounds, to avoid all possible sources of infection. For this purpose the " ward carriage," introduced into hospital practice in this country by Dr. Thomas (j. Morton, is an admirable contrivance. (Fig. 10.) The most important feature of this apparatus is an arrangement by which water is drawn from a portable reservoir, so that every wound can be washed with a stream of fresh, running water. If sponges be employed, every patient should have his own, and they should be frequently renewed; a pledget of tow or absorbent cotton forms a good substitute for a sponge, and has the advantage that its cheapness permits it to be thrown away after once using.1 The lint, or other material em- ployed in dressinir wounds, should never be used twice ; hence the great importance of finding inexpensive substitutes, as has been ingeniously done by Dr. Addinell Hewson and Dr. D. H. Agnew, in introducing paper lint as a cheap surgical dressing. It i> well for the surgeon to wash his own hands frequently in going from case to case, and he should enforce scrupulous cleanliness on the part of his dressers and nurses; these may seem trivial matters, but it is upon the attention paid to just such things as these that the well-doing of a surgical ward often depends. Causes of Death after Operation—A patient may be in a good condition for an operation, the operation itself may be most skilfully exe- cuted, the hygienic conditions by which the patient is surrounded may be excellent, and yet the apparently best-grounded hopes of success may be disappointed by death following the operation, .sometimes with great rapidity There is no subject which has greater claims for the surgeon's consideration than that of the causes of death after operation. These causes may, of course, be very various; but there are some which seem to be so immediately connected with the circumstances of an operation having been performed, as to merit special mention in this place. Shock.—A patient may die from the direct shock of the operation. As will be explained more fully when speaking of shock as one of the consti- tutional effects of external violence, there is a positive physical affection known as shock, to be distinguished from the mental emotion and pertur- bation which sometimes receive the same name. Hence it is erroneous to say, as is often done, that the occurrence of shock is prevented by the use of anaesthetics ; the sensation of pain is indeed done away with, and much of the mental anxiety which was formerly the cause of intense agony before and during an operation2 is no doubt avoided ; but there is a powerful cause of positive physical depression which, in some degree, attends every operation, and to obviate which, no certain means, as far as I know, have yet been found. A patient may come to the operating-table in a perfectly composed and even cheerful frame of mind, remain in a state of complete amesthesia during the whole operation, and yet, without any great loss of blood or other obvious cause, die within a few hours after its termination from a purely physical condition of shock. The shock of some operations is much greater than that of others • thus a large amputation, as through the thigh or at the hip-joint, is attended with more shock than one through the leg or arm ; the removal of a tumor i Mr. Sampson Gamgee employs an artificial sponge made of absorbent cotton and cocoan u t-fi bres. 2 A most vivid and painful description of the sutfering under amputation before the days of anaesthesia, may be found in a letter from Prof. Wilson to Sir J. Y. Simpson (Obstet. Mem. and Contrib., vol. ii., and Acupressure, p. 566.) " CAUSES OF DEATH AFTER OPERATION. 67 in the immediate proximity of the base of the skull is attended with more shock than the taking away of a much larger mass from another part of the body ; and there is sometimes observed in the comparatively slight opera- tion of castration, a marked failure of the pulse at the instant of dividing the spermatic cord. I have no doubt that shock is often increased by the patient becoming chilled during an operation ; hence I always insist that all of the body except the immediate seat of operation shall be kept covered with warm blankets, and in cases of a very severe character I often have hot cans applied even on the operating-table itself. The treatment of shock, after an operation, is to be conducted by keeping the patient as quiet as possible, in a recumbent position, and endeavoring to promote reaction by internal and external stimulation. Sinapisms may be applied to the chest, abdomen, and inside of the thighs, and hot bricks, or bottles filled with hot water, should be placed under the bedclothes, so as to produce an equable warmth of temperature. In hospitals, metallic foot-warmers are usually provided, and should always be kept in readiness. While the body is to be kept warm, free access of air to the lungs must be secured by open- ing the windows, if necessary, and even by fanning. Frictions are often directed, but are of somewhat doubtful utility, as rather tending, in them- selves, to exhaust the patient. Brandy and ammonia may be given by the mouth, if the patient is able to swallow, and if not, may be administered by the rectum, or ether may be given by subcutaneous injection. A stim- ulating enema of oil of turpentine, beaten with yelk of egg, is often very serviceable. Lund employs enemata of quinia and camphorated tincture of opium, while quinia is also recommended as a prophylactic by Easley, and by McOuire, of Richmond, Va. The internal administration of belladonna is advised by Dr. Reinhard Weber, and that of digitalis, in large doses, by Dr. Brunton. Atropia, hypodermically, is employed by Dr. Stimson. As soon as partial reaction has taken place, a full dose of morphia should be given, and this, I think, is preferably done subcutaneously. A sixth or a quarter of a grain of morphia, injected under the skin, is more quickly ab- sorbed, and therefore more prompt in its effects, than a much larger dose exhibited in the ordinary way. It is surprising how much benefit a pa- tient suffering from shock will derive from even a quarter or half an hour's natural sleep ; a cup of strong beef-tea, well seasoned with pepper, should be in readiness to be administered as soon as the patient awakes. As there is always risk of reaction running into violent traumatic or in- flammatory fever, it is well for the surgeon, as far as possible, to use ex- ternal stimulation, and those internal remedies which are more evanescent in their effects, such as ammonia, rather than brandy or other preparations of alcohol. It is sometimes necessary to delay the dressing of an operation wound on account of the occurrence of shock ; under such circumstances, when reaction has occurred, the dressing should be effected as simply and with as little pain as possible. I have seen grave injury accrue from the introduction of sutures in the case of patients just recovering from the shock of an operation. The older writers described what they called "secondary or insidious shock," which might come on subsequently to, or independently of, the occurrence of the primary form. This, which is the most fatal variety of shock, is developed at an interval of from several hours to one, two, or more days after an operation ; it is, I believe, in most if not in all cases, depend- ent on the formation of heart-clots,1 which may cause death by directly 1 Fayrer has particularly insisted upon the frequency of death after operations from the formation of fibrinous coagula in the right side of the heart, and believes that a malarious state of the blood acts as a predisposing cause of such coagulation. 68 OPERATIONS IN GENERAL. embarrassing the action of that organ, or more remotely by fragments be- coming detached and plugging the arteries of the brain or lungs, a fatal result being thus caused by the process known as embolism. Either pri- mary shock or great loss of blood would, by diminishing the force of the circulation, tend to increase the risk of this formation of heart-clots. The most promising mode of treatment consists in the free administration of ammonia, either by the mouth—five grains of the carbonate being given every half hour—or by the intravenous injection of diluted aqua ammoniae, as recommended by Cotton, of Edinburgh. Hemorrhage at the time of or subsequent to an operation is very often the cause of death; nothing can be more erroneous than to assert, as is sometimes done, that a moderate loss of blood during an operation is bene- ficial to the patient. Every drop of blood is valuable, and though we may not go so far as to say, with some of our predecessors, that blood is the liquid life of the body, there can be no question that there is no surer way of making an operation unsuccessful than to neglect even apparently slight hemorrhage. The absolute amount of blood lost during an operation is not so immediately the cause of danger as the rapidity with which the bleeding occurs. I have seen an amputation at the hip-joint, in which one or at most two or three jets from the femoral artery, together with the shock of the operation, produced a state of collapse from which the patient never rallied ; while I have seen a much larger quantity of blood lost in other operations, where the flow was more gradual, and in which the resulting depression was scarcely perceptible. Intermediate or intermediary hemorrhage, as it is sometimes called, is apt to occur when the patient begins to react from the state of anaesthesia, and after he has become warm in bed, from vessels having escaped the surgeon's notice when the force of the circulation was depressed ; hence, if there has been much shock, or if the operator has been unable to detect the mouths of vessels which yet he knows must have been divided, it is well to postpone the final closure of the wound until after com- plete reaction. Secondary hemorrhage may come on at any period between the occurrence of reaction and the ultimate healing of the wound; it may result from the premature detachment of ligatures, either from their having been in the first place insecurely applied or from subsequent inflammatory changes in the coats of the vessels, or it may be due to the occurrence of slouching, opening vessels which had not been divided, or at a part higher than the point of ligation. The treatment of surgical hemorrhage will be described when considering wounds of arteries. A patient may die after an operation from the violence of the inflam- mation or of the accompanying traumatic fever, which, except in slight cases, necessarily ensues. The symptoms and treatment of these conditions have been sufficiently discussed in Chapters I. and II., and need not be again referred to here. A patient may die after an operation from causes previously in existence which the operation has not been able to remove, or which it has unavoid- ably aggravated; as an instance of the former contingency, I may refer to the deaths from hectic and suppurative exhaustion which follow excisions of joints; of the latter, death from pre-existing peritonitis after the opera- tion of herniotomy. The unfavorable influence of renal disease upon the results of operations was pointed out many years since bv Dr. Chevers and Verneuil has recently shown that a similar unfavorable influence is exercised by diseases of the liver and other viscera. Fatty degeneration of the bowel is believed by Furneaux Jordan to be a cause of^persistent vomiting and death after many operations, particularly those upon the abdominal or pelvic organs. PREPARATION OF PATIENTS FOR OPERATION. 69 Finally, patients after operation are frequently carried off by various affections, which, while not necessarily dependent on the performance of an operation, yet follow the use of the knife with sufficient frequency to entitle us to consider the operation as their exciting cause. They are chiefly ery- sipelas, pyaemia, hospital gangrene, diffuse inflammation of the areolar tissue, and, more rarely, tetanus ; these will all be referred to in their proper place, and are mentioned now merely to complete this view of the subject. Scarlet fever is regarded by English surgeons as a serious and not uncom- mon sequel of operations, but I have seen nothing in my own experience to lead me to consider its occurrence other than a coincidence. I have, how- ever, several times seen erythema follow operations, and have known it to be mistaken, on the one hand for scarlet fever, and on the other for ery- sipelas.1 An operation wound, as any other wound, may become the seat of diphtheritic deposit, accompanied by low constitutional symptoms which must be treated on the same principles as guide the practitioner in treating a case of diphtheria occurring under other circumstances. Preparation of Patients for Operation.—In view of the great dangers which are thus seen to accompany every operation, it certainly behooves the surgeon, whenever it is practicable to do so, to take measures as far as possible to avoid those dangers ; and hence the importance of attending to the preparation of a patient for operation. In many cases, unfortunately, there is but little time offered for pre- paration ; a patient with a severe compound fracture requiring immediate amputation, or one who is suffocating with pseudo-membranous croup, can- not wait for any course of preparatory treatment, but must take the chance, if an operation be deemed proper, without regard to the state of his general health ; yet even under the most unfavorable circumstances, the morale of the patient may often be improved by a few soothing and encouraging words, while, if there be much physical depression, a warming and stimu- lating draught may suffice to render him better able to submit to the ordeal of the knife than he would be otherwise. Consent of Patient.—A vcy important question, and one which admits of grave doubt, is as to how far a surgeon may be justified in assuming the responsibility of operating, when a patient is unwilling to give his assent. Of course no one would think of performing any operation of complaisance without the full consent of the patient, but where an operation is imme- diately necessary to save life, as in a case of strangulated hernia or of in- jury requiring primary amputation, the surgeon's position is one of great perplexity. If the patient be a child, the consent of the parents is quite sufficient; if an adult, but unable from intoxication or other cause to judge for himself, the consent of a near relation or friend who is competent to decide the mat- ter should be obtained ; in the absence of the parents or other relatives, the surgeon must place himself as it were in lo< o parentis, and do fearlessly what he thinks best for his patient. If, however, an adult in full possession of his faculties refuse an operation, or if, in the case of a child, the parents refuse for him, I cannot think it the duty of the surgeon to persist in ope- rating under such circumstances; he should remember that spontaneous recoveries do occasionally occur in the most unpromising cases, and that, on the other hand, death may very likely follow the most eligible and best- executed operation ; and when the true state of the case and the imperative necessity (humanly speaking) of the operation have been clearly and fully 1 See an interesting paper on " Eruptions after Recent Operations," by Mr. E. C. Stirling, in St. George's Hospital Reports, vol. x., 1879. 70 OPERATIONS IN GENERAL. explained, I cannot think that the surgeon should be held responsible for the consequences of obstinate refusal on the part of the patient or his friends. Preparatory Treatment.—The requisite consent having been obtained, in any case that admits of a short delay, it will be desirable to occupy a few days in preparatory treatment. I do not consider it ever necessary to deplete a patient, whether by bleeding or violent purging, before an opera- tion. The diet should be regulated, such articles as are known to be irri- tating and difficult of digestion being avoided, while the intestinal and other secretions are brought into a healthy condition by the use of mild laxatives, etc. In the case of hospital patients, who are often brought from a con- siderable distance to undergo an operation, it is proper to wTait until they have rested from the fatigues of travelling, and have become somewhat accustomed to their new quarters and the new faces that surround them ; as they are frequently in a state of debility, it is often essential to put them upon a course of tonics, with nutritious food, and even free stimulation, before they can be brought into a condition for operation. In the case of diabetic patients, Fischer advises the preliminary administration of carbolic acid, in small but frequently repeated doses. It is usually proper, the night before an operation, to administer a mild cathartic, such as a dose of castor oil, and the next morning to empty the lower bowels by an enema; this is especially important in case the rectum or adjoining parts are to be involved in the operation, but is desirable under all circumstances, as it obviates the need of a fecal evacuation for some days afterwards, and thus saves a good deal of fatigue and exposure, which are always undesirable, and occasionally very prejudicial. In the case of a woman, the operation should not be done during a menstrual period or during pregnancy, if the exigencies of the case admit of post- ponement. The patient should be loosely clad, and, if much bleeding be anticipated, should wear an additional garment, which can be removed after the operation. No solid food should be given, if an anaesthetic is to be used, for several hours previous to its administration. All preliminary arrangements should, if possible, be completed before the amesthetic is given, as there can be no doubt that prolonged anaesthesia exercises an unfavorable influence upon the success of an operation. The rule upon this point must, however, vary with the individual case ; thus if an opera- tion on a woman will necessitate exposure of the person, it is obviously better that the anaesthetic should be administered before the patient is re- moved from her bed, and that the final arrangements should be postponed until she has become unconscious. Preliminary Arrangements.—The surgeon should himself see that the patient is in good condition for the operation, and that all necessary pre- parations have been made; the operating-table should be firm and solid, of a height sufficient to prevent the necessity of the surgeon's being fatigued by stooping, and surmounted by a thin mattress covered with oil-clotlTand a clean sheet, or by folded blankets; it should be placed in a good li"-ht (a northern exposure is usually considered the best), and should be provided with pillows, and with additional coverings to throw over the patient. The best time for an operation, in this region of country, is in the fore- noon ; if it be a dull day, or if the operation be unavoidably performed in the afternoon or evening, the surgeon must see that proper arrangements have been made for providing artificial light. The necessary instruments should be carefully arranged in the order in which they are to be employed, placed in a suitable tray, and covered with a clean towel until the time has come to use them; it is a good rule to think over beforehand all the steps of the operation and the possible contingencies that may arise, and to pro- OPERATION. 71 vide the proper instruments accordingly. The surgeon must instruct each of his assistants as to the duties he is expected to perform, and each as- sistant should, as far as possible, confine himself to his own duties and not interfere with those of the rest. For most operations two or three as- sistants are sufficient, and few can require more than five, or at most, six. One should take charge of the anaesthetic ; another hand the instruments ; a third support the part to be operated on ; a fourth be ready to suppress hemorrhage, etc. All the needful dressings, sponges, basins, bandages, etc., should be arranged where they can be readily reached. Having seen to all these preliminaries (the patient being in position, anaesthetized, and the part to be operated on divested of superfluous hair and clothing, and thoroughly cleansed), the surgeon is ready to begin the operation. It may seem almost superfluous to say that on such an occasion the surgeon's per- sonal demeanor should be quiet and dignified; eccentricities of costume and conduct should be avoided, the perfection of an operation consisting greatly in the simplicity of its concomitant circumstances. Though the operator and his assistants may, from natural disposition or from long habit, come to look upon an operation as an every-day affair, it must be remembered that, to the patient and his friends, it is an occasion fraught with the deepest interest and most anxious solicitude; hence, both for his own reputation and out of regard to the feelings of others, the surgeon should repress manifestations of excitement, and still more of levity. It may seem needless to dwell so long upon this matter, and I do it only because I have frequently seen these reasonable rules neglected, simply through thoughtlessness. I know of one instance in which, after the first incision was made, an assistant was obliged to remove the operator's hat, lest it should fall into the blood, and in which almost all the bystanders continued to solace themselves throughout the operation with pipes or cigars. Operation.—The steps of an operation should all be planned in advance, and the less talking that is done after the knife has been once taken in hand, the better. Time is not quite as important now as it was before the days of anaesthesia, but it is certainly not good for the patient if the surgeon be obliged to stop and hold a consultation at each stage of the operation. The incisions should be made as much as possible in the lines of the natural depressions of the part, so that they will come together without undue tension or deformity -,1 they should be sufficiently free, and made with a firm pressure, sufficient to carry the knife through the skin and superficial fascia at the first cut; at the same time the operator should never be in a hurry, and should not be misled by any idea of fancied boldness into stabbing rashly into his patient's body—a course which is never requisite, and which may occasionally lead the surgeon much deeper than be has any wish or intention of going. Hemorrhage during an operation should be prevented by the use of a tourniquet or Esmarch's bandage, by the pressure of an assistant's fingers, or by quickly catching each vessel as it is cut with self-fastening haemostatic forceps ; it is even sometimes desirable to pause and secure each artery as it is divided. When the operation is completed and all oozing of blood checked (which may be facilitated, after tying the vessels, by exposing the wound for a short time to the air, or by pouring over it a stream of cold or of quite hot water, or by gently sopping it with alcohol), the edges of the incisions should be brought together with sutures. This is best done while the patient is still in a state of anaesthesia, though if there have been much shock or hemorrhage, it should be deferred until 1 Dr. Packard advises that the skin should be cut very obliquely, believing that a smaller cicatrix may be thus secured than could be otherwise obtained. 72 OPERATIONS IN GENERAL. reaction has taken place. The sutures may be made of ligature silk, of ordinary thread, or of metal. The lead suture has the merit that it will not bear a very great strain, and thus acts as a kind of safety valve against undue tension. In other cases, and especially in certain plastic operations, silver or unoxidizable iron wire forms a better material than lead, and when very close approximation is required, the harelip pin may be em- ployed in preference to other forms of suture. If the wound be extensive, it may be necessary to give additional sup- port by means of adhesive plaster. Narrow strips should be used, to be applied between the points of suture, and to extend some distance on either side of the incision. The wound should then be dressed, and the patient placed in a clean bed, which should be at hand and already warmed. It is often a good plan to give a hypodermic injection of morphia, before the patient has quite recovered from the effect of the anesthetic. The after- treatment has already been referred to (see page 65). The surgeon should not, if practicable, leave his patient until he has seen him comfortably fixed in bed, till complete reaction has occurred, and till he is satisfied that no risk of bleeding is to be anticipated. He should also see that a competent nurse is in attendance, to whom he should give full and explicit directions as to the management of the patient in the intervals be- tween his visits. Insanity after Operations.—111, Graube, Worth, Shepherd, Thomas, and other writers have called attention to the occasional occurrence of severe mental disturbance, either mania or melancholia, after gynaecological or other operations. I have myself seen this condition in two cases—both after operations for hemorrhoids. One of the patients was a young woman, and in her case the symptoms were of short duration, and indeed might have been considered as due to violent hysteria rather than to insanity, but the other, a middle-aged man, presented evidences of positive de- mentia, with persistent delusions and occasional maniacal outbreaks, for several weeks. This condition seems to be due to the effect of the nervous tension and anxiety preceding the operation, acting perhaps upon a not very well balanced mind and a body weakened by physical suffering, rather than to the use of an anaesthetic or to any circumstance directly connected with the operation itself. It may be compared with the some- what analogous condition of puerperal insanity, and is entirely distinct from traumatic delirium (see Chapter VII.), with which condition it must not be confounded. The prognosis is generally favorable. Anaesthetics. It must be acknowledged that a great change has been brought about in the practice of operative surgery by the introduction of Anaesthetics; patients will now submit to operations which formerly they would rather have died than endure, and thus many operations which without anaesthesia would have been absolutely impracticable, are now perfectly feasible and are frequently employed. In this way the range of operative surgery has been greatly extended. The advantages derived from anaesthetics are un- questionable ; the patient is saved entirely from pain, and in a great decree from the mental anxiety and disquietude which formerly necessarily pre- ceded an operation ; and it is probable, likewise, that the physical shock of the operation is in some degree diminished. The surgeon is also enabled to concentrate his attention upon the duty before him, undistracted by the cries and struggles of his patient. But are the benefits of anaesthesia quite unaccompanied with attendant, though by no means countervailing, evils ? ANAESTHETICS. 73 Statistics have been collected on either side of this question, Sir J. Y. Simp- son maintaining that the mortality after operations has diminished since the use of anaesthetics, and Dr. Arnott that it has increased. My own impression is that, as a matter of figures, the latter statement is correct. But though there may be an increased death-rate, this increase is not, I believe, fairly to be attributed to the employment of anaesthesia. Formerly, a surgeon, in consideration of the great pain which an operation would inflict, would naturally reserve the use of the knife for those cases in which it was most probable that the patient would be markedly benefited, and would decline interference in any case in which the patient was not in a good condition to undergo the inevitable suffering of the operation; now, since the pain of the operation is no longer to be dreaded, we are constantly induced to extend the benefits of our art to cases which formerly would have been left without operative treatment, and to give a last and possibly faint chance to patients who otherwise would have been abandoned to certain death. In the large majority of cases, the chances for each individual arc, I believe, made better by the use of anaesthetics. I have myself repeatedly noted an improvement of the pulse during the inhalation of ether, and have found the patient's general condition absolutely better after an amputation than before it was begun; and I can scarcely conceive of any case in which a serious operation would be proper at all, in which it would not be likewise proper to employ anaesthesia. Still, we must be careful not to err on the other side. It is to be feared that students and young practitioners often get a false impression upon this point, and from seeing the frequency and apparent profusion with which anaesthetics are administered by their clinical teachers, derive a notion that these agents are perfectly harmless, and may be indiscriminately resorted to under all circumstances. The true rule upon this matter (a rule which is, indeed, applicable to all our perturbing modes of treatment) is, that when anaesthetics are not positively beneficial, they are injurious. Hence, under ordinary circumstances, they should not, I think, be employed, except for really important operations, and those which without their use would be tedious and painful. It is seldom right to give anaesthetics for purposes of diagnosis merely: there are, however, parts of the body the lesions of which are so obscure, and in dealing with which a mistaken diagnosis might lead to such grave errors of treatment, that it is often not only justifiable, but even imperative, to employ anaesthesia in their exam- ination. Injuries about the hip-joint may be taken as an illustration of this statement. The reduction of dislocations is rendered so much easier to both patient and surgeon by the use of anaesthetics, that these agents may be almost always be properly employed in such cases ; on the other hand, it is seldom necessary to use them in the dressing of fractures. Cases for what are called capital operations (where life is immediately involved), are almost invariably cases for anaesthesia; for smaller operations, the practice should vary according to the time required for their performance; thus, anaesthetics should be given before operating for piles, or for phimosis, for these are tedious procedures; while opening an abscess and tapping a hydrocele, are quickly done, and do not usually require the use of these agents History.—The history of the introduction of anaesthesia into the practice of surgery is a subject Which is full of interest, and well worthy of the attention of every intelligent practitioner. The limits of this work will not, however, permit more than a very brief reference to it. Many efforts to prevent the pain of operations had been from time to time made, by the use of narcotics, either in vapor or administered internally, 74 OPERATIONS IN GENERAL. by pressure on the nerves of the part,1 by profuse preliminary bleeding, by electricity, and by other methods ; but the first really promising experiment in the introduction of anaesthesia dates back less than half a century, to the year 1844,2 when Dr. Horace Wells, a dentist of Hartford, Connecticut, rendered himself unconscious by breathing nitrous oxide gas (which had previously been experimented with by Sir Humphry Davy), and in that condition' submitted to the extraction' of a tooth. Dr. Wells repeated his experiment before the medical faculty and students of Harvard College, but lamentably failed. In 184(5. Dr. *W. T. G. Morton, another dentist, a pupil and partner of Wells, began to experiment with the vapor of ether, whether independently, or in consequence of hints received from Dr. Wells, Dr. Charles T. Jackson, or both, has never been satisfactorily established. It is stated that Morton's first experiment was made with chloroform (under the name of chloric ether), and hence the honor of discovering both of the great anesthetic agents of modern times has been claimed for this country. It seems, proper, however, that the real credit of a discovery should be given to the man who first practically makes that discovery use- ful to his fellows, and hence the merit of introducing chloroform as an anesthetic belongs, I think, as undoubtedly to Sir James Y. Simpson, as does the merit of introducing ether to Morton himself. The first surgical operation (beyond the extraction of a tooth) done with the aid of ether, was the removal of a tumor, by Dr. John C. Warren, at the Massachusetts General Hospital, in 1846, tin' anesthetic being admin- istered by Dr. Morton. The first case in which ether was used in this city, was, I believe, one of dislocation, at the Pennsylvania Hospital, the operator being Dr. Edward Peace. In the fall of 1847, Prof. Simpson, of Edinburgh, began to experiment with chloroform, which soon became the favorite with British and Continental surgeons, by many of whom it is still preferred to ether. The latter substance is, on the other hand, preferred in some parts of France, and very generally in this country. Either agent has some advantages over the other, and some correspond- ing disadvantages. Chloroform is more prompt in its effects than ether, the patient is usually quieter while coming under its influence, it is less apt to cause vomiting, a smaller quantity than of ether is required to produce anesthesia, and the patient reacts more quickly when the inhalation is stopped. It, however, requires much greater care in its administration than ether, and its use is attended with much greater risk to life. The above statement gives my own estimate of the relative merits of these agents, and, I believe, corresponds pretty closely with the opinions usually enter- tained on the subject; it is, however, but right to say that Dr. Lente and Dr. Squibb, of New York, believe that anesthesia may be induced by means of ether as quickly as can safely be done by means of chloroform, and with a quantity costing less and weighing very little more than the requisite amount of the latter; and that other writers have maintained that vomiting is at least as frequently caused by chloroform as by ether. Dr. Kidd, on the other hand, regards ether as quite as dangerous as chloroform. For my own part, I confess that I prefer ether, in a very large majority of cases ; it is certainly, I think, safer than chloroform, and is sufficiently convenient for almost every case that the surgeon is called upon to treat. 1 More recently the late Dr. Aug. Waller has shown that muscular relaxation and anaesthesia may, in some cases, be effectually induced by pressure on the cervical por- tions of the vagi. 2 A claim of priority has recently been made on behalf of Dr. Crawford W. Long of Georgia, who is said to have used ether in surgical operations as early as 1S42. f hope that I may be pardoned for saying that the evidence in Dr. Long's favor seems to me quite inconclusive. ANESTHETICS. 75 In particular cases, however, chloroform would be preferable; thus in ex- traction of cataract, the greater struggling and risk of vomiting produced by ether are decided contra-indicationsto its use ; and as the vapor of ether is very inflammable, and that of chloroform not at all so, the latter may be preferred for operations about the face, when it is probable that the use of a hot iron may be required.1 Precautionary Measures.—Whatever anesthetic be resorted to, certain precautionary measures should be employed in its administration. It is often said that organic visceral disease, especially a fatty state of the heart, should forbid the use of anesthetics ; but whatever may be the risk under these circumstances, it would probably be still greater if the operation were performed without an anesthetic, ami hence I cannot think its use in such cases improper. It would, however, be right, if disease of the heart wTere suspected, to watch the administration with special care, and particularly to give no more of the anesthetic than was absolutely necessary. The pa- tient should be prepared by removing any constriction of the clothing upon the throat or around the waist, so as to prevent pressure on the larynx, or interference with the action of the diaphragm. No solid food should be taken for several hours before the anesthetic is given, though, if there be much depression, it is often well for the patient to swallow half an ounce or an ounce of brandy, with a moderate dose of opium or morphia, imme- diately before the administration is begun ; if the operation be necessarily prolonged, further restoratives should be given from time to time, the use of the anaesthetic being suspended sufficiently to allow the action of degluti- tion to be performed. The patient is best placed in the recumbent position to inhale any anesthetic, though this is less important in using ether than in using chloroform, when it is absolutely essential. The inhalation should be begun gradually, so as not to alarm the patient by the impending sense of suffocation, and all unnecessary noise should be avoided, as tending to produce undue excitement and delay the induction of insensibility. Effects of Anaesthetics.—The first effect of an anesthetic is upon the nervous system; there is excitation, usually pleasurable, followed by insen- sibility to pain and complete unconsciousness, though some of the muscles may remain slightly rigid and tense, and reflex motion be not totally abol- ished ; this is the most favorable condition for many operations which do not require extreme delicacy, such as amputation, excision of tumors, etc., when absence of sensation and voluntary motion is all that is requisite.2 In the next stage there is complete relaxation of the muscular system, while the force of the circulation and respiration is much diminished. This con- dition must be induced for the performance of the more delicate operations, and for the reduction of dislocations. The approach of this stage may be known by the test of touching the conjunctiva; if reflex motion be sus- pended, this action will not produce winking. When anesthesia is pushed beyond this stage, the patient must always be looked upon as in a very critical state. The pulse, the respiration, and the color of the face must all be constantly watched, and the anesthetic either removed or continued in 1 I have found, however, that by removing the ether and waiting a few seconds, the hot iron may be used without risk, even in the cavity of the mouth, and for nine or ten years I have abandoned chloroform altogether. 2 Dr. Packard has described, under the name of " first insensibility from ether," a condition, of brief duration, in which such operations as opening an abscess or felon can be performed without suffering on the part of the patient, and without pushing the administration of the anaesthetic to the extent of producing complete insensibility. Dr. Gribney has observed a similar state of " primary anaesthesia" in the use of chlo- roform. Dr. Hewson and Dr. Bon will state that a condition of " analgesia," sufficient for the endurance of minor operations, may be induced simply by rapid breathing. 76 OPERATIONS IN GENERAL. lessened quantity and with extreme care. Dr. 11. J. Neilson points out that under the influence of chloroform the pupil is first dilated and then contracted, and that when firm contraction is established the administration should be suspended until the pupil again begins to dilate; sudden dilata- tion marks the occurrence of asphyxia, or, if the administration has been stopped, of sickness. Stertorous breathing, as pointed out by Prof. Lister, is of two kinds: one, the palatine, which is caused by vibrations of the soft palate, may occur early (as in ordinary snoring), and is not necessarily important ; the other, or laryngeal stertor, depends on the vibrations of the portions of mucous membrane which surmount the apices of the ary- tenoid cartilages, and is always indicative of extreme danger. Death from the administration of an ana'sthetic may come from failure of either foot of the vital tripod, the head, the lungs, or the heart; in other words, it may be due to coma, to asphyxia, or to syncope. As a matter of practical ex- perience, it is very difficult to distinguish which of these conditions may have been the primary one, for whichever organ fails first, the others cease to act in a very short time afterwards. As shown by Prof. Lister, the appearance of respiration may continue after the supervention of true laryn- geal stertor shows that the access of air to the lungs is greatly impeded, if not absolutely checked ; hence deaths are sometimes attributed to paralysis of the heart, which are really due to asphyxia, or, more correctly, apnoea. The following is the course to be pursued whenever death appears immi- nent during anesthesia : The inhalation must be immediately stopped, and the patient supplied with fresh air by opening windows, etc. He should be turned on his side to allow fluid to escape from the mouth, but should on no account be raised from the recumbent posture. Nelaton, Sims, and others, believing that the risk in chloroform poisoning is from cerebral anemia, advise that the patient should be inverted, so as to favor the flow of blood to the brain. Inhalations of nitrite of amyl are suggested by Schuller, and by Burrall, of New York, and have been successfully employed by Bader and others. The lower jaw should be forcibly pushed forwards, or the tongue drawn out as far as possible, with tenaculum or forceps; extreme protrusion is necessary to insure opening of the larynx.1 Artificial respira- tion should be at once employed, and is most conveniently effected by alter- nately compressing and expanding the walls of the chest." Electricity may be applied over the region of the heart and diaphragm, and through to the spine, while cold water may be dashed over the face and chest, and frictions applied to the extremities. Fitzgerald, of Melbourne, suggests intravenous injections of ammonia, while Baillie* advises the introduction of ice into the rectum. B. A. Watson suggests puncture of the right ventricle. As soon as the patient is able, he should swallow a little brandy. If it should be necessary to reapply the anesthetic, it should be done" with renewed caution and watchfulness. Noel, of Louvain, having constantly observed a venous pulse in the jugular and subclavian veins during the stage of awak- ing from chloroform anesthesia, considers this an evidence of profound functional disturbance of the heart, and urges that the patient should be carefully watched as long as this phenomenon continues. Secondary Effects.—Certain secondary consequences of an unpleasant nature are occasionally due to the use of anesthetics. These are headache sick stomach, and bronchial irritation. In nervous women hysterical symp- toms are sometimes developed, which may continue for some time and mav cause a good deal of annoyance. It is said that apoplexy or paralysis may i B. Howard, however, maintains that drawing the tongue forward produces no effect upon the epiglottis, and advises instead that the head and neck should be placed in the position of extreme extension. ANESTHETICS. 77 be produced in old persons by the use of anesthetics, but I have never met with such an occurrence in my own practice. Fatty degeneration of the heart, and other organs, in rabbits, is found by Unger to be a direct result of the inhalation of chloroform, and there is some reason to believe that the occurrence of fatty changes of both heart and kidneys may, in the human subject, be hastened by the employment of either this agent or ether. The nausea and vomiting which very frequently follow the use of these agents, and especially ether, may be usually relieved by giving small quantities of milk and lime-water, or of iced carbonic-acid water; in more severe cases, chloroform, given in doses of twenty or thirty drops in emulsion, will be found very effective. The occurrence of these annoying s}Tmptoms may often be prevented by giving a hypodermic injection of morphia before the state of anesthesia has passed off, and thus allowing the system to recover itself by a few hours' sleep. The bronchial irritation may be relieved by keeping the patient quiet, and giving a mild sedative expectorant, such as the wild-cherry bark with a little opium or hyoscyamus; in some cases, however, the lung itself becomes affected, being deeply congested, and a low form of pneumonia or a kind of suffocative catarrh may follow, and may possibly prove fatal in the course of a few days. This is a serious occurrence, and must be met by giving stimulating expectorants, such as carbonate of ammonium, and by the administration of wine or brandy, ac- cording to the general condition of the patient. These unfortunate consequences may follow, even when the anesthetic has been given with the greatest care and judgment; they are, however, more likely to ensue wThen too large a quantity has been used, when the administration has been too long continued, or (in the case of chloroform) when it has been given without a sufficient admixture of air. Administration of Ether.—The best mode of giving ether is from a thin and hollow sponge, wrung out of water, and surrounded by a pasteboard or light metallic cone, wThich should be perforated at the top. The hollow of the sponge should be large enough to embrace both mouth and nostrils. The ether should be chemically pure, and should be poured upon the sponge in quantities of not less than half a fluidounce at a time. The first few in- halations should be made while the sponge is a few inches distant from the nostrils, but as soon as the state of anesthesia has begun, the sponge may be closely applied, and need not usually be removed, except wyhen necessary to add more ether, till unconsciousness is complete. Of course, if, as will sometimes happen, the patient be seized with a fit of coughing, and choke, or, from having eaten a meal immediately before the operation, should begin to vomit, the sponge must be withdrawn until tranquillity is restored. If a patient breathe freely, he cannot be too rapidly etherized, and there is no danger, as in the case of chloroform, from the vapor being too concen- trated. Enough air is drawn through the perforation of the cone and the interstices of the sponge to obviate any risk from this cause, and rapid etherization is much less apt to cause pulmonary congestion than slow inhalation of the vapor prolonged through a considerable period; still, as a patient may choke from various causes, as from an accumulation of saliva and mucus flowing backwards over the glottis, or from vomited matters collecting at the back of the mouth, a constant watch should be kept upon the countenance and the respiration, and the approach of any dangerous symptoms promptly met. The patient can greatly assist the production of anesthesia by taking deep inhalations; he should, therefore, be constantly urged by the surgeon, not, as is often done, to " draw in his breath," but to " blow out," to " blow the sponge away from him." This is a practical hint which I learned 78 OPERATIONS IN GENERAL. many years since from that excellent surgeon and brilliant operator, the late 'Prof. Joseph Pancoast. and a moment's reflection will show that, though paradoxical, it is reasonable and strictly correct : the vapor of ether is so penetrating and irritating to the throat, that it is very difficult volun- tarily to draw it in by a deep inhalation ; but it is perfectly easy to blow into the sponge, and, as a full expiration is inevitably followed by a deep inspiration, the surgeon's purpose is thus most readily accomplished. The plan of administering ether which has been described, is both efficient and economical, and I doubt if it can be practically improved. The old method, by a sponge simply surrounded with a towel, is equally efficient but allows more evaporation, and, therefore, wastes more ether. Dr. Lentc uses a cone of newspaper, with a towel pinned inside, and so folded as to prevent any, even the slightest, admixture of air ; and Dr. A. II. Smith has devised an ingenious portable apparatus, which consists of a large India- rubber ball (such as is sold for a football) lined with patent lint, and with an aperture cut for the face. Prof. Porta, of Pavia, stuffs the nostrils with cotton, and causes the pa- tient to inhaletheethereal vapor from a pig's bladder closely fitted to the mouth. Dr. A. F. MUller employs a face-piece connected bv a tube with the ether-bottle, which is plunged into boiling water, so as to hasten vaporization. Other inhalers, more or less complicated and ingenious, have been devised for the administration of ether (including those of Drs. Lente, Squibb, Allis (Fig. 11), and Rohe, and those of Messrs. Morgan and Richardson, of Dub- lin), but I am not aware that they possess any practical advantages over the simple method which I have recom- mended. Whatever apparatus be used, great care should be taken that no compression be exercised upon the larynx. The lips and nose may be anointed with simple cerate or cold cream, to prevent any cutaneous irri- tation from the contact of the ether. According to Dr. Corning, etherization may be hastened by applying elastic bands around the thighs, thus temporarily cutting off a portion of the blood from the general circulation. When the operation is completed, the bands are removed, and the return of the blood which has not been saturated with the anesthetic vapor causes instant restoration to con- sciousness. Etherization by the rectum, as suggested by Roux, Pirogoff, Iversen, and Molliere, has been tried in a number of cases, but has so often caused dangerous diarrhoea, and even death, that it has by general consent been again abandoned. Chloroform is, I think, best given from a folded handkerchief or piece of lint, held at first five or six inches from the nose, and afterwards brought as near perhaps as half an inch to an inch, but never allowed to touch. Not more than a fluidrachm of chloroform should be poured on at once, and evaporation may be prevented by throwing a single towel loosely over the operator's hand and patient's face. This is not as safe an agent as ether, and one of the principal dangers in its administration is the risk of too great concentration of its vapor; hence the surgeon should constantly bear in mind the importance of allowing a sufficient admixture; of air, and should err on the side of allowing too much rather than too little. ' The Fiu 11—AUis's ether inhaler. ANESTHETICS. 79 average amount of chloroform required for an ordinary operation is from half an ounce to an ounce; though Prof. Gross states that he has given as much as twenty ounces in two hours, without any unpleasant consequences following. Yarious inhalers have been devised with a view of regulating the amount of chloroform used, and of securing the proper admixture of air, and when the administration has to be conducted by one unaccustomed to the employment of chloroform, probably one of these instruments may advantageously be resorted to; but in the hands of an experienced per- son, I believe that the greatest safety to the patient is that sense of imme- diate responsibility which should always be felt by the giver of chloroform, and that hence the best inhaler may occasionally prove injurious by inspir- ing a false sense of security. Mr. Clover's apparatus, wThich is probably the best, is thus de- scribed by Erichsen : It consists " of a bag holding 8000 cubic inches of air, which is suspended from the coat-collar at the back of the administrator, and con- nected with the face-piece by a flexible tube. The bag is charged by means of a bellows (Fig. 12, i) measuring 100 cubic inches; and the air is passed through a box wrarmed with hot water, into which is introduced at each filling of the bellows as much chloroform as is required for 1000 Cubic inches Of air. This is Fig 12-Clover's chloroform apparatus. (Erichsen.) done with a graduated glass sy- ringe (Fig. 12, 2) adjusted by a screw on the piston-rod to take up no more than the quantity determined on, which is usually from 30 to 40 min- ims. When the bag is full enough, the tube is removed from the evapo- rating vessel, and the mouth-piece (Fig. 12, 3) adapted to it. The patient cannot get a stronger dose than the bag is charged with; but the propor- tion can be made any degree wreaker, by regulating the size of an opening in the mouth-piece, which admits additional air."1 Even with this instru- ment, according to Kappeler, at least five fatal cases have occurred, and I believe that no mechanical arrangement, howrever accurate, can take the place of the personal care and attention of the surgeon. Langenbeck, Stob- wasser, Iterson, and Fischer believe that special dangers attend the admin- istration of chloroform by gas-light, the anesthetic vapor combining with the gases produced by combustion, and causing sudden asphyxia wrhich occasionally proves fatal. A mixture of ether and chloroform is frequently used in this country, and many surgeons believe that by this plan they unite the advantages and avoid the evils of both agents. For my own part I do not think that any benefit is to be derived from the employment of mixed vapors, more than is obtained from the use of ether alone; and I have seen, at least once, such serious symptoms follow the use of this combination, that the operation had to be temporarily abandoned, when the patient was only re- stored by a prompt recourse to artificial respiration.2 1 Science and Art of Surgery, vol. i. p. 44. 2 Wachsmuth advises that the vapor of turpentine should be combined with that of chloroform, by mixing one part of the former substance with five of the latter. 80 OPERATIONS IN GENERAL. Yarious other substances, principally belonging to the group of ethers, have been found to possess anesthetic properties, and have been occasion- ally employed in surgery ; none of them, however—not even the bichloride of methylene, employed by Spencer Wells, nor the bromide of ethyl, as used by Levis and (iiisohn. nor the ethidene-diehloride, recommended by the Committee of the British Medical Association—have proved so satis- factory as to take the place of the two agents, the use of which has been above described. The same may be said of the intra-venous injection of chloral, as recommended by M. Or6 and other European surgeons. Nitrous oxide, or laughing gtis, which, it will be remembered, was the substance employed by Dr. Wells in his early experiments, has lately been re-introduced in this country and is quite extensively used in dental prac- tice. I have seen an amputation done while the patient was rendered unconscious by the use of this gas, and though the symptoms presented wrere sufficiently alarming, it certainly seemed an effective agent as far as the prevention of pain was concerned. It appears to act by inducing an asphyxial condition, wThich, of course, cannot be long continued with safety to the patient, and it is hence seldom employed in general surgery, except as preliminary to the administration of ether, though it is constantly used in the extraction of teeth. It has been recently suggested by M. Paul Bert, that the risks of giving nitrous oxide might be obviated by mixing it with oxygen gas, and administering the mixture in a chamber of com- pressed air; and successful operations upon this plan have been performed by Labile and Pean. Local Anaesthesia is sometimes useful in preventing the pain of slight operations, where unconsciousness on the part of the patient is unnecessary or undesirable. It is usually produced by the application of cold to the part to be operated on, either by means of a mixture of ice and salt, as recommended by Dr. J. Arnott, or by the rapid evaporation of ether, rhigolene, or other very volatile substance, as proposed by Dr. Richardson The freezing mixture may be applied in the proportion of two parts of powdered ice to one of salt, being kept from the surface to be anesthetized by inclosure in a bag of gauze or of thin muslin. Ten to fifteen minutes' application is usually sufficient to insure the freezing of the skin, which becomes blanched, opaque, and tough, and may then be incised without suffering on the part of the patient. Dr. Richardson's method consists in applying a fine spray of pure ether in the line of the proposed incision, by means of a hand atomizer. The same writer recommends that where this method is employed, the incisions should be made with scissors instead of a knife. According to Dr. Letamendi, the occurrence of anesthesia may be hastened by making a slight incision, not deeper than the papillary layer of the cutis, as soon as the part to be frozen has become red under the application of the ether spray. Local anesthesia has been used suc- cessfully in an operation as important and severe as ovariotomy • I cannot but think, however, that general anesthesia is preferable for all but very slight operations, if for no other reason, on account of avoiding the mental shock which is entirely distinct from the sensation of pain. Moreover the process of freezing is itself very painful in some instances, especially when mucous membrane is involved, as in the case of hemorrhoids and the use of the ether spray is not entirely free from danger- thus in a Case of excision of the tunica vaginalis for hydrocele, which occurred in this city, the use of the spray was followed by extensive sloughing of the scrotum, which well-nigh cost the patient his life. Another mode of producing local anesthesia, which is highly commended by Squibb, Wilson, and Bill, is the topical application of carbolic acid. BANDAGING. 81 The local use of hydrochlorate of cocaine or cucaine, introduced by Dr. Roller, of Yienna, has recently excited much attention ; it has been prin- cipally resorted to in operations on the eye, and usually with success, though in a few cases—principally of cataract operations—its employment has been followed by destructive inflammation. It has also been employed with more or less advantage in laryngeal, rectal, urethral,1 vesical, vaginal, and uterine surgery, and appears to have valuable anesthetic powers in all operations involving the mucous membranes. To mucous surfaces it is simply applied in a four-per-cent. solution, several times before the opera- tion is to be performed, but in other cases it is administered hypodermically, or, as advised by Wagner and Corning, on a sponge attached to the positive pole of a galvanic battery, after multiple punctures made with an instrument specially devised for the purpose. By compressing the sur- rounding tissues with a ring or elastic cord, the effects of the drug can, as shown by the last-named wTriter, be concentrated sufficiently to allow the performance of operations involving the deeper structures. Other substances which have acquired reputation as local anesthetics are drumine, kava- kava, the haya poison, etc. Before leaving the subject of anesthetics, I may give the student one caution, which is never to give an anesthetic to a woman, unless in the presence of witnesses. A curious but undoubted property of these agents is, that they occasionally produce most vivid erotic dreams, and this may happen even with a patient whose mode of life and character are above suspicion. Several most vexatious prosecutions, and even convictions, for indecent assault, have occurred in this country, where yet calm after- investigation rendered it almost morally certain that no assault had been committed, and that the plaintiff's sensations had been quite deceptive, and due to the effect of the anesthetic which had been administered. Hence a woman may, without any evil intention, and really believing that she is telling the truth, inflict an irremediable injury on a medical practi- tioner, if he cannot by the evidence of eye-witnesses prove the incorrectness of her assertions, and thus establish his own innocence. CHAPTER IV. MINOR SURGERY. It is not intended to embrace in this chapter a description of all the operations which are usually treated of in works on Minor Surgery; some of these procedures have already been referred to, and others may be more appropriately considered when discussing the various conditions which demand their employment. I purpose now merely to describe certain minor surgical manipulations which are applicable to a great variety of cases, and which seem therefore to find an appropriate place in this pre- liminary division of the work. Bandaging.—Bandages are used to retain surgical dressings, to exer- cise compression, to assist the coaptation of wounds, or to keep injured 1 Death followed the injection of 12 grains of cocaine into the urethra, in a case recorded by J. H. C. Simes, and marked toxic symptoms the hypodermic use of a single grain in cases observed by Magill and J. H Way, and of half a grain in one recorded by F. Johnson. 6 82 MINOR SURGERY. parts at rest, as in the treatment of fractures and dislocations. The most convenient form of bandage, and one which is almost universally appli- cable, is made by tearing unbleached muslin or other material into strips from two to four inches wide, and from five to eight yards in length. One-inch bandages are occasionally used for application to the fingers or penis, but strips of adhesive plaster are generally more convenient for retaining dressings to these parts. A bandage two inches wide is suitable for the head or neck; one three or three and a half inches wide for the arm or leg, and a four-inch bandage for the thigh. Still wider strips, five or six inches, are required for the trunk. To be ready for use, these bandages are tightly rolled, either by hand or by a little apparatus which is figured in most works on minor surgery, and which is convenient for use in hospitals, or where a great many bandages are daily employed. When thus prepared, the bandage is called a roller or a roller bandage. Some surgeons use bandages rolled from both ends, or double-headed rollers, but the single-headed roller is more generally applicable, and indeed is sufficiently convenient for every practical purpose. The ordinary bandages used by the surgeon are the spiral, the figure-of-8 orspica, and the recurrent. Spiral Roller Bandage.—As most persons use the right hand with greater facility than the left, the bandage is usually held in the right hand, and applied from left to right above (or in the direction in which the hands of a watch move), as regards a transverse section of the part to be bandaged. As a rule, also, the roller is started at the distal part of the limb to be bandaged, and made gradually to approach the trunk. The surgeon should, how- ever, accustom himself to bandage with the left hand as well as with the right, and downwards, or in a Fin. 13.—Reversed spiral of the lower extremity. direction receding from t he trunk, as well as upwards. The plain spiral bandage, as its name implies, consists of simple turns of the roller around a limb or other part in a spiral direction. It is applicable only where the part to be bandaged has a uniform diameter, as in the limbs of verv thin persons. Where the limb is conical, rather than cylindrical, the reversed spiral is to be applied. In making the reverses, the surgeon fixes the pre- vious turn of the bandage with the fingers of the left hand, and holding the roller lightly in the right hand, gives it a quick half turn, so as to cause the part which is unrolled, and which should not be too tightly drawn to fold evenly upon itself; the roller is then carried around the limb as in the ordinary spiral bandage. It will be found advantageous, in applyinf the reversed spiral, to alternate the reverses with plain turns, or, if the limb be too conical to admit of this, to cover in every two or three reverses with a plain spiral turn ; the effect is indeed less agreeable to the eye, but a BANDAGING. 83 bandage thus put on is much more likely to retain its position than one consisting of reversed turns alone. Figure-of-S or Spica Bandage.—This bandage is used for application to the various joints. It consists of simple turns of the roller, which pass above and below the joint, and cross each other at any con- venient point, usually at the flexure of the articulation. The term spica is applied to the figure-of-8 bandage for the ankle, the hip, or the shoulder. In the case of the shoulder, one branch of the spica goes around the arm, while the other may be applied to the neck, though more usually and better to the chest. A figure-of-8 bandage may likewise be used around both shoulders, to draw- them together, or, when applied so as to bring the crossing in front, may be made available in giving support to the female breast. Recurrent Bandage.—The recurrent is principally used in applying dressings to the head or to a stump. One or tw-o circular turns are first made around the head or the upper part of the stump, and the bandage is then brought in Fiq. 14 —The posterior figure-of-8 of the knee. Fig. 15.—The spica of the shoulder. Fin. 16.—The four-tailed bandage of the chin. recurrent semicircles backwards and forwards from the forehead to the occiput, or over the face of the stump, as the case may be; the recurrent turns are secured by additional circular turns corresponding to those first made. Compound Roller Bandages.—Besides the bandages above described, which are all made from a single roller, various more complicated appli- ances may be occasionally useful. Those most often employed are the single and double "[" bandages,- the four-tailed bandage, and the many- tailed bandage, or that of Scultetus. The T bandages, the forms of which are described by their names, are convenient for retaining dressings to the perineum ; the single T being applicable to the female, and the double "J" bandage to the male. The four-tailed bandage, which is made simply by splitting both ends of a piece of a broad roller, may be convenientl}7 used for the knee-joint, or in cases of fractured jaw, while the bandage of Scul- tetus, which consists of numerous, short, overlapping strips of bandage 84 MINOR SURGERY. (Fig. 17), may be resorted to in the treatment of compound fractures, and is of great use in the after-treatment of excisions of the knee. Handkerchief Bandages.—An ingenious Swiss Surgeon, M. Mayor, introduced some fifty or sixty years since, a new system of bandaging, in which broad handkerchiefs or squares of muslin or other material, took the place of the ordinary roller. The handkerchiefs were to be folded into triangles or into cravats, and it is surprising to see, from the illustrations which accompany Mayor's essay, to what a great variety of circumstances these simple means are applicable. Though the handkerchief can never supersede the roller, nor indeed rival it in general utility, yet it is well for the surgeon to bear in mind the pos- sibility of resorting to this system, as an emergency might well arise in which the handkerchiefs of bystanders could be more easily obtained than other means of bandaging. Fixed or Immovable Bandages.— Yarious substances have been em- ployed of late years to give greater firmness and solidity to the ordi- nary roller bandages, and may be applied either to the common spiral and spica bandages, or to that of Scultetus. The most usual forms of immovable bandage are those made with starch, with gypsum or plaster of Paris, with gum and chalk, with dextrine, with simple flour paste, writh the silicate of potassium, and with paraffine. Whatever material be used, there is apt to be some con- striction exercised upon the limb in the process of drying, and hence it is best to protect all the bony prominences with a moderately thick layer of cotton wTadding, the elasticity of wrhich will prevent any injurious conse- quences from this cause. The starched bandage requires two rollers, the inner one of which is saturated with thick starch, the outer one being left dry, or only starched on its inner surface as it is applied. The starched bandage requires from thirty to fifty hours to dry, and is on this account not so convenient as that made of plaster of Paris. For the gypsum or plaster-of-Paris bandage, a roller, wrhich should be coarse and of loose texture—crinoline is a suitable material—is prepared by rubbing into it the dry, powdered, plaster of Paris. It is dipped in water for a few seconds to prepare it for use, and is then applied as an ordinary spiral, over a simple flannel or muslin bandage, or a closely-fitting stocking. When its applica- tion is completed, it is smeared over with a little dry plaster of Paris. This bandage has the advantage of becoming firm in about a quarter of an hour, and constitutes, I think, the best form of immovable apparatus. It is an excellent dressing for fractures of the lower extremity after the union of the fragments has become moderately firm. Tripoli is preferred to plaster of Paris by Langenbeck. The gum-and-chalk bandage requires mucilage and chalk to be rubbed together in a mortar till a mixture of a creamy con- sistence is obtained; this is then smeared over a dry roller, previously Fio. 17.—Bandage of Scultetus. REVULSION AND COUNTER-IRRITATION. 85 applied. It requires four or five hours to become dry. The dextrine band- age was particularly recommended by Yelpeau; the dextrine, or British gum, is first dissolved in camphorated alcohol (ten parts to six), and when of the consistence of honey, five parts of hot water are added, when, after shaking for a few minutes, it is ready for use. Yelpeau used two rollers, Fiq. 18.—Hunter's saw for removing plaster bandages. the first dry, and the second soaked in the dextrine before application. The flour-paste bandage is applied like those of starch or dextrine, and is considered by Prof. Hamilton to be as satisfactory as either. The silicate of potassium (liquid or soluble glass) has been used by several Ger- man, French, and American surgeons as a substitute for starch in the application of immovable bandages, and has the advantage of drying more rapidly (in from four to twelve hours, according to the number of bandages used), and of being easily softened by the use of hot water when it is desired to effect its removal. From two to six layers of bandage may be employed, the silicate being applied in a state of syrupy consistence by means of a brush. The silicate of potassium was particularly recom- mended by the late Prof. Darby, of New York, as is glue, mixed with oxide of zinc, by Dr. Levis, of this city. Melted paraffine is employed by Tait and Macewcn, the former applying it upon flannel band- ages, and the latter upon sheets of cotton-wool. Immovable bandages may be applied by themselves, or may be reinforced by the employment of light splints, made of thin wood or metal, leather, gutta-percha, or paste- board. If, as often happens, the apparatus becomes loosened after a few- days, from the subsidence of swelling, it may be slit up on one side with a strong-backed knife, or short saw (Fig. 18), or with a pair of Seutin's, Wathen's, or Yon Brun's pliers, the edges being then trimmed, and held in place after readjustment with tapes or bandages; or, as suggested by Darby, holes may be bored in either edge, and the apparatus then laced up as a boot. By slitting up an immovable bandage on both sides, two light and accurately fitting splints are formed, constituting what the French call a "bandage amovo-immobile." When applied to ulcers or compound fractures, a trap may be cut opposite the seat of lesion of the soft parts. In order to facilitate the removal of the bandage, Dr. W. B. Hopkins applies it over a brass, vertebrated chain, wThich is removed when the bandage has set, leaving a hollow, longitudinal ridge, which can be readily divided with a rasp. Revulsion and Counter-Irritation___Counter-irritation is often employed by the surgeon, and may vary in the intensity of its effects from the slight lvdness produced by a brief application of a mustard poultice, to the extensive sloughing caused by the actual cautery. Rubefaction.—The most convenient rubefacients are mustard-flour and oil of turpentine. The latter is applied warm upon flannel, while mustard should be mixed with water and applied in the form of a poultice, which may be rendered milder in its effects by diluting the mustard with Indian- meal. A very convenient application is what is sold under the name of 86 MINOR SURGERY. Fm. 20.—Corrigan's but'on cautery. " prepared sinapism.'' made by causing the mustard-flour to adhere to paper by means of gum ; it is made' ready for use by simply dipping it in warm water. When it is desired to produce mild but persistent counter-irritation, without blistering the part, the best application is the officinal tincture of iodine. It should be painted daily, or every other day, around but not over the affected region, as advised by Furneaux Jordan, and thus used will be found very effective. It is sometimes well to dilute the tincture of iodine with an equal quantity of chloroform. Vesication may be produced in a variety of ways. The most usual is bv means of the ordinary blister plaster, made with the officinal cantharidal cerate of the Pharmacopoeia; can- tharidal collodion may be painted over the part to be blistered, and, if the skin be not too thick, will be found a very prompt and con- venient mode of producing vesi- cation; or the solid stick of nitrate of silver may be used as a vesi- cant, or the strong aqua ammonie, or iron heated by immersion in boiling water. The last method is best employed by means of Sir D. Corrigan's "thermal hammer," or " button cautery." "When vesication is produced by the use of cantharides, it is well, in order to guard against strangury, to withdraw the blister when it has begun to act, and to complete the "raising" of the vesicle by the application of an emollient poultice. If it be desired to produce a permanent blister, the raw surface may be dressed with cantharidal or savine ointment, or other irritating substance. The endermic method of medication, which was formerly more used than it is now, consists in applying various drugs, especially morphia, to a freshly blistered surface ; this plan of treatment, though efficient, is now almost altogether superseded by the hypodermic mode, which is usually preferable. Issues may be established by the employment of moxa, by means of various caustics, or by the knife. Moxa may be made of different mate- rials, the simplest, and therefore the best, being cotton-wool or lint saturated with a solution of nitre, and rolled, after dry- ing, into the form of a cone. This should be applied by means of an instrument called a " porte-moxa," or moxa-bearer, and should be ignited at the top of the cone, the surrounding tissue being protected by means of wet lint. The moxa is a very painful application, but is probably the best means of making an issue wrhen a profound impression is desired. Caustic issues may be made with Yienna paste ; this is a mixture of five parts of caustic potassa with six of quicklime. It is made into u paste with alcohol, and applied through a perforation in a piece of adhesive plater. Fifteen or twenty minutes' contact will usually insure the formation of a sufficient eschar. An issue may be made with the knife, by making a simple or a crucial incision, preferably by transfixing a fold of skin and cutting out- wards. When suppuration is fairly established, the; issue may be kept open by the use of irritating ointments, or by the appli- cation of glass beads or issue peas, held in place by strips of plaster. Setons.—A seton is a sinus, kept from healing by the introduction of a foreign body; it is, in fact, an issue with two orifices. In the subcuta- neous tissue a seton may be established by means of a long and broad needle, which carries a thread or strip of muslin (to be left in the wound), or by transfixing a fold of skin with a sharp, straight bistoury, and passing :a Fia. 21. Porte-moxa. REVULSION AND COUNTER-IRRITATION. 87 an eyed probe carrying the foreign body along the track of the knife A seton may be kept open for a long time, when it is intended to act as a derivative, or it may be temporary merely, when the object is to excite a limited degree of irritation. Actual Cautery.—The cautery is the most powerful counter-irritant which the surgeon possesses. It is applied by means of irons of various shapes heated to a red or white ' heat in a convenient char- coal furnace. The gas cau- tery is used by directing a- jet of burning gas upon the part to be cauterized, while the galvanic cautery, orig- inally suggested by Hei- der, and made practically useful by Marshall and Middeldorpff, consists of a pair of forceps with long and narrow blades, hold- bn/m°eansr nf ?lf^T ^ Whlch aro aPPIicd Cold> and afterwards heated b> means of the galvanic current (Fig. 23). Ritter has invented, and Fin. 22—Different forms of cautery iron. Fia. 23.—Marshall's galvanic cantery. f/3 haS imV^jed, a "secondary battery," by which electricity can be thP oT"^' aS l\ Wei'eil f°rJUture USe- This veiT mgenious addition to the oahanic cautery has been successfully employed by Buchanan, of Ixlasgow. Paquelin has introduced a modification of the actual cautery Fio. 24.—Paquelin's cautery. 88 MINOR SURGERY. which acts by utilizing the property of heated platinum-sponge to become incandescent when exposed to the action of certain gases, and particularly the vapors of naphtha or rhigolene. (Pig. "24.) Acupuncturation is sometimes used as a means of counter-irritation in cases of neuralgia, etc., or to allow effused fluids to drain off", as in cases of oedema. It is effected by introducing long and slender needles with a slow rotary motion, accompanied with slight pressure, taking care not to wound important structures. Elect ro-punctur at ion is effected by passing a current of electricity through the ordinary acupuncture needles, which are previously introduced. Hypodermic Injection__The hypodermic method of treatment is now very much used, and it is probable that its full capabilities have not even yet been developed. The physician employs a considerable variety of drugs* by this method, but the only remedy which is much used in surgery by hypodermic injection is morphia, though mercury is occasionally thus administered in cases of syphilis, and ergot in cases of fibroid tumor of the uterus. The most convenient preparation of morphia for hypodermic use is the strong solution of the sulphate known as Magendie's solution. Its strength is sixteen grains of the salt to the fluidounce, and eight minims, therefore, contain about a quarter of a grain of morphia, which is a large enough dose to begin with. The cylinder of the hypodermic syringe should be of glass, and graduated to minims, and the piston should fit accurately. In giving a hypodermic injection, the surgeon should pinch up a fold of skin with the fingers of the left hand, and thrust in the nozzle of the syringe with a quick motion and in a somewhat oblique direction ; great care must be taken to avoid any subcutaneous vein, as from neglect of this precaution serious symptoms of narcotic poisoning may be rapidly induced, the druir being instantly thrown into the circulation, instead of being gradually in- troduced by absorption from the subcutaneous areolar tissue. The nozzle of the syringe should be kept sharp and scrupulously clean; if it be not clean, its use is apt to be followed by considerable irritation, and sometimes the formation of a small abscess; a result which I have never known to follow the hypodermic injection of Magendie's solution with a clean syringe. The hypodermic injection of ether has been successfully employed in cases of surgical shock, as well as in those of collapse from post-partum hemor- rhage. Vaccination.—Yaecination is usually performed by the physician or accoucheur, rather than by the surgeon ; still, it may be regarded as a surgi- cal operation, and a brief reference to it will, therefore, not be out of place. A'accination may be effected either with the lymph of the vaccine vesicle, or with the dried scab ; the latter has been largely employed in this coun- try, and is usually quite satisfactory. The scab should be of a dark amber color, and not too thin ; a sufficient portion is to be shaved off with a lancet and rubbed up with a few drops of water till it forms a mixture of creamy consistence. The skin is then to be slightly abraded with a dull lancet until the slightest pink tinge is perceived, when the vaccine matter is to be ap- plied, and slowly worked in. Some surgeons prefer to introduce the vac- cine matter by two or three punctures, and others by minute incisions. The plan which I have described seems to me the best, as less likely to draw- blood, which might wrash away the matter, and thus defeat the operator's object. The place usually selected for vaccination is the left arm, about the point of insertion of the deltoid muscle. Some persons appear to be insus- ceptible to the vaccine influence, while in others the protective power of the operation appears to wear out in the course of years ; hence it is well to re- vaccinate from time to time, especially if the patient be exposed to the in- BLOODLETTING. 89 fluence of smallpox. Bovine matter is now commonly employed, but if humanized virus be used, the surgeon should select a good scab from a healthy child ; he should also look closely to the cleanliness of his lancet. Yaecination, like any other operation, may be followed by inflammation, or even by erysipelas, and there seems to be no doubt that on several occasions syphilis has been inoculated by careless vaccination ; hence too much caution cannot be exercised as to the source of the vaccination scab, and as to the cleanliness of the instrument employed. The best age for vaccinating in- fants is, I think, about the end of the third month, though it may, if neces- sary, be done at a much earlier period. Bloodletting__As was mentioned in the chapter on inflammation, the surgeon is now much less often called upon to draw blood than formerly ; still every practitioner should know how to bleed, apply cups, etc., and I shall, therefore, briefly notice the principal methods of surgical depletion. These are scarification, leeching, cupping, puncturation, venesection, and arteriotomy. Scarification.—This is done with light touches of a very sharp lancet or other knife. It is particularly useful in cases of violent conjunctivitis, when attended with great swelling or chemosis, and is often requisite to prevent destruction of the cornea in such cases. Leeching.—There are two varieties of leech employed in practice ; the American, which draws about a fluidrachm of blood, and the European, which draws at least four times as much. The part to be leeched should be well shaved and washed, and the leeches may be induced to begin their work by smearing the skin with a little warm milk or blood ; according to the late Prof. Gross, an almost infallible plan is to dip the leech in small-beer. Leeches may be applied with the fingers, or in rolled cards, or several together in a pill-box, etc. They should not be forcibly detached, but allowed to drop off of themselves, a process which may be hastened by sprinkling them with a little salt. The bleeding from the leech-bites may be encouraged by warm fomentations, or mav be repressed by exposure to the air, or by pressure with dry lint. If the bleeding be excessive, it may be neces- sary to touch the spot with nitrate of silver or the perchlo- ride of iron, or even to close the edges of the little wound with a delicate twisted suture. Leeches may be applied to the inside of the various mucous outlets of the body through appropriate specula. Capping is a convenient mode of employing local deple- tion. The cup is first applied so as to invite the blood from the deeper parts to the cutaneous surface; this is done by atmospheric pressure, the air in the cup being exhausted by means of a portable air-pump, or an elastic bulb of vulcan- ized India-rubber ; or, in the absence of these, a sufficient rarefaction may be produced by introducing the flame of a spirit-lamp for a few seconds into the interior of the cup, which is then quickly applied. The scarificator is provided icaiieech. with a number of blades, which are projected by means of a spring, and which can be set so as to cut more or less deeply, as may be required. The cup is first employed so as to produce superficial conges- tion ; it is then removed, and the scarificator instantly applied, and as quickly as possible replaced again by the cup, into which the blood will continue to flow until the vacuum is destroyed by the internal becoming equal to the external pressure. Dry cupping is effected by the use of the 1>U MINOR SURGERY. cup without the scarificator; it may be employed as a derivative in cases in which depict ion is not indicated. M. Junod has introduced an apparatus consisting of a pump, the cylinder of which is large enough to embrace a whole limb; it is made air-tight by means of a wide India-rubber band, and serves to dry-cup, as it were, the whole limb at once. Its inventor claims that it gives the benefits of general depletion without the evils at- tending the loss of blood, but though the instrument is certainly ingenious, I am not aware that it has been found of much practical utility. Under the name of mechanical leeches (Fig. 25), small instruments are sold which combine in one a cup, an exhausting apparatus, and a scarificator; they may be used when it is desired to draw blood from a very limited area, and when ordinary leeches cannot be obtained. Theobald, of Baltimore, recommends that, instead of using the scarificator, a superficial " nick" should be made with a delicate knife before adjusting the cup, and that a solution of carbonate of ammonium should be applied to prevent clotting and to encourage the flow of blood. Puncturation occupies a position midway between cupping and scarifi- cation. It is best done with the point of a sharp scalpel or bistoury, and, in addition to its depletory effect, is often serviceable by relieving tension. It is principally used in cases of diffuse areolar inflammation or of erysipe- las. The punctures may often be advantageously extended into limited incisions, but should not penetrate deeper than the subcutaneous tissue. A form of puncturation which is often employed by the general practi- tioner, is "lancing the gums," in cases of difficult dentition. Venesection.—Yenesection. or phlebotomy, consists, as its name implies, in the division of a vein; it is the ordinary operation by which general bleeding is effected. It may be done with a bistoury, with an ordinary thumb-lancet, or with a spring-lancet or fleam. On the very few occasions on which I have had recourse to venesection, I have employed a simple lancet, and believe it to be as convenient and perhaps safer than any other instrument. In this country, and in England, bleeding is almost always done from one of the veins at the bend of the arm, preferably, the median- cephalic, as its course is further from the line of the brachial artery than that of the median-basilic. In France, bleeding is occasionally practised from the veins of the foot. To prepare a patient for bleeding, the upper arm should be surrounded with a fillet or folded handkerchief, so as to in- terrupt the venous but not the arterial circulation, and thus render the superficial veins full and prominent; the sitting posture is usually the best, and the patient may grasp a stick, to steady the limb, which is held out in a semi-supine position. The opening in the vein should be made with an oblique puncture, the lancet cutting its way out, as it is withdrawn. The vein should be compressed below the point of section with the thumb of the surgeon's left hand, until the cut is completed, that a premature gush of blood may not obscure the seat of operation. If tin; blood flow sluggishly, the patient may be directed to alternately increase and relax his grasp of the stick which he holds, the action of the muscles of the forearm tending to increase the rapidity of the flow of blood. The bleeding will usually cease at once upon the removal of the fillet, when the wound may be li»htly dressed writh a small compress and a figure-of-8 bandage. When bleedin-' is done at the foot, the saphena vein is opened above the inner malleolus. Sometimes the external jugular vein is opened in cases of apoplexy, or in children when the arm is very fat; a compress is placed over the vein im- mediately above the clavicle, and the vessel is opened where it crosses the sterno-cleido-mastoid muscle; the chief risk in this operation is from the admission of air into the vein. TRANSFUSION OF BLOOD. in bv Arteriotomy is practised on the temporal artery, or preferably on its anterior branch, above the outer angle of the eyebrow; the section should be made obliquely with a sharp bistoury, and, when enough blood has been drawTn, should be made complete, so as to allow the ends of the vessel to retract. A firm compress and bandage should then be applied. Transfusion of Blood.—This operation may be sometimes re- quired in cases of profuse hemorrhage, as in flood- ing during or after labor. The chief precautions necessary are to prevent the blood from coagula- ting before it is injected, and to avoid introducing air into the patient's vein. Blood from a healthy by- stander is drawn into a tumbler, kept at the tem- n , i , t i Fia. 26.—Apparatus for transfusion of blood. perature of the body by being surrounded with warm-water, and, having been defibrinated1 "whipping" with a glass rod, table-fork, or other convenient implement, is injected, in quantities of two fluidounces at a time, by means of an or- dinary syringe (or, as advised by McDonnell, of Dublin, a glass pipette), into the median-basilic vein, which has been previously laid bare; the whole amount injected should not exceed three-quarters of a pint to a pint. By using a syringe with a sharp-pointed nozzle, the vein may be injected without having been previously exposed. An ingenious but somewhat more complicated apparatus for transfusion of defibrinated blood has been devised b}T Mr. T. W. Carroll Jones. The late Prof. Gross employed a convenient instrument by which the blood wras made to flow into an ex- hausted receiver, and thence by a gum-elastic tube directly into the patient's vein, while M. Maisonneuve uses a simple flexible tube with a bulb provided with valves, so as to pump the blood directly from one vein into the other. Other forms of apparatus for the direct transfusion of un- defibrinated blood have also been devised by Monocq, and by Roussel, of Geneva. Duncan, of Edinburgh, advises, in cases of dangerous hemor- rhage during an operation, that re-infusion of the patient's own blood should be substituted for transfusion. The blood is caught in a vessel containing a 5-per-cent. solution of phosphate of sodium—one part of the solution to three or less of blood—so as to prevent coagulation, and is then slowly injected into an open vein. Arterial transfusion, or the in- jection of defibrinated blood into the radial or posterior tibial artery, is recommended by Hueter as preferable to the ordinary procedure. Saline injections into the veins have been tried with some success in cases of cholera collapse, as has the injection of milk by Dr. E. M. Hodder, of Canada. Milk injections have also been employed under various circum- stances, with more or less benefit, by Dr. T. G. Thomas, Dr. J. W. Howe, and Dr. Bullard, of New York ; by Dr. Pepper, Dr. Hunter, and Dr. E. Wilson, of this city ; by Mr A. Meldon, of Dublin, and by other sur- geons ; according to Laborde, the amount injected should not exceed 200 grammes (about fjvj) at one sitting. Karst, Schmeltz, and Ziemssen, 1 Afanassiew, a Russian physiologist, suggests that the blood should be peptonized instead of being defibrinated. 92 AMPUTATION. recommend hyjwdermic injection of defibrinated blood as a substitute for transfusion, while Ponfick, Bizzozero, Kaczorowski, and <{<>lgi advise similar injections into the ]>critoneal cavity, a procedure, however, which caused fatal peritonitis in a case recorded by Mosier. Rutgers, of Rotter- dam, employs saline solutions by the intraperitoneal method, and Wylie recommends the use of hot saline enemata as a substitute for transfusion. Fabrini suggests inhalations of defibrinated blood, administered with an ordinary spray apparatus. According to Lombroso and Atthill, the ope- ration of transfusion is in itself not free from risk, and should not be re- sorted to in any case in which cardiac or pulmonary disease is present. In order to prevent the shivering which usually follows the operation, Bitot advises that quinia should be administered two days previously. Aspiration__This is an operation which has for its object the with- 'drawal of fluid from a closed cavity without the admission of air. The use of a suction-trocar has long been familiar to American surgeons through the labors of Drs. Bowditch and Wyman, of Boston, to whom its introduc- tion is due, but the aspirator of Dieulafoy is a more perfect instrument, and that gentleman is justly entitled to the credit of having generalized and popularized its employment. The aspirator, as improved by Potain (Fig. 27), consists of a jar or bottle connected by flexible tubes on one side with an exhausting pump, and on the other with a delicate canula carrying a fine trocar, the apparatus being provided with stop- cocks to prevent the admission of air. A vacuum having been established in the jar, the trocar and canula are introduced by a quick thrust into the part affected, when, the stopcock being opened and the trocar with- drawn, any fluid that Fki. 27.—Aspirator. is present is forced out (if not too thick to flow through the canula) by atmospheric pressure, and is collected in the reservoir. The most useful applications of the aspirator are, I think, to cases of hydrothorax and empyema, to cases of cold abscess connected with the hip or spine, and to cases of distended bladder from stricture or prostatic enlargement. Tachard has proposed to modify the construction of the aspirator by the introduction of the siphon principle. CHAPTER V. AMPUTATION. It is often said, by unreflecting persons, that amputation is the oppro- brium of surgery, and indeed the proposal to cut off" a limb must be con- sidered as an acknowledgment of failure on the part of the surgeon to effect a cure in any other way. But when we consider that an amputation is HISTORY. 93 never done except with a view of saving life, wrhich is more or less endan- gered, or to remove what is no longer of service, but a mere useless and troublesome appendage, it must be confessed that no operation can more truly deserve the name of conservative; "the humane operation" it was called by some of the older surgical waiters, and it is probable that there is no other procedure in the whole range of operative surgery which has saved so many lives and obviated so much suffering as this. The w^ord "amputation," as now used, is generally understood to apply to the removal of a limb, though wre still speak of amputating the penis, and some writers employ the term also for excision of the breast. A limb may be amputated through its bones or through its joints; the former operation is an amputation in the continuity of the limb, or. simply an amputation ; the latter, an amputation in the contiguity, a disarticulation, or an exarticulation. History—The ancients generally amputated merely through parts already dead, probably from fear of hemorrhage, to control which they had very imperfect, if any, means. It is probable, however, that Celsus, who lived about the beginning of the Christian era, wyas in the habit of ampu- tating through living structures, and he also divided the bone at a higher level than the soft parts (thus anticipating in some degree the modern circular operation); he was acquainted with the use of the ligature, but whether or not he applied it to the vessels after amputation, is not quite certain. The use of a fillet to control the circulation, before amputating, is due to Archigenes, who, however, neglected the preliminary dissection of the soft parts, dividing the entire limb at the same level, and using a hot iron to arrest the bleeding. Until the latter part of the seventeenth century, there was little improvement upon these rude procedures; Pare had indeed introduced the ligature, but it was not generally adopted, and amputations were still done in essentially the same way that wras pre- scribed by Galen and his followers. Many surgeons dreaded to cut through living parts at all, and others sought to prevent bleeding by the use of heated knives. The first tourniquet wras introduced by Morel, in 1674, and a few years later an English surgeon, named Young, devised, apparently independently, a similar contrivance. These early tourniquets consisted merely of a fillet twisted with a stick, very much, in fact, like the simple apparatus which is now known as the Spanish windlass. Morel's tourniquet was subsequently improved by the celebrated Petit, and the instrument wiiich he devised is essentially that which is used at the present day. This illustrious Frenchman, and the English Cheselden, began about the same time to operate by a double incision, cutting first the skin and subcutane- ous fascia, and then the muscular tissue and bone at a higher level. Louis, on the other hand, returned to Celsus's plan, and cut down at once to the bone, which he then divided higher up; he also employed digital pressure in place of the tourniquet, believing that the latter interfered with the retraction of the muscles. The modern circular operation, a combination of Petit's and Cheselden's with that of Louis, wras perfected by Benjamin Bell and Hey towards the latter part of the last century. Another form of circular amputation wras practised by Alanson, who, after dividing the skin, attempted to cut the muscles into the shape of a hollow cone, by a sweep of a knife held in an oblique position. Other operators, howTever, did not succeed in carrying out Alanson's instructions (the almost inevi- table result of his operation, according to his opponents, being a spiral incision which would terminate at a higher point than its commencement), and the "triple incision" of Hey soon became the common English opera- tion, though Alanson's was still successfully practised by Dupuytren and 94 AMPUTATION. others in France. Tn the meanwhile, amputation by means of a flap, cut from without inwards, was introduced, or, according to Yelpeau, re-intro- duced, by Lowdham and Young in England, and shortly afterwards the formation of a flap by transfixion, by Yerduin, of Amsterdam. The flap operation was subsequently improved by several other surgeons, and was finally adopted and brought into common use by the labors of Liston and Guthrie in England, of Klein and Langenbeck in Germany, and of Pupuy- tren, Larrey, Roux, and some others in France. All the different methods of amputation may be considered as mere varieties of these two principal modes, the flap and the circular.1 Conditions Requiring Amputation—The circumstances which may render amputation necessary are manifold ; they will be fully discussed in subsequent chapters, in considering the various injuries and diseases to which the human frame is liable, but I may here briefly enumerate the following, as the principal conditions which are considered to indicate the removal of a limb. 1. When a limb is torn off by the action of machinery, or carried away by a cannon-ball, there can be no question as to to the propriety of amplia- tion. The operation may indeed be said to have been already done by the accident which caused the injury, and all that remains for the surgeon to do is to put the wound in such a condition as to promote its healing, and insure the formation of a well-shaped stump. 2. Mortification, when the gangrene is more extensive than a mere superficial slough, is usually a cause for amputation. The ordinary rule, and a very sound one under most circumstances, is that the surgeon should not operate until the line of separation is wrell established: thus, in the form of gangrene resulting from the intensity of the inflammatory process (as after frost-bite), no operation should be done wThile the mortification is still extending, but the surgeon should wait until nature herself indicates that the limit of the destructive process has been reached, and may then amputate at any convenient point above the line of separation. On the other hand, in the strictly local forms of gangrene resulting from direct injury, as in compound fractures, amputation should be performed as soon as the signs of mortification are unequivocally manifested; delay will commonly cause the loss of the patient, before time has been afforded for the formation of any line of demarcation. In traumatic or spreading gangrene, also, immediate amputation is imperative. There is another class of cases, principally met with in military practice, which often demand immediate amputation. This is where gangrene follows upon an arterial lesion at a distant point, as in mortification of the foot from a wound of the femoral artery. The gangrene, in such cases, first shows itself by a change in the color of the affected part, which is at first pale and tallowy, and subsequently becomes mottled and streaked; there is at first numbness, followed by insensibility of the mortified member. In such cases, I think with Mr. Guthrie, that while the gangrene remains limited to the toes or foot, it is right to wait, in hopes that it will not pass further; but if it manifests a tendency to spread above the ankle, amputation should be at once performed at the point where experience shows that the morbid action is likely to cease, that is, a short distance below the knee. In a similar condition of the arm, amputation should be performed at the shoulder-joint. With regard to the dry gangrene which attacks the extremities of old persons, it is generally advised to refrain from amputation altogether, from 1 I would invite the reader who is interested in the history of amputation to consult my article in the International Encyclopaedia of Surgery, 2d edit., vol. i. p. 557 where I have gone into the subject much more fully than I can do here. CONDITIONS REQUIRING AMPUTATION. 95 the fear that the morbid action would recur in the stump; and, indeed, the constitutional state of patients thus affected is usually so unfavorable for any operation, that the surgeon would naturally hesitate about proposing to amputate. It has, however, been suggested that as this senile gangrene, often at least, depends on arterial obstruction, a better chance would be afforded by amputating high up in the thigh than by any other mode of treatment; and this plan has been actually put in practice by James, of Exeter, Jonathan Hutchinson, and some others, with favorable results. It is obvious, however, that the additional risk from the operation itself would be so great, that it could be only justifiable in exceptional cases. Amputation is sometimes required in cases of hospital gangrene, either after the cessation of the process, on account of the extensive destruction of parts, or even during its progress, on account of profuse hemorrhage which may occur from the opening of a large artery. 3. Amputation is sometimes necessary to remedy the evils produced by exposure to heat or cold. In case of frost-bite, if merely the fingers or toes are affected, it is better to allow the dead parts to be spontaneously separated, and to trim off the stump subsequently ; if the mortification be more extensive, amputation may be done through the dead tissues (in order to remove a useless and offensive mass), and a second amputation be performed wThen the line of separation has been clearly established. In cases of burn or scald, it is proper to wait until the sloughs have spon- taneously come away, and until the reparative power of nature has been fully tested, wrhen, if it be found manifestly inadequate to the task, an amputation may be performed with the best prospects of a favorable result. 4. Compound fractures and luxations frequently render amputation necessary. The majority of primary amputations in civil hospitals are for these accidents, and the number of such cases wThich require removal of the limb is constantly becoming larger, with the multiplication of railroads and the consequent increase of travel. 5. Lacerated and contused wounds produced by railway or machinery accidents, by the attacks of wild animals, etc., may require amputation, even though the bones have escaped injury. 6. Amputation is very often rendered necessary by gunshot injuries. Though so much has been done of late years to save limbs in military practice by the introduction of excision as a substitute for amputation, still the latter must always continue to be a frequent operation in the hands of the army surgeon; and, indeed, in no case is it more truly the "humane operation" than in the frightful injuries which are produced by the missiles of warfare. 7. Various affections of the bones and joints require removal of the limb. The number of cases of this kind which are now submitted to amputation is happily gradually becoming more limited, thanks to the introduction of excision, and to the modern improved methods of treating these affections without operation. Still, it is probable that there will always remain a certain number of cases, in which the destruction of tissue is so extensive that nothing short of amputation will avail to save life. 8. Amputation is required in certain lesions of arteries ; thus, if the popliteal artery be ruptured, amputation is almost always indicated. Again, certain traumatic aneurisms, or spontaneous aneurisms which have become diffuse, are more safely treated by amputation than in any other wray. 9. Morbid growths may render amputation imperative. Even non- malignant tumors may, from their size or other circumstances, call for removal of the affected limb, while malignant affections of the extremities, especially if the bones be involved, almost always demand amputation. 96 AMPUTATION. 10. Tetanus has been considered a cause for amputation, and the opera- tion has occasionally been followed by recovery from the disease. The experience of the profession has, however, shown that amputation cannot be regarded as a remedial measure under such circumstances, and few- surgeons would now think it right to add the risk of a capital opera- tion, when there is so little prospect of benefit accruing; if, however, amputation were in any case otherwise indicated, the occurrence of tetanus would be an additional'reason for the performance of the operation. Ampu- tation is not justifiable in cases of hydrophobia, nor in those of poisoned wound, from bites of serpents, etc. 11. Filially, amputation may be required for the relief of deformity, whether natural or acquired. These are operations of complaisance, and should, therefore, only be performed within the limitations specified in the chapter on operations in general. Instruments__The instruments required for amputation are a tourni- quet or other means of controlling the circulation, knives of various shapes and sizes, saws, bone-nippers, artery forceps and tenacula, ligatures, retrac- tors, sutures and suture needles, and scissors. Tourniquet.—The use of the tourniquet in amputation has been repro- bated by some excellent surgeons, among others by the late Mr. Guthrie. The only objections to it are that it produces a certain amount of venous congestion, and that it may interfere with the muscular retraction which is desirable in the circular operation.1 But by taking care to elevate the limb before screwing up the tourniquet, and not to do the latter till the moment before making the incisions, the interference with the return of venous blood is so slight as to be unimportant, while the difficulty as regards the muscles can easily be obviated by retrenching the bone, if necessary, after the vessels have been secured and the tourniquet removed. In fact, the evils of this instrument are more apparent than real, while its advantages are manifest and incontestable. Guthrie; and Hennen speak of compressing the artery with one hand while the amputation is done with the other, but such a course seems to me more adapted to show the skill and fearlessness of the surgeon than to promote the good of the patient; safety should never be sacrificed to brilliancy, and there can be no question that a well-applied tourniquet renders an ampu- tation safer than the best directed manual pressure; for while the latter can only check the flow of blood through the main vessels, a tourniquet controls all the arteries at once, and it is often the smaller vessels that give the most trouble. To prevent loss of venous Fio. 28.—Esmarch's apparatus for bloodless operations. blood, Silvostl'i and Esmarch suggest that the limb should be first bound with an elastic bandage from below upwards, and then surrounded at the highest point with a band or tube of caoutchouc instead of a tourniquet; the lower bandage is then to be removed, when the opera- tion may be performed in temporarily bloodless tissues. Esmarch's method 1 It has been recently maintained that pyemia is caused by the use of the tourni- quet, which is supposed to cause venous thrombosis at the point of application ; but all that is known of the circumstances under which pyaemia occurs discountenances such an idea. INSTRUMENTS. 97 has been largely employed by surgeons during the last few years, and with very general satisfaction ; from my own experience I am prepared to recom- mend it as a valuable resource in cases in which the anaemic state of the patient renders it more than ordinarily important to avoid the loss of blood, or in which it is necessary that the field of operation should not be obscured by bleeding. It should not, however, be employed unnecessarily, as its use has been sometimes followed by troublesome consecutive hemorrhage, by paralysis or even gangrene of the limb to wrhich it has been applied, and, it is said, by embolism of the pulmonary artery and death. To prevent the oozing which follows removal of the tube, Nicaise advises compression of the wound with a sponge, dipped in a 1-50 solution of carbolic acid, while Riedinger applies an. induced currrent of electricity. Esmarch him- self dresses the stump in a vertical position before removing the tube, and keeps it in that position for half an hour subsequently. My own practice is to employ both the tube and ordinary tourniquet (at a higher point), removing the former as soon as the main vessels have been secured. Ingenious modifications of Esmarch's tourniquet have been devised by Foulis, H. L. Browne, and others. The best tourniquet for ordinary use is that known as Petit's, from hav- ing been introduced by the celebrated French surgeon of that name. It consists of two metal plates, the dis- tance between which is regulated by a screw with a strong linen or silk strap provided with a buckle. It is thus applied : a few turns of a roller are passed around the limb, and a firm pad or compress thus secured immediately over the main artery. Upon this pad is placed the lower plate of the tourniquet, so that the artery is held between this plate and the bone, and the strap is buckled tightly enough to keep the instrument in place. When the surgeon is ready to make his incision, the screw is turned so as to separate the plates and thus tighten the strap till the arterial circulation is entirely checked. It is often said that, pro- vided that the compress is placed over the artery, it makes no differ- ence to what part of the limb the no. 29.—Petit's tourniquet. tourniquet plate is applied; this is a mistake, and a moment's reflection will show that it is so: the mechanism of the tourniquet is such that it makes direct pressure at two points only, viz., immediately below the plate, and at a point diametrically opposite; at every other point of the circumference the pressure exerted by tightening the strap is oblique or gliding. Hence, unless the plate be immediately over the artery, or diametrically opposite to it, the effect of turning the screw will be inevitably to push the vessel more or less to one side, and thus the circulation may not be controlled, though the instrument be ap- plied as tightly as possible. Hence, as a rule, the tourniquet plate should go immediately over the artery ; where this is not practicable, as in the 1 98 AMPUTATION. case of the axilla or the popliteal space, it should be placed at a point dia- metrically opposite. Various other forms of tourniquet have been devised, but none of them approach in value to that of Petit. The ordinary field tourniquet, as it is called, consists merely of a strap and buckle with a pad to go over the ves- sel ; ii is no better than the common gar rot, or Spanish windlass (Fig. 30), made with a stick and handkerchief. Other forms are the horseshoe, or Si(/noronfs tourniquet (Fig. 31), Skey's tourniquet (Fig. ii'2), and the Fi(i. 30.—Spanish windlass. Fio. 32.—Skey's tourniquet. Fio. 31.—Signoroni's tourniquet. Fig. 33.—Lister's aorta-compressor. (Erichsen.) various artery compressors, which are designed so as not to control the smaller vessels ; however useful these may be for cases of aneurism or acci- dental hemorrhage, they are not, I think, as good as Petit's instrument for employment in ordinary amputations. In certain special operations, INSTRUMENTS. 99 however, these are very valuable; thus hip-joint amputation is shorn of half its terrors by the use of Skey's tourniquet or Lister's aorta compressor (Fig. 33). Amputating Knives.—Formerly surgeons used for the circular operation a knife with but one edge and a very heavy back, shaped somewhat like a sickle; the modern amputating knives, however, which are adapted for either the circular or the flap operation, have a sharp point, and are usually double edged for an inch or two at the extremity. The length of the knife should be about one and a half times the diameter of the limb to be removed, and its breadth from three-eighths to three-quarters of an inch. Thus, a knife with a cutting edge eight or nine inches long will answer for most amputations of the thigh, while one with an edge of six or seven inches will do for smaller limbs. Double-edged catlins (Fig. 35) are used Flu. 34 —Amputating knife. Fiu. 35.—Catlin or double-edged knife. principally for the leg and forearm, and are convenient in freeing the inter- osseous space for the application of the saw; their width should not exceed three-eighths of an inch. Beside the ordinary amputating knives, the sur- geon should have at hand one or two strong bistouries or scalpels (Figs. 36 and 37), about three inches long, while for smaller amputations, as of the fingers, a very slender The blade of such a knife Fm- 36.-Bi«tonry. should be about two inches are rather smaller than those usually directed, but are, I think, such as will be found satisfactory in most cases; for my own part, I much prefer a small knife to a large one, and have, indeed, occasionally used a three-inch blade for the largest limbs, having found it quite ample even for amputation at the hip-joint. The handles of amputating knives should be of a rough ebony, which is less likely to slip when bloody than either bone or ivory. Fio. 38.—Amputating saw. Saxes.—The amputating saw should be about ten inches long by two and a half wide ; it should be strong, with a heavy back, so as to give acldi- 100 AMPUTATION. tional firmness, and the teeth not too widely set, but just enough to pre- vent binding. For operations about the hand or foot, a small saw with a movable back (Fig. 39) will often be found useful. Fig. 40.—Bone nippers. Fio. 41.—Levrouest's periosteotomy Fio. 39.—Small amputating saw. Bone-nippers or (Jutting Pliers may be used in amputating the pha- langes, or for smoothing off any rough edges left by the saw in larger operations. Ten or twelve inches is a good length, of which the blades should not occupy more than two inches; the blades, which are sharp, should be set at an obtuse angle with the handles, which must be very strong, and roughened to prevent the hand from slipping. The Periosteotome or Raspatory (Fig. 41) is used for sep- arating a cuff of periosteum which, after sawing the bone, is drawn down over its end and secured with cat-gut sutures so as to avoid necrosis and prevent adhesion of the soft tissues. Artery Forceps and Tenacula are used for taking up the ves°els; 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 distance above the points, that the ligatures may easily slip over without including the instrument itself in the knot; they may be made to fasten with a catch, or, which I think is better, be provided with a spring which keeps them closed except when opened by pressure of the sur- geon's fingers. The tenac- ulum, or sharp hook, must be of sufficient size and but slightly curved ; it is not as good an instrument as the forceps for most cases, but is sometimes useful, especially where the parts are matted to- gether 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 with two tenacula, and throw a ligature around the wThole. Though I have never seen any harm result from this ligature en masse, it should not be practised when it can be avoided, and, as far as possible, each vessel should be drawn from its sheath and tied separately. Fni 42.—Artery forceps closing by their own spring. -Tenaculum, or sharp hook, with which the arterial" orifice is picked out. INSTRUMENTS. 101 The late Dr. Hodgen, of St. Louis, devised an ingenious artery forceps, which drew the artery from its sheath by its own weight, and was provided 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, horse- hair, iron or silver wire, or more commonly, and I think better, unless the antiseptic method is adopted, of fine whip-cord or strong sewing-silk. For antiseptic operations the ligatures are best made of catgut, prepared with carbolic acid or with oil of juniper and alcohol. Plaited silk is better than that which is twisted, and it should be cut into lengths of about eighteen inches, and well waxed to fit it for use. The ordinary skein of silk con- tains about six yards, and is thus sufficient for twelve ligatures. In ordi- nary amputations the number of vessels requiring ligature is from eight to twelve, but if there has been inflammation, causing enlargement of the small arteries, as many as twenty or twenty-five ligatures may be neces- sary. 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 peculiarities of wThich can be better understood from the annexed cut than from any description (Fig. 44). It is usual after tighten- ing 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 Fig. 44.—The reef-knot. Fia. 45.—Surgeon's knot and reef-knot combined. which surrounds the main artery, knotting them together for purposes of distinction. Catgut ligatures should be tied with a "surgeon's knot" and "reef-knot" combined (Fig. 45), and both ends should be cut short. Some surgeons apply a single knot only to small vessels. I see no advantage in this plan, wrhich is certainly not as safe as the use of the common reef-knot. Acupressure may be used to secure arteries after amputation, as may vari- ous ingenious modifications of acupressure, in which a wire is used instead of a needle; these will be considered in the chapter on wounds of arteries. The Retractor consists of a piece of muslin, six or eight inches wide, one end of which is split into two tails for the thigh or arm, and into three for the leg or forearm. It is applied around the bone or bones to keep the soft tissues from being injured by the saw, and to prevent bone- dust from being caught among the muscles, an occurrence which might interfere with the healing process. The Sutures may be applied with the ordinary "surgeon's needle," which for use in stumps should be strong and straight, or but slightly curved; or, if the flaps be very thick, a needle, mounted 102 AMPUTATION. in a handle and with the eye near the point, such as is used in the operation of strangulating a naevus.'will be found convenient, The best material for the suture is, I think, silver, lead, or malleable iron wire, though this is a matter which may be safely left to the fancy of the operator. Scissors are used to cut the ligatures and sutures, or to retrench any projecting nerves, tendons, or masses of fascia. Operative Procedures.—The various modes of amputating may be considered as mere modifications of the two original forms of the operation, the circular and the flap ; thus the oval operation, or that of Scoutetten, is based upon the circular, while the different methods of 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 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, while another assistant holds the affected Fio. 47.—Amputation by circular method. (Druitt.) limb in such a position as is convenient for the operator. The latter should stand so that his left hand will be towards the patient's trunk; thus in amputating the right leg the surgeon stands on the patient's right side, while in removing the left leg he stands between the patient's limbs. The surgeon then, steadying and drawing upwards the skin with his left hand, slightly stoops, and carries his right hand, which holds a knife of sufficient length, around the patient's limb, so that the back of the knife is towards his own face. Pressing the heel of the knife well into the flesh, he makes a circular sweep around the limb, rising as he does so, and thus being enabled to complete the whole or at least the greater part of the cutaneous incision with one motion; a few light touches of the knife will now allow consid- erable retraction of the skin, and, if the limb be sle-nder, this degree of retraction may be sufficient. The first incision must completely divide all the structures down to the muscles. If the skin have not retracted suffi- ciently, the surgeon now, either with the same knife or with an ordinary scalpel, rapidly dissects up a cuff of skin and fascia, about half as long as the limb is thick. In doing this, care must be taken to cut always towards the muscles; neglect of this rule will cause division of the cutaneous vessels and consequent sloughing of the part. Having done this, the ope- rator grasps the cuff of skin with his left hand, and, with the large knife, OPERATIVE PROCEDURES. 103 makes another circular cut at the point of the cuff's reflection, 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 sufficient, how- ever, the surgeon quickly separates the muscular structures from their periosteal attachments, with the finger or the handle of a scalpel, pressing them back and thus clearing the bone for the space of about two inches. If the limb contain two bones, the interosseous tissues must be divided with a double-edged knife or with the ordinary scalpel. The retractor being applied and firmly drawn upwards, the bone is now to be sawn at the highest point exposed. It is well first to divide the periosteum and push it back with a raspatory or periosteotome (Fig. 41), and to use the saw lightly at first, so as to avoid splintering. In the forearm, both bones should be divided simultaneously, and at the same level ; but in the leg, the fibula should be sawn first, and about half an inch higher than the tibia. 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 sawr nor to allow the bone to break before the section is completed. As soon as the limb is removed the surgeon secures the vessels, momentarily loosening the tourniquet, if necessary, that the gush of blood may indicate the position of the smaller arteries, and, when all bleeding is checked, proceeds to dress the stump. If any projecting spicula have been left by the saw, they must be removed with strong cutting pliers, and any tendons or nerves that hang out from the stump should be cut short with sharp scissors. The skin cuff is then brought together with sutures, so as to convert the circular into a linear incision, its direction being horizontal, vertical, or oblique, according to the fancy of the operator. 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.1 Flap Method.—Amputation by the flap method is susceptible of an almost infinite number of variations. Thus there may be onty one flap, more commonly two, or even a larger number. The flaps may be cut antero-posteriorly, laterally, or obliquely ; they may be made by transfix- ing the limb and cutting outwards, or may be shaped from without inwards, or one may be made by transfixion and the other from without. They may include the whole thickness of tissue down to the bone, or merely the skin and superficial fascia, or they may embrace the 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 operation, 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. Holding the blade in the axis of the limbs, 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- ries it on the other side of the bone, brings it out with the same precautions as at first, and cuts his second flap. He then applies the retractor, makes a circular sweep to divide any remaining fibres, and saws the bone as in the circular operation. In many situations, as in the front of the leg where 1 Mr. R. Davy makes a very long cuff of skin, and, after securing the vessels, purses it up and ties it with a piece of tape. He calls this the " coat-sleeve method" of amputation. 104 AMPUTATION. Fig. 48.—Amputation by antero-posterior flap opera- tion. (Bryant.) 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 re- tracting more than the muscles, which project and interfere with the closure of the wound. Hence it is often better to make at least one flap by cutting from without inwards, dividing the skin and superficial fascia by the first incision, and the muscles by a second, at a higher point. In view of the wasting and gradual disappearance of mus- cular tissue, which always take place in a stump, some surgeons think to save time and trouble by making flaps of skin only; but apart from the danger of sloughing, which always at- tends these long skin flaps, un- supported by muscle, the resulting stump is less serviceable, for though the true muscular structure does indeed disappear, the fibrous sheath of the muscle remains, becoming condensed into a thick pad which forms a very necessary covering for the bone. In making antero-posterior flaps by transfixion, the anterior one should be cut first; if the flaps are shaped from without inwards, the lower should be formed first, as otherwise the blood from the first incision would obscure the line of the second. In making lateral flaps, the outer should be the first cut, and, generally, it may be stated that the flap should be first formed which does not contain the principal artery. I have advised that for the flap as well as for the circular operation the surgeon should stand with his left hand towards the patient's trunk. Many Authors, however, including Mr. Liston and Mr. Erichsen, direct that exactly the opposite posture should be assumed, with the left hand on the part to be removed. I have no doubt that every one will find that position most convenient to which he is most accustomed ; but I consider that above recommended to be the best, as permitting 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 metacarpophalangeal joints, and, with a slight modification, constitutes Larrey's well-known method of amputating at the shoulder-joint. Another form of the oval operation, which in this case should rather be called elliptical, is particularly adapted to the knee and elbow-joints, though it is applied by the French to other parts as well. The incision in this form of amputation constitutes a perfect ellipse, coming below the joint on the front or outside of the limb; the resulting flap is folded upon itself, making a curved cicatrix and furnishing an excellent covering for the stump. Modified Circular Operation.—This plan seems to have been suggested by Mr. Liston, and was afterwards improved and largely employed by Mr. Synie. 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 OPERATIVE PROCEDURES. 105 cutting with a suitable knife twTo 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. 49 —Modified circular amputation. (Skey.) TeaWs Method by Rectangular Flaps.—This operation, which was introduced and systematized by Mr. Teale, of Leeds, about thirty years ago, undoubtedly furnishes a most elegant and serviceable stump. There are twro flaps of unequal length, the shorter always containing the main vessel or vessels of the limb. The flaps are of equal width, but while one has a length of half the circumference of the limb at the point where the saw is to be applied, the other is but one-quarter as long (i. e., one-eighth of the circumference). The lines of the flaps should be marked with ink or crayon before beginning the operation, as otherwise, especially in dealing with a conical limb, it" is almost impossible to cut the long flap of the requisite rectangular shape. Both flaps are to embrace all the tissues down to the bone, and the long flap, wThich is in shape a perfect square, is, after sawing the bone, folded on itself, and attached by points of suture to the short flap (Fig. 50). 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 withdrawn from the line of pressure, in adapting an artificial limb; its disadvantage 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 increasing that of the short flap. I have myself employed this modified form of Teale's operation (keeping, how7ever, the rectangular shape of the flaps), and have found it to answer quite as wrell 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 plans, and that the difference in the results of amputation in the hands of various operators is not as much due to the particular procedure employed, as to the judgment displayed in selecting cases for operation, and the care manifested in conducting the after-treatment. The surgeon should not, I 10»j AMPUTATION. 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 gave the best stumps in the forearm, the circular or modified circular in the upper- arm, the modified circular in the upper part of the thigh, the double flap operation immediately above the knee, the lateral flap method be- tween the knee and ankle, 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 amputa- tions. Simultaneous, Synchronous, or Consecutive Amputation__ It occasionally becomes necessary, in cases of severe injury, to remove two or more limbs by primary amputation at the same time. Sometimes this Fin. 50.—Teale's amputation. (Bryant.) Fig. 51.—Simultaneous quadruple am- putation. (From a patient under the care of Dr. Jackson.) Fio. 52—Synchronous triple amputation. (From a patient under the care of Dr. Lowman.) SIMULTANEOUS AMPUTATION. 107 Fig. 53.—Primary synchronous amputation of left leg and right hip-joint. (From a patient in the Uni- versity Hospital.) has been done by two surgeons operating simultaneously, but it is better for one to do both amputations consecutively, beginning with the limb that is most severely hurt. Though the prognosis of these double amputations is always unfavora- ble, yet recoveries have followed with sufficient frequency to jus- tify the surgeon in having re- course to the knife, when the condition of the patient will at all permit it. If the hemorrhage can be effectually controlled by tourniquets, both limbs may be removed before stopping to take up any vessels; though if the first amputation have produced much depression, it may be neces sary to pause and administer re- storatives before proceeding to the second. Among the most remarkable cases of synchronous amputation on record are that of Dr. George E. Jackson, of Lakota, who has kindly sent me the photograph (Fig. 51), of a patient from whom he success- fully amputated all four limbs simultaneously for frost-bite ; that of G. C. Wallace, of Rock Rapids, Iowa, who successfully removed both forearms, one leg, and half of the other foot, likewise for frost-bite ; and those done by Drs. ^.---/ •/,✓/ f ] \ \\ Luckie, Alexander, Koeh- ler, Lowman, and Arm- strong, the first named sur- geon having twice, and the others each once, removed both legs and one arm sim- ultaneously, all six patients making excellent recover- ies in spite of these severe mutilations. Fig. 52, from a photograph kindly sent me by Dr. Lowman, shows the result in his case. I have myself successfully resorted to synchronous amputation of the right hip-joint and left leg (Fig. 53), for a railway injury occurring in a lad of fifteen, and in seventeen double major amputations have had seven successes. I have twice synchronously amputated three limbs from the same patient, one case ending in recovery (Fig. 54), but the other patient, an adult of intemperate habits, dying on the tenth day.1 1 Quadruple amputations, or amputations of both upper and both lower extremities, have been successfully performed by Dr. Alfred Muller, Acting Assisting Surgeon, U. S. A., Fig. 54.—Simultaneous triple amputation. (From a patient in the University Hospital ) 108 AMPUTATION. Dressing of the Stump.—After an amputation, the stump should not be dre>sed until all hemorrhage has cea>eil. Sometimes, after all the recognizable vessels have been secured, a troublesome oozing continues from the face of the stump; this is usually venous bleeding, and will com- monly cease of it>elf when the tourniquet is removed. If it do not, it may probably be checked by elevating the stump, and pouring over it a stream of cold or very hot water, or by sopping it with alcohol.1 Weeding from the medullary cavity of the sawn bone may be stopped by inserting a piece of dry lint, a'plug o'f wood, or better, a pellet of previously softened white wax ; the latter has the advantage of being perfectly unirritating, so that, if necessary, it may be allowed to remain when the flaps are brought to- gether. A plug of catgut is preferred by Kiediuger. 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 wet towel, or a piece of lint dipped in olive oil, being meanwhile laid between 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 ligatures, if of silk, are to be brought out atone 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 a plan seems to be more adapted to delay union by producing increased irritation, than to promote quick healing. The edges of the amputation wound are to be brought together, not too tightly, by the use of sutures, and the flaps, if heavy, may be additionally supported by the use of adhesive strips. If short-cut ligatures are used, a large drainage tube should be carried across the floor of the wound, cut close to the skin at each side, and kept from slipping in by transfixing its ends with small safety-pins. It is a great mistake to hermetically seal a stump; there is always a considerable flow of serum for some hours after an amputation, and if this fluid be not allowed to es- cape from the stump, it inevitably decomposes and produces irritation. Various modes of dressing a stump have been employed; Mr. Teale di- rected what has been called dry-dressing, which was, in fact, no dressing at all, the stump being simply laid on a pillow (which was covered with gutta-percha cloth), and protected by throwing over it a piece of thin gauze. Sir J. Y. Simpson highly commended the exposure of both amputa- tion and other wrounds to the air, calling the scab produced by this expo- sure a " natural wound lute." Dr. J. R. Wood, of New York, went still further, treating stumps by what he called the " open method," without either sutures, plasters, or dressings. MM. Guerin and Maisonneuve, on the other hand, devised ways of treating stumps in exhausted receivers, giving their respective plans the euphonious titles of " pneumatic occlu- sion" and "pneumatic aspiration." A. Guerin recommended the employ- ment of cotton, as a means of excluding the deleterious germs which are supposed to exist in the atmosphere. The " antiseptic method" of Prof. Lister is now generally used in the treatment of stumps, and is found very Dr. Begg, M. Champenois, and other surgeons, but it does not appear that, except in Dr. Jackson's case, the operations in any of the eight to which I have references, were synchronous. Triple amputations, besides those mentioned in the text, are attri- buted to Stone, Lesgleuc, Ritter, Marten, Bruberger, Field, ami other surgeons. 1 Under the name of parenchymatous hemorrhage, Dr. Lidell has described (following 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. Sun. Commission Surgical Memoirs, vol. i. pp. 2!i7-2"jO.) STRUCTURE OF A STUMP. 109 satisfactory. A very good dressing consists of a piece of sheet lint soaked in pure laudanum, covered with oiled silk or waxed paper, and secured in place with a light recurrent bandage ; the local use of the narcotic is sooth- ing to the patient, wrhile the styptic and antiseptic properties of the alco- holic menstruum are often useful. In military practice cold water is the most convenient application to a recent stump, and, if not too long continued, answers very well. Whatever dressing be used, the stump should not be disturbed for forty-eight or seventy-two hours, unless required by oozing of blood or discomfort of the patient; the wound may then be dressed with diluted alcohol, with lime-water, or with any other substance that the con- dition of the part may indicate. If silk sutures have been used, they should commonly be removed about the third or fourth day ; metallic sutures may remain longer, and need not usually be taken away until firm union has occurred, and until they are therefore of no further use. The ligatures may be expected to drop from the smaller vessels after the fifth or sixth day; from the larger arteries after the tenth or twelfth. The ligatures should always be allowed to drop of themselves ; but when the time usually requisite for their 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 removed on the second day ; that on the main artery on the third or fourth, according to the extent of the clot formed, which may be estimated by the point at which pulsation in the flap ceases. Antiseptic Dressing of Stumps.—Every surgeon has his own prefer- ence as to the particular form of antiseptic dressing to be used, and I shall describe here only that which I am myself in the habit of employing in my wards in the University and Pennsylvania Hospitals. Before stitching the wound, I have it thoroughly douched with a hot 1-2000 solu- tion of the bichloride of mercury, and again, after the" stitching is com- pleted, flush the wound with the same solution, introduced with a long- nozzled syringe, so as to wash out all clots and make sure that the drain- age tube is patulous. I then cover the line of sutures with a strip of protective oiled silk and adjust the deep dressing, wrhich consists of from eight to twelve layers of carbolized or sublimated gauze, freshly wrung out of the solution ; this deep dressing is laid under the stump, folded over its face, and doubled up from the sides, and is then covered with the super- ficial dressing, consisting of an equal number of layers of dry gauze, with a sheet of mackintosh, or waterproof paper, interposed between the outer layers. The superficial dressing is in turn covered with sublimated cotton, applied in strips like a Scultetus bandage, and the whole is finally secured with a closely adjusted recurrent gauze roller. As soon as any stain of blood shows itself through the dressings, these are reinforced with an ad- ditional pad of cotton and another bandage. The dressings are usually re- newed after two or three days, the drainage tube being washed out and freed from any clots which may occupy its lumen. The tube is removed about the eighth day, and the sutures withdrawn at the end of a fortnight. If, as sometimes happens, the sublimated gauze pustulates the neighboring skin, this must be protected by apiece of lint spread with boracic-acid oint- ment. Structure of a Stump.—A stump continues to undergo changes in its structure for a long wrhile after cicatrization is completed ; the muscular substance wastes, and the muscles and tendons become converted into a dense fibro-cellular mass, which surrounds the bone ; the bone itself is rounded off, and its medullary cavity filled up; the vessels are obliterated 110 AMPUTATION. up to the points at which the first branches are given off, firm fibrous cords marking their place below ; the nerves' become thickened and bulbous at their extremities, these bulbs being composed of fibro-cellular tissue, with numerous nerve fibrils interspersed. Upon the firmness and painlessness of a stump, depend greatly the facility and comfort with which an artificial limb can be worn. In the case of the upper extremity, there is compara- tively little difficulty, and very ingenious and serviceable arms and hands are now supplied by the manufacturers. In the lower extremity it is found that very few stumps will bear the entire pressure produced by the weight of the body in walking upon an artificial limb, and hence a portion at least of the pressure should be taken off by giving the apparatus additional bear- ings upon the neighboring bony prominences; thus for an amputation of the leg, the artificial limb should bear upon the knee, while in the case of a thigh stump, the tuber ischii and hip should receive the principal pressure. Affections of Stumps.—Any one of the constituents of a stump may give trouble after an amputation, and the treatment of the morbid condi- tions of a stump is a very important matter for the surgeon's consideration. 1. S/>astn of the muscles often occurs and causes much suffering a few hours after an amputation ; it is best treated by the use of a moderately firm bandage around the part, and by the exhibition of anodynes. Dr. Mitchell and Dr. H. C. Wood have recorded cases in which persistent and intractable 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, 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 downwards; the action of the muscles is thus restrained, and the soft parts coaxed downwards, as it were, and enabled to heal Km. 55 —Thigh stump, with splint for whilo the tension is removed ; or extension extension. (Bryant.) mav fa applje(j Jjy meanS of a Weight and broad strips of adhesive plaster, or a light splint, as in Fig. 55. There is, however, another cause for the production of conical stumps, in cases of young persons, apart from muscular retrac- tion or wasting 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 its occurrence in these situations, rather than in the thigh or forearm, is easily accounted for by remembering the physiological fact, that the upper extremity grows principally from the upper epiphysis of the humerus and the lower epiphyses of the radius and ulna, while the lower extremity grows chiefly from the lower epiphysis of the femur and the upper part of the tibia. Hence, in amputations of the thigh or forearm, the principal source of growth for that particular member is taken away; while in the upper arm or leg, it remains, and is liable to cause subsequent 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, Genzmer, Dickson, Ley den, and Dreschfeld, while Chuquet, Luys, Beck, and Bourdon have observed cerebral atrophy on the opposite side. Bdrard, many years ago noted atrophy of the anterior roots of the spinal nerves corresponding to the amputated part. AFFECTIONS OF STUMPS. Ill Fig. 56.—Aneurismal varix in a stump. (Erichsen.) protrusion of the bone through the soft parts. To whatever cause the ex- istence of a conical stump be traceable, if the stump will not heal over the bone, or if, though a cicatrix form, it be thin, tender, and constantly liable to 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 dressings applied, and the general treatment adopted which will be described when speaking of those diseases. 4. Secondary hemorrhage may occur from the vessels of a stump, at any time before complete cicatrization has taken place. If it be not pro- fuse, elevating the part, and the application of cold, or pressure, will often be sufficient to check the bleeding; if it continue, or recur, more decided measures must be adopted, which will be discussed in the chapter on wrounds of arteries. 5. Aneurismal enlargement of the arteries of a stump occasionally occurs ; the annexed wood-cut (Fig. 56), from Mr. Erichsen's Surgery, illustrates a case of aneurismal varix occurring after ampu- tation through the ankle-joint. 6. Neuroma, or painful enlargement of the nerves of a stump, occasionally occurs. This distressing affection is, according to Mitchell, not due to the bulbous enlarge- ment of the nerve (which is, indeed, met with in all stumps), but to the existence of neuritis,1 or of a sclerotic condition result- big from inflammatory changes. Should the pain evidently arise from any distinct tumor connected with a nerve, it would be proper to cut down and remove it; under other circumstances the nerve may be stretched, or a portion excised at a higher point, or re-amputation performed, though unfortunately these are by no means infallible remedies ; Dr. Nott gives a case in which a man submitted to three re-amputations and three nerve excisions for neuralgia of a stump, deriving at last only questionable benefit from this large ex- perience in operative surgery. As a palliative remedy, the application to the stump of the strong tincture of the root of aconite is occasionally use- ful, or hypodermic injections of morphia may be used, as in other cases of neuralgia. Girard records a case in which relief was obtained by the re- Fig. 57.—Neuromata of stump, after am- putation of the arm. Large neuromatous mass at a ; opposite 6, the tumors are more defined. (Miller.) 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. Paralysis of the leg after amputation of the arm has been observed by Bourdon, who attributes it to consecutive cerebral atrophy. 112 AMPUTATION. peated employment of electro-puncture. Leeches, ice, and counter irri- tants 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 of the foot, the natural arch of that organ being destroyed, the tendo Achillis may be drawn up by the powerful muscles of the calf, and a painful form of club-foot result, the cicatrix being thrown against the ground in walk- ing. 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 when milder measures will not suffice. s. Periostitis, Osteitis, and Osteo-myelitis, one or all, may occur in a stump, and may defeat the surgeon's anticipations of a successful issue. If acute and extensive, these affections endanger life, and, especially in the femur, are apt to terminate fatally. The diffuse suppurative form of osteo- myelitis is especially apt to occur when the division of the bone has ox- posed the medullary cavity, and is almost sure to end in pyaemia and death; the best mode of treatment is re-amputation at the nearest joint, which 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 .-aturated with a strong solution of chloride of zinc. Less violent forms of bone inflammation result in the occurrence of— 9. Necrosis, which may likewise be produced by injury from the saw, at the time of operation. The treatment of this condition consists pretty much in waiting for the natural separation of the necrosed part, which will then be exfoliated, as a ring of dead bone, or as a long conical sequestrum (Fig. 58). I do not believe that anything is to be gained, under these circumstances, by interference with the slow but safe processes of nature; in the case, however, of the occurrence of acute necrosis, as it is sometimes called, or more properly diffuse subperiosteal suppuration, it may be necessary to amputate to save life, just as it would be under the same circumstances occurring elsewhere than in a stump. 10. Caries may occur in the bone of a stump. I have seen benefit result in such cases from the injection of the preparation introduced by M. Notta, under the name of Liqueur de Villate. (R. Zinci sulphatis, Cupri sulphatis, aa gr. xv; Liq. plumbi subacetatis l^ss; Acid. acet. dibit. 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 pressure. If this bursa become painful, the artificial limb should be altered so as to relieve it from pressure; if this be not sufficient, an effort may be made to obliterate the bursa by the introduction of the tincture of iodine, or by establish- ing a small seton, or the bursa itself may be excised. 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 cumin? into this category are the age and the constitutional state of the patient, and the hygienic conditions to which he is subjected before, at the time of' and after the amputation. The relation between the barometric condition of the atmosphere and the mortality after amputation has been particularly investi- gated by Dr. Addinell Hewson. He finds that, at the Pennsylvania Hospital, Fia. 58. Necrosis of the bone after ampu- tation. (LlSTu.V.) MORTALITY AFTER AMPUTATION. 113 the mortality varied from 11 per cent, with an ascending, to 20 per cent. with a stationary, and 28 per cent, with a falling barometer. While the column of mercury was rising, the average duration of life, in fatal cases, was only seven days, but was thirteen while the column was falling; and of all the cases that died within three days, over 75 percent, proved fatal while the barometer was rising. " Surely," he adds, "these figures need no com- mentary 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. 34.) Recent statistics as to the influence of the age of patients upon the re- sults of amputation have been collected by several surgeons, including Dr. T. G. Morton, Mr. Golding-Bird, Dr. Gorman, and Mr. Holmes, the latter of whom finds that "the risk of amputation is constantly rising throughout life, and at any given period after thirty years of age the risk is more than twice as great as it was at the same period after birth." Beside the circumstances which have been referred to, there are others which affect the results of amputation, and which are peculiar to this as distinguished from other operations; these are now to be considered. 1. Locality.—The part of the body at which an amputation is 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, as a rule, varies directly with the prox- imity to the trunk of the point of amputation. These facts will appear from the following table which I have prepared from the published statistics of British1 and American2 hospitals, and from those of our late war,3 together with those of the war in the Crimea.4 Table showing Mortality of Amputations in Different Parts of the Body, for Traumatic Causes, in Civil and in Military Practice. Civ il Hospitals. American and Wars Crimean AGGREGATES. Locality. Cases. Deaths. Mortality per cent. Cases. Deaths. Mortality per cent. 61.33 Cases. Deaths. Mortality per cent. Thigh . . 367 197 53.68 8157 5003 8524 5200 61.00 Leg . . . 633 264 41.71 63S2 2231 34.95 7015 2495 35.56 Arm 332 86 25.90 6415 1805 28.14 6747 1891 28.03 Forearm . 298 41 13.76 2181 444 20.35 2479 485 19.56 Totals . . 1630 588 36.07 23,135 9483 40.98 24,765 10,071 40.66 In amputations of the thigh, the mortality varies according as the opera- tion is done in the upper, lower, or middle third. The following are the percentages given respectively by Legouest and Macleod, both referring to the British army in the Crimea, though for different periods of the war, and by Otis and Huntington for the late civil war in this country. Upper third Middle third Lower third Legouest. 87.2 58.5 55.0 55.3 50.0 Otis and Huntington. 53.8 44.5 53.6 1 St. George's Hosp. Reports, vol. viii.; Med. Chir. Trans, vol. xlvii.; and Guy's Hosp. Reports, 3d s., vol. xxi. 2 Am. Journ. Med. Sciences, April, 1875 ; Boston City Hosp. Reports, 2d s., 1S77 ; and Boston Med. and Surg. Journ., 1871. 3 Surgical History of the War. 4 Legouest, Chirurgie d'Artmle, pp. 722-735. 8 114 AMPUTATION. 2. The part of the bone which is divided in an amputation influences the result, the mortality being greater when the medullary cavity is opened than when only the*cancellous structure at the end of the bone is involved. This appears to be owing to the greater probability of pyaemia superven- ing under the former circumstances. 3. The nature of the affection for which an amputation is done, exer- cises a most important influence upon the result: thus, amputations for injury are much more fatal than those for disease ; the removal of a limb for cancer is more likely to be followed by death than the same operation if practised for caries or a chronic joint-affection; while amputations of complaisance or expediency (as for deformity) are less successful than those for other pathological conditions. The relative mortality of ampu- tations for injury and disease, as exhibited by the published reports of hospital practice in various countries, is shown in the following table:— Amputations for Injury. For Disease or Deformity. Totals. Place of Observation. Cases. Deaths. Mortality , per cent, j 00 O « ID o 406 251 117 774 Mortality per cent. 42.87 22.67 18.60 28.85 3 1 Q 1599 784 1717 501 1881 517 5197 1802 Mortality per oent. French Hospitals1 English Hospitals2 . . American Hospitals3 . . Aggregates . . . 652 378 6101 250 1252 400 57.98 | 40.98 31.95 947 1107 629 49.03 29.18 27.49 25141028 1 40.89 2683 34.67 The mortality which attends amputations of expediency has been parti- cularly 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 is 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 for 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 development of inflammation, a period rarely exceeding twenty- four hours, though, if there have been much shock, it may reach to forty- eight hours, or possibly still longer, from the time at which the injury was received. A better classification is that of military writers who make a third class, the intermediate, which embraces all operations done during the existence of active inflammation, reserving the term secondary for such as are done after the subsidence of inflammatory symptoms, and when the condition of the part somewhat assimilates the case to one of amputation for chronic disease. Verneuil applies to these three divisions the terms antepyretic, intrapyretic, and metapyretic, respectively. It is now, I believe, universally acknowledged among military surgeons » Malgaigne (Arch. Gen., Avril et Mai, 1842), and Trelat (Legouest, op. citat., p. 707). * St. George's Hosp. Reports, vol. viii.; Med.-Chir. Trans., vol. xlvii.; Guy's Hosp. Reports, 3d s., vol. xxi. * Am. Journ. Med. Sciences, April, 1875; Boston City Hosp. Reports, 2d s., 1877; and Boston Med. and Surg. Journ., 1871. MORTALITY AFTER AMPUTATION. 115 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 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 errone- ous, and that a careful collation of statistics will show that in both civil and military practice, primary amputations are followed by better results than others. To illustrate this point, I have drawn up the table which follows, and in which the results of primary amputations, or those per- formed in the pre-inflammatory stage, are compared with those of all others for traumatic causes. Primary. Sf.condary and 1 Intermediate. Observations from Civil Hospitals. c .- a i .- a "3 " Reporter. Reference. Q 69.4 O 20 a 13 1 e. 49 34 65.0 Malgaigne. Arch, de Med., 1842. [vol. xvii. 64 15 23.4 28 10 35.7 James. Trans. Prov. Med. and Surg. Assoc, 18 7 38.9 5 2 40.0 South. Notes to Chelius, vol. iii. 74 39; 52.7 43 26 60.5 Laurie. James, loc. cit. 169 «2! 36.7 53 37 69.8 Steele. Ibid. [367. 180 60 33.3 87 61 70.1 McGhie. Macleod, Surg, of Crimean War, p. 50 9 18.0 6 1 16.7 Hussey. Ibid. [p. 81. 48 18 37.5 43 19 44.2 Erichsen. Science and Art of Surgery, vol. i. 40 8i 20.0 9 6 66.7 Parker. Cooper's Surg. Diet., vol. i. p. 121. 71 23 32.4 10 3 30.0 Fen wick. Ibid. 93 15 1H.1 37 13 35.1 Callender. Med.-Chir. Trans., vol. xlvii. 144 60'41.6 42 17 40.4 Spence. Lectures on Surgery, vol. ii., etc. 37 12 32.4 24 7 29.1 Buel. Am. Journ. Med. Sci., 1848. 29 14148.3 13 7 53.81 Lente. Trans. Am. Med. Assoc, vol. iv. 656 164;25.0 lib 45 38.1 Morton. Surg, in the Penna. Hosp., 1880. 241 84134.9 87 32 36.8 Chadwick. Bost. Med. and Surg. Journ., 1871. 164 68141.5 50 21 42.0 Gorman. Bost. City Hosp. Rep., 1877. 240 104 43.3 94 53 56.4 Golding-Bird. Guy's Hosp. Rep., 3d s., vol. xxi. 75 31 41.3 5 4 80.0!l Varick. Am. Journ. Med. Sci., 1881. 55 16 29.0 17 8 47.0 Ashhurst. Internat. Encycl. of Surg., vol. i. 258 47 18.2 119 910 29 24.3 Cupples. Report of Surgery in Texas, 1886. 2755 890 32.3 414 45.5 Aggregates. It will be perceived from this table that, except in the reports of Mal- gaigne, Hussey, Fenwick, Spence, and Buel, the primary amputations have been invariably 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 nearly 1 in 2 for the intermediate and secondary operations. I do not know of any extended statistics to show the relative mortality of the two latter classes of amputations 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 symptoms have subsided are comparatively successful. These numerical considerations, however, though interesting, scarcely give a fair view of the whole merits of the case; for primary operations are naturally done in cases where there is no possibility of saving the limb, while consecutive amputations are, on the other hand, performed in cases lltj AMPUTATION. 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 were the best, it would by no means be proved that more lives would 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 which 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 con- dition has become assimilated to that'of a case of chronic disease rather than of traumatic lesion. To complete this part of the subject, I quote from Dr. Macleod the fol- lowing summary of the results 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 which, it will be observed, corresponds pretty closely with that derived from observations in civil hospitals. The statistics of amputation in the late War of the Rebellion also con- firm what has been said: thus 12,246 primary amputations, recorded in the Surgical History of the War, gave 3992 deaths, or 23.9 per cent., while 5501 intermediate amputations gave 1918 deaths, or 34.8 per cent., and 2023 secondary amputations gave 584 deaths, or 28.8 per cent. Causes of Death after Amputation—The causes of death after amputation have been made the subject of special study by several writers, 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 niainly to previous disease or injury. " 3. That secondary hemorrhage is hardly ever a cause of death, except in persons with diseased arteries. " 4. That death from exhaustion hardly ever occurs without previous disease, obviously proved both by symptoms and post-mortem appearances. "5. That the other hospital affections (erysipelas, diffuse inflammation, and pbagedaena or hospital gangrene) are rare in subjects previously healthy, and that, as a rule, they only prove fatal when they are the pre- cursors of pyaemia.- " 6. That therefore any attempt to estimate the dangers of amputation in hospital practice, or to diminish its mortality, must be based upon a knowledge of the conditions under which pyaemia occurs in cases treated separately, and in patients congregated in hospital wrards." (St. George's Hospital Reports, vol. i. pp. 321-322.)' 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. 117 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 whole number amputated. " That exhaustion is the cause of death in 33 per cent, of the fatal cases, and in 8 per cent, of the whole number amputated. "That the following causes of death are fatal in the annexed propor- tions:— Of fatal cases. Of whole number. Secondary hemorrhage . . 7.0 per cent., or 1.66 per cent. Thoracic complications Cerebral '' Abdominal " Renal " Hectic " Traumatic " 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 pyaemia 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 1T1 cases, in which the operation was 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.)' 5.6 k (( 1.33 " 3.0 it It .66 " 1.4 u II .33 " 3.0 !< 11 .66 " 3.0 (( 11 .66 " 7.0 " (( 1.66 " 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 whitlow. As no mechanical contrivance can possibly equal the natural hand in utility, it should in all cases be the surgeon's object to save as much as possible; there is but one exception to this rule, and that is when 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 will 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. 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 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. 118 SPECIAL AMPUTATIONS. Kki. 59 —Amputation of part of a finger by cutting from above. (Erichsen ) 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 phalanges 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 remembered 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. Tbe palmar flap may be made first, either by transfixion or otherwise, and the joint opened subsequently ; I think, however, the plan first mentioned is the best. An- other method is to attack the joint from the side, cutting one lateral ligament, dis- articulating, and then making a long lateral flap from the other side of the finger ; this has been particularly recom- mended 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 Metacarpo-phalangeal Joint is best done by the oval method, though it may also be conveniently executed by making two lateral flaps. In the oval operation, the point of the knife is entered just below the knuckle, on the back of the hand, and the blade is drawn ob- liquely 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 lie rendered more symmetrical by its removal, but this gain of symmetry is more than counterbalanced 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 inflammation and suppuration in the deep tissues of the palm, and thus renders the operation more serious than it would be otherwise. Hence, if the meta- carpal bone itself be uninjured, its head should be, as a rule, allowed to remain; if, however, it be decided to remove it, this can be easily effected bv cutting it with strong pliers (Fig. C>0), the section, in the case of the fore and little fingers, being oblique, so as to give a tapering form to the part when 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. fil), 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 joint, and coming down 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 AMPUTATIONS OF THE HAND. 119 of entrance, and cutting downwrards and outwards. In amputating the right thumb, it is more convenient to make the palmar flap first, by trans- Fig. 60.—Amputation of an entire finger. (Skey.) Fig. 61.—Amputation of the left thumb. (Erichsen.) '"^ ""s^nwr^ fixion, the remaining steps of the operation being done subsequently. The thumb alone is almost as useful as the other four fingers together; hence, in operations on this important 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 dimensions to cover the parts without undue stretching. In making these flaps, the palm should be respected as much as possible, the necessary incisions be- ing 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 scrupu- ously preserved, as even a single finger, with the thumb, is far more useful than the best artificial substitute. Fig. 62, 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 without injury of its corresponding finger, the former may be excised while the latter is retained, or the finger may, perhaps, be adapted to another metacarpal bone which has lost its own finger, as was ingeniously done by the late Prof. Joseph Pancoast. The risks of amputation below the carpus are slight, 7.902 cases referred to in the third volume of the Surgical History of the War, having fur- Fio. 62.—Partial amputation of the hand. (From a patient in the Episcopal Hospital.) 120 SPECIAL AMPUTATIONS. nished but 198 deaths. The mortality of amputations through the hand is, according to these figures, 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 wrrist. Amputation at the wrrist-joint may be conveniently effected by the circu- lar operation, by means of the ellipti- cal 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 artifi- cial limb than one that is shorter. Its principal advantage is in its preserving the power of pronation and supi- nation, though even this may be lost from inflammatory adhesions binding together 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 10.4 per cent. 2. Amputation of the Forearm.—The best operation in this locality is, I think, the circular; though excellent 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-pos- terior flaps cut from without inwards, but having on several occasions met with dangerous secondary hemorrhage from the interosseus artery, which, in this operation, is apt to be cut obliquely, I have been led to pre- fer either the circular or Teale's, in neither of which is this risk so apt to Fm. 63.—Amputation at the wrist. (Ekichsen.) Fin. 64 —Amputation of forearm by modified circular method. (Bbvant.) lie 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 such circumstances, the surgeon should draw them down, and cut them off at as high a point as possible, that they may re- tract, and not interfere with the healing process. Perhaps the most bril- liant 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 proportioned to the size of the limb, but two inches may be given as the average. Five or six vessels usually require ligature in amputations of the forearm, and of these the interosseous is that which is most likely AMPUTATION AT THE SHOULDER-JOINT. 121 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 elliptical incision ; it may also be done, though less conveniently, by mak- ing an interior or an external flap by transfixion. It is sometimes recom- mended to leave the olecranon in place, dividing the ulna below it with a saw; no particular advantage, however, attends this plan, and the olecranon, if left, is apt to become necrosed, and to interfere with the healing of the stump. Amputation at the elbow was done in forty cases during the late war, 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 which seem to me the best are in the lower part the circular, and in the upper part the oval or the modified circular. The bone, however, 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 with a clean sweep of the knife around the back of the bone, before applying the sawT. 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 bleed- ing from six or seven, or, if the parts have been long inflamed, twelve 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 compressed 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 formidable operation, and yet it is one of which the results are tolerably favorable. Thus, 841 determined cases, recorded in Dr. Otis's Surgical History, gave 596 recoveries and 245 deaths, a mortality of only 29.1 per cent. When performed for other than traumatic causes, it is still more suc- cessful. Amputation at the shoulder-joint may be practised in several ways, the most important being those commonly known 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 downwards (and slightly convex, if the limb be muscular), so as respectively to termi- nate 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 subclavian be well commanded over the first rib, there need be no fear of hemorrhage, and it will then be most convenient to make the posterior incision first, that its position may not be obscured by bleed- ing from the other. The 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 the biceps, and finally rotating the arm inwards 122 SPECIAL AMPUTATIONS. so as to reach the supra-spinatus and infra-spinatus muscles, and the teres minor. The. lateral incisions are lastly connected by a transverse cut Fio. 65.—Amputation at shonlder-joint by Larrey's method. Fia. 66.—Result of Larrey's amputa- tion. (From a patient in the Episcopal Hospital ) through the tissues of the arm, either from without or from within. Before this final incision (which divides the brachial artery) is made, an assistant should slip his thumb into the wound and control the vessel, which may always be found in the first mus- cular interspace from the anterior edge of the axilla; the limb being removed, the vessels are to be se- cured, 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 well shown in the accom- panying illustration (Fig. 07), from the photograph of a patient on whom I performed this amputation at the Episcopal Hospital. 2. Dupuytren's Method.—This method consists in making, either by transfixion or from without inwards, a large flap embracing almost the whole of the deltoid muscle, then disarticulating, and finally cutting a short flap (in which 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, as generally applicable. In either method the principal diffi- -Amputation at shoulder joint; Dupuytren's method. (Bryant.) AMPUTATION AT THE SHOULDER-JOINT. 123 culty is in disarticulating, to accomplish which (in the case of fracture pre- venting the use of the arm as a lever in effecting rotation) it may be necessary to introduce 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 Larrey's opera- tion, 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 which it presents no particular advantage. The shoulder-joint can also be reached by a circular incision, as practised by Yel- 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 which I have described have been most generally adopted. Amputation above the Shoulder, or amputation of the arm with a part or the whole 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 wrhich, whenever 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 view of the extent and direction of the lacera- tion, and in cases of amputation for tumors, etc., must be guided by the size and shape of the morbid growth. Berger strongly urges that resection of a portion of the clavicle and division between two ligatures of both subclavian artery and vein should be the first stage of the operation, and that the arm and scapula should be sepa- rated from before backwards. The results of this operation have been more favorable than might have been anticipated: at least 161 cases are on record which, though the arm and a part or the whole of the scapula were torn off by accidental violence, terminated favorably, while 75 cases in wThich the arm and part or all of the scapula, with or without a portion of the clavicle, were removed by the surgeon at the same operation, gave 55 recoveries and only 19 deaths, the result in the remaining case being uncertain. Fig. 6S.—Result of amputation by Dupuy- tren's method. (From a patient in the Epis- copal Hospital.) 1 The late Dr. Stephen Rogers collected 12 cases in papers puhlished in the American Journal of the Medical Sciences for October, 1868, and the New York Medical Journal for December, 1870. Additional cases have been since reported by Kathaletzky, Ellis- Jones, George, Loumeau, and Ogilvie. The result in Dr. George's case I do not know, but all the rest are said to have terminated successfully. 124 SPECIAL AMPUTATIONS. Table of Amputations above the Shouldct No. Operator. Result. Cured. No. 26 Operator. Result. No. 51 Operator. Result. 1 Andradas, Hamilton, Cured. Niepce, Cured. 2 Asiari, u 27 Hayward, " 52 O'Grady, 3 Bell, " 28 Heath, been by adhesion or through the medium of lymph. Union by adhesion should always be aimed at in the treatment of stumps, and of most operation wounds, and may be generally secured INCISED WOUNDS. 141) throughout the greater part of the incision. Scalp wounds, and wounds of the face and neck, commonly unite in this way, as do also, though more rarely, incised wounds of other parts of the body. Superficial wounds, when 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 application of the phrase " union by the first intention," by modern writers, to that process wrhieh 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 with- out lymph, to which it was 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 bv the second formative change, or the production of pus. The cut surfaces become covered with granulations, precisely identical in structure and characters to those met with in a healing ulcer (see page 47), and the free surface is bathed with pus. The granulations gradually fill' up the gap, and, when they have reached the level of the surrounding skin, cicatriza- tion occurs just as in the repair of ulceration, which has already been fully described. ^ The union by secondary adhesion, or by the third intention, is identical with the mode of union now under consideration, except that the granulating surfaces are so adjusted 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 where, from excessive 'inflammation, from a large number of ligatures acting as foreign bodies, or from other causes, union by adhesion cannot be obtained.1 Treatment of Incised Wounds.—The object of the surgeon, in the management of every incised wound, should be to obtain, if not immediate union, at least union by adhesion. The credit of establishing the rule which is now universal, at least in England and in this country, to attempt to get primary union whenever possible, is due, in great measure, to the 1 D. J. Hamilton, of Edinburgh, has 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 adhe- sion 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 bodies, and are either reabsorbed or discharged as pus. According to the same writer, oianulations are not new formations, but consist of capillaries which are distended into the form of loops on account of the removal of the restraining pressure of the integu- ment. Hence, Mr. Hamilton regards what is known as union by granulation 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 sub- stance, of a carbolized sponge, to act as a framework for the support of the granulations. This plan has been successfully adopted also by Mr. Sanctuary, Drs. Estes, Beall, and Adams, and other surgeons. Mr. Winslow Hall has successfully employed sponge- grafts for obstinate sinuses. Ferguson, of Perth, finds that every purpose is accom- plished by leaving the sponge in position for a few (4-8) days, and then detaching it, so that it is doubtful whether it acts otherwise than as a stimulating dressing. 150 EFFECTS OF INJURIES IN GENERAL. 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 when adhesion is obtained than when union occurs by granulation, and the resulting scar less conspicuous and disfiguring, but the patient is saved the exhausting consequences of prolonged suppuration, and is, in a great measure, preserved from the risk of the secondary affections which often complicate wounds, such as erysipelas, various forms of blood-poison- ing, 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 substances, and (3) by suit- able dressings to adjust the cut surfaces closely and accurately, to prevent the access of atmospheric air, and to prevent the inflammatory 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 vessels, 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 which plans will be fully discussed when we come to speak of wounds of arteries. (2) Hemorrhage having ceased, the surgeon must carefully but gently cleanse the wound, so as to remove all foreign substances which may have lodged between its lips. This may be conveniently done by means of a stream of running water (as applied 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 with sponges." Mr. Callender employed camel's-hair brushes. To deter- mine the freedom of a wound from foreign bodies, the surgeon may put in service his hands as well as his eyes, it being sometimes possible to detect with the finger a grain of sand or spicujuni of bone, which, imbedded 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 wound, 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 whatever be the origin of this Ivmph (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 approximated the better. In closing wounds, the sur- geon makes use of sutures, plasters, and bandages. The various materials employed for sutures have already been described in previous chapters, and it will be sufficient to say here, that, for ordinary purposes, lead, silver, or malleable iron wire is the most suitable and convenient. The neetlles used by surgeons are of various sizes and shapes, as shown in Fig. 46; it is occasionally advantageous to have a strong needle mounted in a handle (Fig. 81), and with an eye at its point, like the "naevus needle," for use in situa- tions difficult of access, or when the tissues to be Fig. 81—Mounted needle, armed with a ligature. penetrated are Unusually INCISED WOUNDS. 151 dense. Various needles have been devised for special use with wire, but present no particular advantages over those generally employed. The various forms of suture commonly used by the surgeon are the interrupted suture, the continued or glover's suture, the twisted or harelip suture, and the quilled suture. The interrupted suture (Fig. 82),wrhich is that most frequently used, con- sists, as its name implies, in a number of single stitches, each of which is entirely independent of those on either side. In applying it, the surgeon holds one lip of \\\ the wound with the fingers of the left hand, ^g or with forceps, and introduces, with a quick__________TTt._________ thrust, the needle previously threaded, three or four lines from the cut edge; he then takes the |______________________.. opposite lip in the same wTay, and passes the t^S needle, in this case from within outwards, _________/it_______ taking care that there shall be no undue ten- sion or uneven dragging of the wound. Some [_______________________ surgeons employ two needles, passing both ~SO from within outwards; but this causes un- T|? necessary delay, and offers no advantage over 11 ? the common mode. Each stitch may be se- _,,„ ao T, . .' . , , ... J Fig. 82.—The interrupted suture. cured as it is introduced, or all may be passed, their ends being left loose to be fastened subsequently. If silk be employed, it is tied in a reef-knot; if wire, it is simply twisted. If the mounted needle (Fig. 81) be employed, it must be thrust through both lips of the wound before being threaded (the suture being thus passed as it is withdrawn), and must, therefore, be re-threaded for each stitch. The distance between the points of the interrupted suture, and the depth to which each stitch is passed, vary with the nature and extent of the wround; as a rule, the skin and superficial fascia only should be included in the stitches, and there should be an interval of about half an inch between the consecutive points of introduction. The continued or glover's suture (Fig. 83) is principally used for wounds of the intestines, though it is occasionally employed in other situations where the tissues are of loose structure, as in the eyelids. It is made with silk, or with a fine thread, which passes across the wround continually in the same direction; it is the stitch formerly employed in the manufacture of gloves, whence it derives its name. The quilt suture (Figs. 84 and 85), in connection with the continued suture, is employed by Zesas to effect very close approximation and prevent bagging, in cases where the use of drainage-tubes is undesirable. The twisted or harelip suture (Fig. 86) is an excellent method of uniting wounds where 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 with wire, 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. Rigal (Fig. 87), which was used in this city by the late Dr. W. L. Atlee in dressing cases after the operation of ovariotomy. The twisted 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 pre- vent their hurting the patient; or, they may be protected by bits of cork, or by the ingenious "needle guard" devised by Tyrrell, of Dublin. 152 EFFECTS OF INJURIES IN GENERAL. The quilled suture (Fig. SS) is seldom employed at the present day, ex- cept in the treatment of lacerations of the perineum. It consists of a num- Fio. 83.—The continued, or glover's suture. FiG9. 84 and 85.—The quilt suture. ber 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 Fio. S6.—The twisted suture. Fig. 87.—India-rubber suture. Fiu. 88.—Quilled suture. 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, Duplay, and Will, and are principally used in plastic operations. The clamp and button su- INCISED WOUNDS. 153 tures of Dr. Sims and Dr. Bozeman will be again referred to in speaking of the treatment of vesico-vaginal fistula. Except in very extensive wounds, 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 shop is a very good article for gen- eral use ; it should be cut into strips, of widths varying from, half an inch upwards, 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 adjusted so that the wround comes opposite to the middle of the strip (Fig. 82), and they should be applied with care and neatness, so as to support the edges of the wound without dragging or undue pressure. Ad- hesive strips should never be made to completely surround a limb, unless in a spiral direction. In removing them, care must be used not to drag apart the edges of the wound by rough manipulation. It is, perhaps, scarcely necessary to say that the surface to which the 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 will give the patient considerable 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. It is specially adapted for use with antiseptic dressings, as it can be made to adhere by moistening its surface with an antiseptic solution. An excellent article has been introduced under the name of " American surgeon's adhesive plaster;" it contains India-rubber, and has the great advantage that it will adhere without artificial heat. Wet strips of muslin are employed instead of adhesive plaster by Porcher, of Charleston. The use of sutures is occasionally undesirable, particularly in localities where it is wished to avoid any needless mark, as in the face ; or in the scalp, where the use of stitches is believed by many surgeons to expose the patient to the risk of erysipelas. Hence it becomes important to possess an article which will be more permanent than the ordinary plaster, and yet which will not cause the disfiguration, inevitable with sutures. Such a material is collodion, which was first employed in surgery by Dr. Maynard, of Boston, and which may be most conveniently used in the form of the gauze and collodion dressing, introduced into this citv by the late Dr. Paul B. Goddard. The gauze and collodion dressing is thus employed. Strips of tarlatan, or, which is better, of " Donna Maria gauze," about an inch wide by four or five long, are laid across the approximated lips of the wround, previously washed and dried, and are secured by the application, with a camel's-hair brush, of collodion, first to one end, and when that is firmly adherent and dry, then to the other. With neatness and care, a superficial w7ound 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 imperme- able to water, and the dressing may be hermetically sealed, if thought neces- sary, by merely spreading the collodion over the wound itself as well as on either side. The " styptic colloid" of Dr. Richardson, which is essentially a solution of tannin in collodion, may be advantageously substituted for 151 EFFECTS OF INJURIES IN GENERAL. the ordinary collodion in eases in which there is a tendency to oozing: or a combination of these substances with carbolic acid, as suggested by an Italian physician, Dr. Paresi, may be employed in connection w ith dress- ings according to the antiseptic method. Lead ribbon has been substituted for the gauze in this mode of dressing, and was satisfactorily used by Dr. Hewson, at the Pennsylvania Hospital; my own experience has, however, not been favorable to this modification. Serre-fines (Fig. 89) may be u>ed for slight and superficial wounds, either alone or in addition to other measures, when very close and accurate union is desired. Sutures and plasters, applied as has been described, only serve to approx- imate the edges of a wound ; its deep surfaces should be brought into con- tact by the use of compresses (of lint, oakum, or eharpie) and appropriate bandages, or, in some cases, by the employment of deep sutures (relaxation sutures) passed not through the edges but through the central portion of the wound. The bandage of Scultetus and other still more complicated devices were formerly much used by surgeons in the treatment of wounds, but are now almost universally supplanted by the common roller (Ph bandage, which in skilful hands can be made to meet every in- \\ dication. Cgfc/ Ordinary incised wounds should be dressed antiseptically, or, I j) if not, as lightly as possible; a piece of lint, wet or dry, or an oiled or greased rag, held in place by a few strips of plaster or The"serre- Tur,ls of a roller, will commonly be sufficient. Guerin, Warren, fine. Green, and others commend the use of cotton-wool, winch they believe acts as a filter to prevent the access of deleterious germs to the wound; and Hewson, of this city, has reported very favorably of the employment of dry earth as a primary dressing; while Prof. Hamil- ton, of Xew York, is equally enthusiastic in his praise of the continuous warm bath, a mode of treatment which, I believe, originated with Langen- beck, and which has been modified by Duplay, who plunges the limb into an " antiseptic bath" containing one per cent, of carbolic acid. In scalp wrounds, 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 re- moved from the seventh to the fifteenth day, or sooner if they have 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 pain- ful, it must be treated on the principles laid down 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 which the edges are torn and not sharply cut, and a con- tused wround is one of which the edges are bruised. These wounds are inflicted by blows from dull implements, such as stones or clubs, by ma- chinery accidents, by injuries from railwray trains, etc. Gunshot wounds are likewise included under this head, but are of such importance as to de- mand 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 wounds; there is less tendency to gaping, and there is less bleeding. This arises from the mouths of the vessels being twisted and crushed, rather than evenly divided. More or less sloughing commonly attends these wounds, and they are peculiarly liable to be followed by erysipelas, secondary hemorrhage, and tetanus. As a rule, and always universally in this part of the world, LACERATED AND CONTUSED WOUNDS. 155 lacerated and contused wounds heal only by granulation, or by second intention ; in certain rare cases, however, 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 usualty 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 wound, of variable lengths, 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 well-known case of avulsion of the whole upper extremity, but occasionally the bleeding is very profuse, and proves directly or indirectly fatal. In a case of this kind, in which a child's thigh, being caught between the spokes of a carriage-wheel, was torn off at the middle, I found the great sciatic nerve hanging fifteen inches from the stump, having given way below its division in the ham ; a curious fact in this case was, that, while the cutaneous surface of the stump was acutely sensitive to the touch, there was 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 severe lacerated or contused wound. 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 wTound will then heal by granu- lation, or, if the sloughing be extensive, amputation may be required. Fig. 90, from a photograph kindly given me by Dr. R. H. Harte, shows the extensive cicatrices following severe lacerated wounds inflicted by the bite of a shark. (2) There may be gangrene from arte- rial obstruction at a point above the apparent seat of injury ; this form of gangrene is principally met with in cases of gunshot injury, and is often a cause for amputation (see page 94). (3) The most fatal form of gangrene is the true traumatic or spreading gan- grene,2 which is always of the moist variety from implication of the venous system, and is usually met with in con- nection with severe compound fractures, or other destructive lacerations produced by railway and machinery accidents. One of the most rapidly fatal cases wrhich I have ever seen was in the person of a professional lion tamer, whose thigh was frightfully lacerated by the teeth and claws of the Fig. 90.—Cicatrices following shark bite. 1 In some cases the tendons give way at a point much higher than that at which the other tissues separate. 2 This grave affection has also been described under the names of putrid pneumo- hemia (Maisonneuve), bronzed erysipelas (Velpeau), gangrenous emphysema, traumatic poisoning (Chassaignac), acute purulent oedema (Pirogoff), acute putrid infection (Perrin), and acute gangrenous septicaemia (Terrillon). The malignant oedema of Brieger and Ehrlich is an analogous affection which Bremer found in one case to be complicated with fat-embolism. 156 EFFECTS OF INJURIES IN GENERAL. animal with which he was in tlie habit of performing. Traumatic! gan- grene occasionally, however, 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 characteristic. The limb swells and becomes tense, and a dusky-red or purplish color super- venes, attended with a deep-seated, burning pain. Soon the dusky hue gives way to a dark mottled appearance, vesications and bulhe are formed, the surface becomes soft and boggy, and emphysematous crackling, running along the deep planes of cellular tissue, gives evidence of the formation of gases as the result of decomposition. Below the seat of gan- grene, the limb has a cadaveric appearance, while above, (edema and dis- coloration 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 upwards, the part first attacked falls into the condition of a disorganized, black, and pultaceous mass. The general symptoms indicate from the first an extreme constitutional 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 when air enters the veins in an operation. Treatment of Lacerated and Contused Wounds.—Small portions of the body, especially of the face, even if entirely separated, will occasionally re- unite when replaced and carefully supported ; hence, as a rule, all lacerated or partially detached flaps of tissue should be gently cleansed and read- justed, for, even if sloughing eventually take place, the attempt to preserve the injured part will at least have been attended by no harm. Great cau- tion should, however, be used in any case of lacerated or contused wound as to the employment of sutures. These wounds are always followed by a good deal of inflammation and consequent swelling, 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. I have not seldom 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 fewr 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 plasters and judicious bandaging. For lacerated wounds with- out much contusion, especially about the face, where the tissues are very vascular, cold water, or glycerine and w7ater, is an excellent primary dress- ing; it may be applied simply by wetting pieces of lint, or by irrigation. When the edges of the wound are contused as well as lacerated, warm dressings are usually more grateful, and here warm water, or, still better, diluted alcohol or diluted laudanum, answers a very good purpose. ('otton- wool, dry earth, and the warm bath, are recommended by their respective advocates, as in the case of incised wounds. Chloral in solution (gr. v-f.lj) 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, when 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 prepa- rations of chlorine, dilute carbolic acid, or the permanganate of potassium, ANTISEPTIC TREATMENT OF WOUNDS. 157 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 pre- parations 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 re- moval 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 whole, 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, when, by insinuating the finger beneath the surface, all the deeper-seated tissues, muscles, vessels, and nerves, were found pulpefied, as it were, and crushed into an almost indistinguishable mass. If amputation be required, it should be done as soon as sufficient reaction has occurred ; the advantages of primary over secondary amputation were fully considered in Chapter V., and need not be referred to here. If an attempt be made to save the limb, how ever, secondary amputation may become necessary from the occurrence of hemorrhage, or from the onset of one of the forms of gangrene described on page 155. If the true traumatic gangrene should occur, amputation must be at once performed, though the chances of a suc- cessful issue are, it must be confessed, under these circumstances, very doubtful. It is, perhaps, scarcely necessary to give the caution not to be deceived into amputating for a mere superficial slough, an error which can be avoided by carefully watching the case for a few hours, when, if morti- fication have really taken place, the occurrence of putrefactive changes in the part will sufficiently clear up the diagnosis. When amputation is re- sorted to under these circumstances, it should be done at a point sufficiently removed from the seat of gangrene, to avoid, if possible, the recurrence of disease in the stump. Brush-burn is a name used by Mr. Erichsen for the form of contused wound which is produced by violent friction. It is frequently caused in manufacturing districts, by portions of the body being caught by rapidly revolving straps of leather or other material. Brush-burn may vary in severity from a mere superficial abrasion to absolute destruction of the skin and subjacent tissues. It is a very painful injury, but not dangerous, unless very extensive and severe, and it presents no particular 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," Sir Joseph Lister, formerly of Edinburgh, but now of King's College, London, has urged the employment of carbolic or phenic acid, or other germicidal agents, as a dressing in surgical cases, and the practice has, with various modifications, been generally adopted by other surgeons. Various substances, such as boracic and salicylic acids, iodo- form, bichloride of mercury, oxide of zinc, thymol, creoline, etc., are also employed, but carbolic acid has, upon the whole, been usually preferred by 158 EFFECTS OF INJURIES IN GENERAL. Prof. Lister himself,1 and by his immediate disciples. Mayo Robson re- commends the use of "salufer," or the silico-fluoride of sodium. The theory of the method is founded on the observations of Pasteur, and supposes that animal decomposition is due to the presence of organic germs floating in the atmosphere, and the various substances employed are used on ac- count of their known destructive effects upon low forms of organic life. To carry out in all particulars the " antiseptic system" in dressing a wound or performing an operation, there are needed: two solutions of carbolic acid, one con- taining one part of the acid to forty of water, and the other one to twenty; an "atomizer," or sleam-sprav appara- tus2 (Fig. 91), with a very large flame pro- duced by burning the vapor of alcohol—the solution of carbolic acid Fio. 91.—" Atomizer," or steam-spray apparatus. to be atomized Contain- ing one part to thirty, and being diluted by the steam to the strength of one to forty ; a " protec- tive," consisting of oiled silk covered on both sides with copal varnish, and then with a mixture of dextrine starch and carbolic acid; "antiseptic gauze," which is simply loose cotton-cloth thoroughly imbued with a mix- ture of one part of carbolic acid, five of paraffine, and seven of common resin; Mackintosh cloth ; drainage-tubes; carbolized silk sutures; and carbol- ized catgut ligatures, made by soaking catgut in a mixture of carbolic acid, glycerine, chromic acid, alcohol, and water. If adhesive plaster is to be used, it is to be rendered aseptic by dipping it in a hot solution of carbolic acid. All the instruments, sponges, drainage-tubes, etc., to be used, 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 with the 1-20 solution of carbolic acid. (In the case of an acci- dental 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 opera- tion 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 drain- age-tubes are to be placed deeply in the wround and cut on an exact level with the surface,3 being held in place by means of pieces of carbolized silk. 1 In the British Medical Journal for May 28, 1881, Prof. Lister was announced to have said that he had found the oil of eucalyptus to be '• a perfect substitute for carbolic acid," but in the same Journal for October 25, 1884, was reported an address before the Medical Society of London, in which Prof. Lister recorded a death from septic poisoning in spite of this dressing, and advocated the employment of corrosive subli- mate with serum derived from horse's blood in the proportion of 1-100. His favorite at the present time is, I believe, the "sal alembroth" dressing, the exact composition of which does not appear to have been published, but which is understood to be a combination of corrosive sublimate and sal ammoniac. 2 Richardson, of Dublin, has devised a spray-apparatus to be worked by the foot. 8 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 ANTISEPTIC TREATMENT OF WOUNDS. 159 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 six1 layers of dry gauze, one of Mac- kintosh, an eighth layer of gauze, large enough to cover in all that have preceded, and finally a bandage of the same material. Whenever the dressings are changed, this is to be done under the spray, and special pre- caution 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, wrhile the inner dressings may in some cases be allowed to remain for weeks without renewal. Under the name of "prolonged or continuous pulverization," Verneuil recommends, during the after-treatment, the exposure of the part to the carbolized spray, the application being continued for two or three hours at a time, and repeated several times a day. The limits of this volume will not permit a description of all the modifi- cations of Prof. Lister's method which surgeons have adopted, and I shall therefore give an account only of the particular form of the antiseptic method which I am myself in the habit of employing. Before beginning an operation, I have the part shaved, thoroughly scrubbed with turpen- tine and then with soap-suds, so as to remove all impurities, and finally washed off with a solution of the bichloride of mercury. A 1-2000 solution is quite strong enough for use in any operation, and it is safer to err on the side of greater dilution than to run the risk of poisoning the patient with a too concentrated preparation. In abdominal surgery 1-10,000 is suffi- ciently strong, and, indeed, I am disposed to believe that distilled or simply boiled and filtered water is safer for intra-abdominal injections than any sublimate solution whatever. The instruments are laid in a tray and covered with carbolized water (1-20), and the ligatures, which are of catgut pre- pared with oil of juniper and alcohol, are kept in a similar solution made with glycerine. Instruments are quickly corroded by sublimate solutions, and should only be immersed in carbolized water as above directed. The sponges are kept in the mercurial solution, and are squeezed out at the mo- ment of using. I never use the spray, and, indeed, very few surgeons still employ it, and I have for more than a year abandoned the practice of irri- gating the weund during an operation, being satisfied that much harm is often done by wetting and chilling the patient with large quantities of antiseptic solutions. After the operation is completed, I have the wound thoroughly douched with a hot 1-2000 sublimate solution, and am sure that the patient thus suffers less shock than when constant irrigation is prac- tised. I use large rubber drainage tubes, cut on a level with the skin sur- face, and kept from slipping in by transfixing their ends with small safety- pins. I sew up the wound closely with silver-wire sutures, and cover it with a strip of "protective;" I employ both a deep and a superficial dress- ing, of either carbolized or sublimate gauze, the deep dressing being wrung out of the hot solution, and the superficial dressing including a sheet of Mackintosh or water-proof paper between its outer layers; I surround the part with sublimate cotton, and secure the whole with an ample gauze band- 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. 1 If the corrosive sublimate gauze is used, at least sixteen layers are thought desir- able by Prof. Lister for the first dressing. 100 EFFECTS OF INJURIES IN GENERAL. age, applied with moderate firmness. The dressings are renewed, on an aver- age, once a week, boracic-acidointment, spread on lint, being substituted for the protective after the occurrence of granulation. Where there is much suppuration, as after operations for necrosis, where primary union is not looked for, I dust the surface well with powdered iodoform; but I look upon this substance as quite useless in the early dressings. For accidental wounds, compound fractures, etc., a similar plan is employed, the wound being thoroughly washed out with the 1-2000 solution, applied with a syringe, and being amply furnished with drainage tubes. In previous editions of this work, I have expressed a doubt as to the supe- riority of the "antiseptic method" over other plans of wound-treatment Having now employed it for more than two years in large clinical services at the University, Pennsylvania, and Children's Hospitals, as well as in private practice, I feel compelled to say that I have modified my opinion, and that while I cannot subscribe to the extravagant laudations which this plan of treatment receives at the hands of its more enthusiastic advocates, I believe that, when used with judgment, and, if I may be pardoned the expression, when diluted with common sense, it is capable of affording very valuable aid to the surgeon. I have not, indeed, found any diminution in the mortality after operations by its employment, but I find that the average period of convalescence is shortened; that the violence of the trau- matic fever and the frequency of secondary fever are both lessened ; that upon the whole the comfort of the patient is promoted; and that the labor and anxiety of the surgeon are very materially diminished. For all which I am duly thankful. 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 somewThat the character of an in- cised wound; if dull, the injury more resembles a contused wound. Punc- tured 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 important cavity, they are attended by much risk to life. The form of punctured wound most frequently met with in civil practice is that pro- duced by the common sewing-needle, which easily penetrates the flesh, and then is broken off, the point remaining in the tissues. These wounds may be met with in any part of the body, but are, for obvious reasons, most often found in the hands, feet, knees, and buttocks. If the surgeon see such a case shortly after the 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 sur- geon's fingers on careful palpation. If it be necessary to cut down upon the needle (which 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 for- ceps a short distance below the point at which it is broken; it is occasion- ally more convenient to push the needle outwards, thus making its point emerge by a counter-opening at a little distance. If the case be not seen for some hours after the introduction of the needle, when swelling has already occurred, or if unskilful efforts at extraction have only served more deeply to imbed the foreign body, it is often impossible for the surgeon to satisfy himself as to the position of the needle. In such cases it is usually better to wait until the establishment of suppuration has dislodged the foreign body, when it will gradually work its way towards the surface. The pre- sence or absence of a needle might, in case of doubt, be determined by the magnetic test of Mr. Marshall, holding a powerful magnet upon the part PUNCTURED WOUNDS. 161 for fifteen or twenty minutes, so as to influence the fragment, the presence of wThich would then be revealed by the deflection of a polarized needle, deli- cately 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 to be due to a wound of the periosteum thus inflicted. After the removal of the foreign body, cases of needle-wound are to be treated on general principles. If an important part, such as the knee-joint, be in- volved, entire rest and the local use of dry cold will be particularly indi- cated. Bayonet Wounds form almost the only class of punctured wounds now met with in civilized warfare. They are very rare, only 400 cases being recorded in the Surgical History of the War, as compared with over 246,000 wounds of other descriptions ; of these 400, only 30 proved fatal. Formerly, wThen duelling was very frequently resorted to by soldiers, the small-sword was the weapon usually employed, and punctured wounds were thus constantly inflicted; they were treated by the drummers of the regiment, who sucked the part dry from blood, and then applied a piece of chewed paper or wet cloth to the wound, which frequently healed under this treatment in a remarkably short space of time. This mode of practice is said by Percy and Laurent to have originated among the Romans (who employed suction as a remedy for poisoned weunds), and to have been introduced into military surgery by Cato, who would not allow doctors in his army, disliking them because they were usually of Grecian birth. Arrow Wounds are frequently met with in our western border in con- flicts with the Indians. They are very serious injuries, being particularly fatal when they involve the abdominal cavity. The following tables, taken from Dr. Bill's article in the second volume of the International Encyclo- paedia of Surgery, show the relative fatality of arrow wounds in different parts of the body, and the causes of death in fatal cases:— Heap or Spinal Thorax. Abdomen. Column. o Is ded. ts n ded s = . ■a ■a B a s s c c 1 S a >>« ^"^ is 2. 3 be 3 so a t- <£ fc. ° 17 © S © S z;~ $* Z* IS O & £ Number of cases saved, 2 4; 12 5 10 2 11 44 107 " died, 7 | ... ! 1 13 | ... 2 "~2 18 3 2 1 47 Total . . . 9 4 13 18 10 20 14 46 18 154 Cause of Death. Is '3 o fit a o as a 03 .a a. z> W 3 si 1 e S a « eg 'a o c a a a Ph E-a' © t. £ ° •- © si Wound of heart (shock?). o ^ o Number of cases . . . 10 16 4 1 1 1 1 2 8 47 Dr. Otis, in Circular No. 3, S. G. O., 1871, published 83 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 11 162 EFFECTS OF INJURIES IN GENERAL. 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 import- ance of not hastily pulling tlie shaft away while leaving the head, and the equal inportance of careful but persistent efforts to remove the latter. This may be done by catching the head of the arrow with curved forceps, or 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 (»f poisoned arrows; it would appear, however, from the reports of Dr. Bill and other army surgeons, that in reality this is very seldom done ; I am, however, informed by Dr. Schell, who was stationed'for some time at Fort 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, even when there is no evidence of the introduction of any morbid poison. The late Prof. Gross met with cases in which great inflammation and suffering followed abrasions of the hand received in striking another per- son on the mouth, and I have myself seen a bite of the thumb followed by fatal tetanus. Syphilis is occasionally inoculated in this way. The treatment of punctured xoounds consists in the use of simple ano- dyne dressings, and in the adoption of means to prevent the development of excessive inflammation. Poisoned Wounds__The Stings of Insects are seldom productive of serious consequences, in this country at least. In tropical climates, the insects appear to be more venomous, and, according to the reports of African and other travellers, death not unfrequently results from such a cause. Even in this part of the world, however, death, sometimes pre- ceded by gangrene, has occasionally resulted from the sting of a bee or the bite of a mosquito, probably owing to idiosyncrasy on the part of the patient. The pain of a sting may be relieved by the application of spirit of hartshorn (aquaammoniae), and the subsequent inflammation should be treated on general principles. Snake Bites are often productive of serious symptoms, and not unfre- quently of death. All snakes, however, are not venomous; and even in the case of those which are known to be poisonous, if by the action of biting a few times they have exhausted their stock of venom (which, in the instance of the rattlesnake, is contained in a small pouch under the upper jaw), the wounds which they can then inflict, until the venom reaccumu- lates, may be no more serious than other punctured wounds of similar characters. The bite of the rattlesnake is usually attended with much pain, though this is not always the case; there is sometimes free external bleeding, and always rapid interstitial hemorrhage, causing great swelling of the affected part, which is usually one or other extremity. In cases which terminate unfavorably, the swelling rapidly ascends the limb, which is deeply dis- colored ; vesications make their appearance, and the part falls into a gan- grenous condition. In favorable cases, the swelling and other local symptoms disappear almost as rapidly as they came. The constitutional symptoms of rattlesnake poisoning are those of extreme prostration, the mind often remaining clear until within a few minutes of the fatal issue. Death may take place in a very short time (forty minutes only in a case reported by Dr. Shapleigh), from the direct effect of the poison on the nervous system, or after the lapse of several days or weeks, from extensive POISONED WOUNDS. 163 sloughing and suppuration resulting from the local injury. The coagula- bility of the blood appears to be much impaired by the effect of the poison, this fact accounting for the great interstitial hemorrhage, and consequent swelling and discoloration. Various substances have been proposed as antidotes to snake poison, those which have attained most reputation being the eau de luce (contain- ing ammonia), the Tanjore pill (of which arsenic is a principal ingredient), Bibron's antidote (containing corrosive sublimate, bromine, and iodide of potassium), and the liquor potassa?, recommended by Dr. John Shortt. Prof. Halford, of Australia, has proposed the direct injection into the veins of dilute aqua ammonia?, and has reported several cases in which the treat- ment was followed by recovery. The use of ammonia in this way might doubtless prove efficacious as a cardiac stimulant, but the treatment has completely failed in the hands of Prof. Fayrer, and there seems to have been a doubt as to the venomous nature of the snakes in some of those cases in which success followed the use of the remedy. 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. 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 now, I believe, abandoned even by those who most highly extolled its virtues. The treatment recommended by Dr. S. Weir Mitchell, who is one of the highest living authorities on this subject, consists in the internal adminis- tration of alcoholic stimulus, of course not pushed to the point of producing deep intoxication, with suction by means of a cupping-glass, the applica- tion of carbolic acid, diluted with 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 cur- rent except when momentarily relaxed by the surgeon ; by the use of this means a small portion of the venom can be admitted at a time into the general circulation, and the enemy, as it were, met and fought in detach- ments. 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 wounds 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, which he considers pre- ferable to ammonia, and by the use of external heat, galvanism, and per- haps the cold douche. Should the breathing fail, artificial respiration should be resorted to, in hope that life may be 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 affec- tion appears to be communicated by means of the saliva, though whether it originate in that secretion or be merely mixed with it, coming from other structures of the mouth, is uncertain. The proportion of cases of hydro- phobia 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 2^. After the reception of a bite, the poison may remain latent for a variable period, 164 EFFECTS OF INJURIES IN GENERAL. 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 tint the stage of incubation may vary from about four weeks to eleven months, sometimes, however, undoubtedly surpassing the latter limit. The difference is sup- posed by Mr. Forster to depend on the part bitten, and the circumstances under which the bite is received. If the face be the seat of injury, the period of latency will probably not exceed four or five weeks, and if the disease have not appeared in that time, the patient may be considered safe. When the hand is the part affected, the period of latency varies from five weeks to a year; and when the clothes have been bitten through before the skin is injured, several years may elapse before the development of the disease. An apparently authentic case has been reported by Fereol, in which the period of incubation was two and a half years, and Colin has recorded a case in which it was said to have been nearly five years. The wound is usualty 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 special symptoms of the disease, and those which Mr. Forster considers in themselves sufficient for diagnos- tic purposes, are intense pain and cutaneous sensibility, and spasms of the pharyngeal muscles, rendering it almost impossible to swrallow anything, but especially liquids. To these there are usually added a feeling of great anxiety and a sense of impending danger, together with delusions alterna- ting with the wildest delirium. There may be general convulsions, while there are almost always spasmodic movements of the mouth and of the laryngeal muscles, with expectoration of viscid and very tenacious mucus and saliva ; hence the popular notion that the patient barks and tries to bite. Hydrophobia has, until recently, been thought an invariably fatal affection, but instances of recovery under the hypodermic use of woorara have been recorded by Offenburg, Polli, and B. A. Watson Death may occur in one day, or life may be prolonged for nearly a week. As a pre- ventive measure, excision of the part bitten is usually recommended. Mr. Youatt had great confidence in cauterization with nitrate of silver, and I may add that I was told by a negro, who 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 con- sequences, having always used this remedy. I am disposed, however, to question (with Mr. Foster) whether any of these plans is really productive of benefit; the immense majority of bites will not be followed by hydro- phobia under any circumstances, and on the other hand, hydrophobia has occurred even after free excision of the injured part. Duboue, of Pau, ad- vises the daily administration of large doses of bromide of potassium dur- ing the whole period of incubation. Peyraud suggests inoculatiojis with the essential oil of tansy. When the disease occurs, the patient must be kept quiet in a darkened room, and free from all avoidable sources of irri- tation; his strength must be supported by such concentrated food and stimulus as can be taken, or by nutritious enemata, while an ice-bag may be placed to the spine, as recommended by Dr. Todd and Mr. Erichsen, and the violence of the spasms may be relieved by inhalations of ether, or nitrite of amyl (Forbes), or by the use of large doses of bromide of potas- sium. Dr. J. B. Read, of Alabama, suggests the hypodermic employment of gelsemium ; Gingeot that of hoang-nan ; and Dr. Nursimula, an Indian physician, that of atropia. Bouisson speaks very fayorably of the employ- POISONED WOUNDS. 165 ment of a hot-air bath. Dr. Hammond recommends the persistent employ- ment of a primary current of electricity, one pole being applied to the head, and the other to the feet. Skinkwin, of Cork, advises transfusion, and Culver, of Jersey City, following a hint of Majendie's, intravenous injec- tions of saline solutions ; bromide of potassium, administered in this man- ner, is recommended by Duboue; as already mentioned, several cures have been reported from the administration of woorara, and others are said to have been obtained by the hypodermic use of pilocarpin, by inhalations of oxygen, and by the employment of the monobromate of camphor, of aconite, and of cannabis indica. The only post-mortem appearance visible to the naked eye, which can be considered as characteristic, is, according to Mr. Forster, dilatation of the pharynx ; but in cases recorded by Clifford Allbutt, Hammond, Gowers, and Cheadle, there were 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 by Wassilief, of St. Petersburg.1 Congestion of the nervous structures in the vicinity of the wound, and in- flammatory changes in the salivary glands, have been noticed by Nepveu, as have hyperemia and an accumulation of white corpuscles in the kidneys, by Coats, of Glasgow. Pasteur's Prophylactic Method against Hydrophobia.—Within a few years M. Pasteur, the eminent French scientist, has claimed to have dis- covered a mode of preventing the development of hydrophobia, both in the dog and in man, by inoculation. According to Pasteur, the virus of rabies is found chiefly in the spinal cord, though it also exists in other parts of the nervous system, and in the salivary glands. Its formation is probably owing to the presence of a special microbe, though this has not yet been proved. Aurep, of St. Petersburg, has isolated a crystalliz- able ptomaine of extremely poisonous properties from the brain and me- dulla oblongata of rabbits suffering from rabies. Inoculation of the nervous centres with virus introduced by trephining, is commonly fol- lowed by the furious form of the disease, while paralytic rabies is pro- duced by intravenous or hypodermic injections. The nature of the animal through which the poison passes, modifies its intensity, the period of incu- bation in rabbits occupying about two days more than in guinea-pigs. Virus taken from a dog and inoculated upon a series of monkeys becomes weakened, but wrhen inoculated upon a series of rabbits or guinea-pigs acquires added strength, and, if re-inoculated upon a dog, produces more marked effects even than the virus of " street rabies," or that caused by the direct bite of a rabid dog. By using a weak virus first, dogs may be afterwards inoculated with that which is stronger, and by a course of suc- cessive inoculations, a state of insusceptibility to rabies may be induced. If sections of the spinal cord of a clog dead of rabies be suspended in dry air, the amount of contained virus is gradually diminished, and the surgeon can thus keep on hand a series of diseased spinal cords of graduated po- tency. Pasteur proceeds as follows : Having secured, by successive inocu- lations upon rabbits, a virus which induces rabies after seven days' incubation, he prepares a series of flasks in wrhich the air is kept dry by fragments of caustic potassa. Daily he suspends in one of these flasks a section of spinal cord freshly taken from a rabbit dead of seven days' rabies, and thus secures a series of viruses of gradually lessening strength. 1 The changes noted in the brain and spinal cord in cases of hydrophobia are, how- ever, according to Middleton, of Glasgow, by no means characteristic of that disease, but may be met with in any oases in which there has been great cerebral excitement. 166 EFFECTS OF INJURIES IN GENERAL. To protect a dog from the possibility of acquiring rabies from the bites of other rabid dogs ("street rabies"), he injects hypodermically a syringeful of sterilized bouillon impregnated with a fragment of cord which has been drying so long as to lose all its virulence; the following day he repeats the injection with a portion of cord which has been kept two days' less time, on the third day with one of four days' less age, and so on, slowly increasing the virulence of the injections until the employment of an almost fresh cord completes the dog's insusceptibility to the poison. Pasteur adopts a similar plan in inoculating human beings, and believes that insus- ceptibility may be secured by these prophylactic injections even after the person has been bitten by a rabid dog, provided that the treatment is be- gun with sufficient promptness. In his first case the course of inoculations occupied sixteen days, but he has subsequently shortened the time to seven days or less, and sometimes repeats the course. Up to December 31, 1886, he had thus treated 2682 cases with 36 deaths, and other operators had communicated to him the reports of 830 cases with 13 deaths; 4.S cases of wolf-bite, included in the above figures, had given seven deaths. Of 3Sf> cases of dog-bite reported by Dujardin-Beaumetz as treated by Pasteur's method in the Department of the Seine during 18S8, only 4 proved fatal, or 1.04 per cent., while of 105 cases not so treated, 14 ended fatally, or 13.3 per cent. Pasteur's experiments have been repeated by Ernst, who finds (1) that in the cords and brains of animals inoculated in Pasteur's laboratory there exists a specific virus which is capable of producing simi- lar symptoms through a long series of animals; (2) that these symptoms are certainly produced by trephining and inoculation under the dura mater, but less certainly by subcutaneous injection; (3) that the strength of the virus is lessened by placing the spinal cords containing it in a dry atmos- phere at an even temperature; (4) that the symptoms produced by inocu- lation only appear after a period of incubation, shorter when the virus is inoculated by trephining than when hypodermically ; (5) that inoculations practised after the manner of Pasteur protect in a marked manner against an inoculation with virus of full strength ; and (6) that w7hile heat destroys the power of the virus, cold does not, and hence the virus may be kept by freezing the cord containing it until needed for use. Von Frisch confirms some of Pasteur's conclusions, but finds that protection against " street rabies" can only be obtained by subdural injection, and that healthy animals treated by the method of intensive inoculation may themselves become affected with rabies. He concludes, therefore, that even the pos- sibility of protecting animals by inoculation is not demonstrated; that there is no reason to believe that inoculation is preventive in man; and that, on the other hand, there is strong reason to believe that rabies may be caused by the prophylactic inoculations themselves. The accuracy and significance of Pasteur's observations have been ably disputed also by other writers, among whom may be mentioned Abreu, Peter, Lutaud, Spitzka, and Dulles, of this city. On the other hand, the British Parlia- mentary Commission believes that a positive saving of life has been effected by preventive inoculation, though it concedes that some deaths have followed the use of the intensive method, which, it is added, Pasteur now employs only in cases of extreme urgency. Looking at the matter from a practical point of view, it must be con- fessed, I think, that the expectations raised by Pasteur's early publications! have not been fulfilled. A considerable number of his patients who were reported as having been successfully treated, have since died, some at least of them apparently from hydrophobia; and there has, in some cases, been ground for suspicion that the disease has been caused by the preventive POISONED WOUNDS. 167 inoculations themselves. It must be remembered, too, that while dog-bites are everywhere very common, hydrophobia is, in most localities, very rare. The majority of physicians go through life without seeing a single case of this disease, and few have the chance to observe more than one or two. The surgeon should therefore, I think, feel very certain that the vic- tim of a dog-bite is really threatened with hydrophobia, before advising a mode of treatment which is not only of doubtful efficacy, but may itself possibly cause the very disease which it is intended to prevent. Dissection Wounds are less frequently productive of unpleasant conse- quences at the present day, when anatomical subjects are prepared with antiseptic agents, than formerly ; it is indeed much oftener from making autopsies, especially in cases of erysipelas, puerperal peritonitis, etc., than from the dissection of ordinary subjects, that this form of poisoned wound is met with. Even in performing surgical operations, surgeons are occa- sionally exposed to this form of injury ; witness the case of the late Mr. Collis, of Dublin, who died from the effects of a slight wound received in excising an upper jaw\ A cut received in dissecting or in operating- may act merely as any other wound, producing an inflammatory condi- tion, which will of course be aggravated if the person be in a depressed state of health when the injury is inflicted. Under such circumstances, the wounded part will swell, becoming hot and painful, and the neigh- boring lymphatics will probably become involved with enlargement of the axillary glands, and a condition of general febrile disturbance. The inflammation may end in resolution, or may run on to suppuration, pursu- ing very much the same course as a severe wThitlowr. In other cases there is a positive inoculation of septic material, followed by diffuse cellular inflammation, or by phlegmonous erysipelas, involving a considerable part of the body, and attended by extensive suppuration, and perhaps slough- ing ; the general symptoms are those of extreme depression, and the patient dies of pyaemia or septicaemia, or recovers after a long and tedious conva- lescence, with his health, perhaps, permanently impaired. The first symptom of this more serious form of the affection is usually a small vesicle, which appears at the seat of the injury, sometimes within twelve hours, but usually on the second or third day. If a wound is received in dissecting, it is proper to tie a ligature around the part to encourage bleeding, and to wash the wound thoroughly with soap and water; after which suction should be practised, provided that there be no abrasion about the mouth. The benefit of cauterization in these cases is somewhat doubtful, but if it be thought proper to employ it, strong nitric acid or the acid nitrate of mercury will probably prove the best agent. If, in spite of these precautionary measures, the wound give further trouble, the treatment must vary according to the form which the symptoms assume. The simple inflammatory affection which was first described, should be treated on general principles, poultices or other sooth- ing applications being made to the injured part, and laxatives and diapho- retics administered internally. In the more serious form, in which there is evidence of blood-poisoning, more active measures must be adopted: the vesicle and adjacent parts should be freely incised, and the wound washed with a solution of corrosive sublimate, or diluted tincture of iodine. Ano- dyne fomentations ma}' then be applied, and the strength of the patient must be kept up by the free use of stimulants and food, with quinia, cam- phor, 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. 168 GUNSHOT WOUNDS. 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 had ample opportunities for the study of this class of injuries twenty-five or thirty years ago—more ample, it is to be hoped, than will again be afforded for a very long period; still, injuries from firearms are often enough met with in civil practice to render it important for every surgeon to be familiar with their more prominent features and peculiarities, and to be prepared to perform any of the opera- tions which their treatment especially demands. Characters of Gunshot Wounds.—These vary according to the nature of the projectile by which the wound is inflicted, and the force with which it produces its effect. The momentum of a gunshot 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 with the same velocity, strike at the same moment, the cannon-ball, from its greater mass, will have a greater momentum, and will produce the greater injury. A charge of powder alone, without any ball, or the wadding of the gun, if the latter be fired at short range, may produce a serious or even fatal injury, the great velocity making up for the slight mass. A charge of small shot, if the gun be discharged in close proximity to the person struck, may enter the body en masse, as it were, and produce a large, ragged wound; or if the hand be struck, as occasionally happens to sportsmen from the premature discharge of a fowiing-piece, may absolutely blow off a portion of the member as effectually as would be done by a piece of shell or 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 wound; thus I have on several occasions seen patients who had what might be called " button- hole fractures" of the tibia, caused in this way: simply a round aperture in the front of the bone, the ball sometimes lodging, and sometimes goincr completely through the limb, but causing no splintering, and no great lace- ration of the soft tissues. The peculiar shape of the modern conoidal ball causes it to meet with much less resistance from the air, while the spiral rotatory motion which is imparted to it by the grooves of the modern rifled firearm enables it to retain much more of its initial velocity, and thus to strike with much greater momentum than the old form of musket-ball; moreover, from its centre of gravity not coinciding with its centre of figure, in its passage through the air it acquires a peculiar dip, causing it to strike obliquely, making a large wound, ploughing and tearing up the soft parts, and splintering the bones in all directions. Thus, it is not uncommon for a long bone, such as the tibia or humerus, when struck by a conoidal ball, NATURE OF GUNSHOT WOUNDS. 169 to be splintered and split both upwards and downwards, to the epiphyseal lines, or even into the adjoining articulations.1 Round shot or cannon-balls, unless moving with very slight velocity, are apt to tear off an entire limb, or whatever part of the body they may hap- pen to strike ; even when almost'spent, and rolling along the ground with no more apparent force than a ten-pin ball, they are capable of producing most frightful injuries, as it is said foolhardy soldiers have occasionally learnt to their cost, in attempting to stop such a spent ball with the foot. The reason is obvious: though the velocity is slight, the mass and, there- fore, the momentum are very great. On account of the great elasticity of the skin, it will occasionally escape injury from the blows of spent shot, wThile the parts beneath, bones, muscles, vessels, and nerves, may be fright- fully torn or completely pulpefied. Such are the injuries which used to be attributed to the effects of the wind of a ball, passing close to, but appa- rently not coming in contact with, the person wounded. These injuries are apt to be followed by gangrene, which often seems to be due to rupture of the main artery, at a point higher than the seat of apparent lesion. Shell-wounds are among the most fatal injuries met with in modern warfare. The explosion of a single shell may kill or mortally wound quite a number of persons ; the injuries most analogous to these which are met with in civil life, are such as are produced by accidents in blasting and mining, portions of metal or stone, or splinters of wood, being hurled violently by the force of the explosion against the bystanders, and often inflicting most serious and even fatal lacerations. Nature of Gunshot Wounds.—In whatever way inflicted, 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 dis- tance from the point of contact of the projectile, and in these cases a por- tion 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 down as an axiom, which holds good in this part of the world at least, that every gunshot wound must of necessity be fol- lowed by more or less sloughing. Indeed, it is often said that every por- tion 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 buck- shot were occasionally used in the form of " buck-and-ball cartridges," I saw several cases of very small, perforating, flesh weunds thus produced, in which, although undoubtedly the apertures both of entrance and of exit sloughed, the deep parts of the wound apparently healed without the oc- currence of sloughing ; and to suppose that such might be the case is not at all unreasonable, for the swelling of the tissues would measurably convert the deeper portion of the wound into a subcutaneous injury, placing it thus in a condition which, as we know, will allowr of great laceration without inevitable loss of vitality. The sloughing of gunshot wounds is not due, as was formerly supposed, to any poisonous qualities of the projectile, nor to its temperature,2 nor to any fancied development of electricity, but 1 Prof. 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 effect being inversely proportionate to its volocity. 2 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 increase 170 GUNSHOT WOUNDS. 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 went in1 and the other where it came out. If there be but one wound, it is prima-facie evidence that the ball has lodged and remains in the part; though more rarely a spent ball may drop out by the same opening as that by which 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 point at which it went in. Well-attested illustrations of these statements may be found in works on military surgery. On the other hand, the ex- istence of two wounds 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, while the other lodges; or, which conies 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 wounds. I had under my care, after the battle of Antietani, a Confederate soldier who had three wounds in the fleshy part of the thigh; they were all in a line, superficial flesh-wounds, almost identical in appear- ance, and with nearly equal intervals between them. Either two balls had entered together, and, separating in the tissues, had come out by different apertures, or, which from the po-ition of the wounds seemed more probable, two balls had entered by distinct openings, and, meeting in the limb, had come out together. Not unfrequently a ball perforates both lower extrem- ities, thus making four wounds, and I have even seen five wounds, evi- dently made by the same ball. Thus, I remember a soldier who had ap- parently been struck by a ball passing obliquely upwards, while his arm was flexed at the elbow and somewhat elevated; the ball had grazed the forearm, perforated the upper arm (just missing the brachial artery), and then entered the chest, superficially wounding the lung, and ultimately emerging below the scapula. The apertures of entrance and exit present somewhat different appear- ances ; these were better marked when round balls were in common use than at the present time, when gunshot wounds are usually inflicted by conoidal bullets. The entrance wound is usually smaller than that of exit, and, indeed, from the elasticity of the skin, often appears smaller than the ball which made it; its edges are rather inverted than everted, and, if the weapon has been discharged at a very short distance, the skin may be blackened by the explosion of the powder. The exit wound has everted edges, is ragged, more irregular than that of entrance, and usually larger. These differences are owing to several circumstances, among which 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 explanation 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. of temperature sufficient to cause partial melting of the projectiles, and Gros maintains that the modern bullet carries with it a minute quantity of hydrocyanic acid, which accumulates in the gun-barrel as the result of the explosion of the powder. 1 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 recog- nized during life ; and a curious case occurred during our late war, in which an officer was mortally wounded through the. anus. SYMPTOMS OF GUNSHOT WOUNDS. 171 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 laro-e. and ragged wound, and, undergoing partial rotation from the resistance of the tissues, might emerge point forwards, thus making the exit wound smaller and more regular than that of entrance. Again, the distinctive appearances of the apertures may be obliterated, or their characters reversed, by the processes 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 goodin the im- mense majority of cases, and the surgeon may often derive valuable informa- tion by bearing it in mind ; thus, it has happened that in cases of second- ary hemorrhage it has been impossible to discover the source of bleeding, till by placing the patient in the exact position wiiich he occupied when shot, and looking along the line wiiich the ball must have taken, it has be- come 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 resortingto 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 wounds vary with the part affected, the nature of the missile, and other circumstances. The amount of shock is, according to Drs. Mitchell, More- house, 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 around, 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 wTar were, according to the testimony of Dr. Brinton and other army surgeons, the most patient and enduring of all our wounded ; another peculiarity 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 of 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, the sensation is variously described as that of a blow^ from a cane or sharp stone, as a burning rather than a pain, or as an electric shock. In some cases, when nerve trunks are involved, there is most distressing 172 GUNSHOT WOUNDS. pain referred to other and occasionally far different parts of the body ; in other cases a still more curious phenomenon is observed, viz., local tempo- rary paralysis of motion and solvation, caused by concussion or commotion of a large nerve, from a ball passing near without directly injuring it. Primary hemorrhage, contrary to what might be supposed, is not a prominent symptom of gunshot wounds, but, when it does occur to any great extent, usually proves almost instantly fatal. Even when a limb is carried off by a shell or round shot, the peculiar way in which the vessels are torn asunder allows contraction and retraction to occur, and there is much less bleeding than would be anticipated. In ball-wounds of the ex- tremities, the natural elasticity and resiliency of the vessels seem to en- able them to elude the projectile, and we often find the tract of a wound apparently crossing directly the line of a main artery which yet has en- tirely 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 renewed. Hence, death from hemorrhage on the battle-field is a rarer occurrence than is generally supposed; the cases which do prove fatal in this way, are usually those of wound of the heart itself, or of one of the large internal arteries, such as the aorta or pulmonary artery, or of wound at the root of the neck, where arterial retraction and contraction cannot occur, and where the condition may be additionally 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 wounds of the same severity. There is always a good deal of inflammation, with perhaps more swelling than in ordinary contused wounds, 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 hemorrhage; 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 hemorrhage may, of course, be caused at a still later period by some accidental circumstance, such as the puncture of a large artery by a spiculum of necrosed bone, as in a case recorded by Dr. Chisolm, in which bleeding occurred on the 328th day, or in the still more remark- able case recorded by Dr. William Hunt, in which fatal secondary hemor- rhage similarly occurred nearly three years after receipt of the injury, which was not, however, in this instance a gunshot wound. 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 which they exhibit when occurring after the lesions met with in civil life. Treatment pf Gunshot Wounds__All gunshot injuries may be divided, as regards the question of treatment, into those which 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-wounds, together with all of the more serious class of penetrating wounds of the great cavities of the body. Thus, there are tabulated in the third volume of the Surgical History of the War, only 60,266 gunshot fractures and contusions of the extremities, as compared with 113,940 simple flesh-wounds of the same parts. The immediate indications for treatment, in a case of gunshot wound in which the question of operative interference does not arise, are three in number, viz., (1) to promote reaction, (2) to TREATMENT OF GUNSHOT WOUNDS. 173 arrest hemorrhage, and (3) to remove all foreign bodies. The first point has already been sufficiently considered in previous chapters, and need not be again referred to. Hemorrhage.—With regard to the arrest of hemorrhage, from what was said above it will be seen that there are comparatively few cases in wrhich the surgeon has the opportunity to treat primary bleeding. In nearly 246,000 cases of gunshot wound, treated during the late war in this country, there were but 1155 ligations of arteries, and most of these were for secondary, not primary, hemorrhage. Still, cases are occasionally met with 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, who bled to. death from a wound of the posterior tibial artery, and whose 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 improvise one in the form of the common Spanish windlass (Fig. 30), twisting the knot with a drum-stick or the handle of a sword. It has been recom- mended 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 im- proper 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 wrho has evidently lost a great deal of blood, with a deep wound filled by a recent clot which 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 allows the clot to remain, in hope that under its protection the wounded vessel would close by the natural pro- cesses which will be considered hereafter; and even if the wound were in one of the extremities, it would probably be right 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 situa- tion, and the patient not much exhausted, it would be better to remove the clot as any other foreign body, and to 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 within 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 fig. 92. unglazed porcelain, wiiich, by receiving a metallic streak, surely baton's indicates the presence of a leaden ball, if the latter come in con- probe' tact with it.1 It was by means of this probe that the eminent French sur- geon, whose name it bears, was enabled to demonstrate the presence of 1 Dr. Heighway, of Cincinnati, is said to have employed for this purpose, during the Mexican war, the stem of a clay tobacco-pipe. 174 GUNSHOT WOUNDS. a ball in the wound of the celebrated Italian General, Garibaldi. Long- more speaks favorably of Lecompte's " stylel-pince;" or "probe-nip}>ers," by which the surgeon can withdraw a minute portion of the foreign body for examination. Culbertson, of Ohio, has devised a meerschaitm probe which serves the purpose of Neiaton's instrument, and is besides provided with a roughened surface to catch and withdraw filaments of clothing, etc., which may be in the wound. Electric probes, containing two insulated wires, have been devised by Fa vie, of Marseilles, and others, for the de- tection 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 audicnt of a tele- phone as an indicator. An older instrument is the drum or reverberating probe of L'Estrange, an Irish surgeon, which is provided with a small sounding-board to indicate to the ear the nature of the body struck. De- neux suggests the use of a probe carrying a mass of charpie dipped in dilute acetic acid; by contact with the ball the acetate of lead is formed, and the presence of the metal may then be demonstrated by means of suit- Fio. 93.—Bullet forceps. able reagents. Fhler, of Maryland, injects dilute acetic or dilute nitric acid, and then tests the injected fluid for lead and iron respectively.1 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 screw extractor (Fig. 94); while if superficial, it may often be readily turned out with a scoop, or with the extremity of an or- Fiu. 94.—Screw extractor. dinary grooved director. In other 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 otherwise produce irritation, acting 1 The same surgeon suggests that the presence of a splinter of wood might be recognized by detecting tannic acid in the discharges. AMPUTATION AND EXCISION IN GUNSHOT INJURIES. 175 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, especial!}* in the suppurative stage, to make more or less free incisions to relieve exces- sive tension, just as would be done in the case of any other wound in wrhich the original opening did not give sufficient vent; but in the immense majo- rity 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 wTar, and as a primary application answers very well ; if too long continued, however, it produces a depressing influence on the part, the granulations becoming pale and flabby, and showing an indisposition to heal. If antiseptic dressings are not at hand, the surgeon may use lauda- num, pure or diluted, as with other contused and lacerated wounds ; chang- ing it for poultices or w*arm fomentations when the sloughs begin to sepa- rate, and again using more stimulating dressings, such as lime-wrater, 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 occurrence 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 employment of this provisional tourniquet, as it is called, many lives may be saved that would otherwise inevitably be lost. Amputation and Excision in Gunshot Injuries___Amputation may be rendered necessary in cases of gunshot injury by various circum- stances ; 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 surgeon's only recourse. When it is evident that, from the severity of the injury, amputation will be required, it should, in accordance with the principles enunciated in Chapter V., be performed as soon as pos- sible after the occurrence of reaction. It may, however, even in cases which at first promise well, be required, as will 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 amputation in military practice, is comparatively an affair of modern times ; the operation has, however, been so successful, at least in the upper ex- tremity, that it may now 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 w'henever the destruction of parts does not mani- festly render the latter operation imperative. 176 GUNSHOT WOUNDS. Shoulder.—Gunshot fractures involving the shoulder-joint very often require excision, the operation having, apparently, been first employed by Percy in 1792. The statistics of the operation during our late war, as recorded by Dr. Otis, gave 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 mor- tality during our war was according to the same authority, 29.1 per cent. Expectant treatment (reserved of course for selected cases) gave a death- rate of only 27.5 per cent. Gurlt's tables embrace 1061 cases of excision, with 567 "deaths, a mortality of 34.7 per cent, In spite of its slightly greater fatality, excision should, I think, be preferred to amputation in anv case admitting of a choice between the two operations. Even if the humerus be split for a considerable distance downwards through its shaft, excision mav still be practised, not a few instances having occurred dur- ing our war, in which very large portions of the humerus were removed bv excision, a useful hand and forearm being thus preserved. " Elbow.—Excision of the elbow, introduced into military practice by Percy, was frequently performed during our war,1 764 cases being noted in Dr. Otis's Surgical History. In 716 of these cases, in which the results are known, there were 165 deaths, a mortality of 23 per cent. The death- rate, according to these figures, would appear to be slightly less than that of amputation of the lower third of the arm, 25.9 per cent, and hence ex- cision should be preferred in all suitable cases. The secondary were more successful than the primary excisions, while the intermediate operations were 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 elbow, and his view is adopted by Hueter, Langenbeck, and Gurlt; but the ex- perience of our war, as given by Dr. Otis, is decidedly in favor of the more sweeping operation. Gurlt's tables give 1438 cases of elbow excision with 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 sufficiently satisfactory as regards life, but rather unsatisfactory as regards the utility of the preserved limb. Dr. Otis records 90 cases, of which 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 with in military practice. The compara- tive advantages of excision,2 amputation, and expectant treatment in these cases, have been fully and ably investigated by Drs. Otis and Huntington, U. S. A., in the third volume of the Surgical History of the War, and the statistics which bear upon the question are exhibited in the following tables:— Excisions. Cases. 43 60 41 27 Died. Recovered. Death-rate. Primary ...... Intermediate ..... Secondary ..... Uncertain ..... 40 58 26 24 3 2 15 3 93.0 96.6 63.4 88.8 Aggregate .... 171 148 23 86.5 1 The first case in American military surgery is attributed to Dr. Otis Hoyt, during the Mexican war (1847). 2 First adopted in military practice hy Oppenheim, in 1829. AMPUTATION AND EXCISION IN GUNSHOT INJURIES. 177 Amputations. Cases. Died. Recovered. Doubtful. Death-rate. Primary .... Intermediate . Secondary Re-amputations Uncertain 82 55 40 11 66 75 52 33 4 61 7 3 7 7 4 1 91.4 94.5 82.5 36.2 93.8 Aggregate 254 225 28 1 88.91 Gurlt's statistics showr very much the same mortality, 139 cases having given 122 deaths, or 88.4 per cent. The mortality in cases treated during our war by expectancy was 98.8 per cent. During the late Franco-Prussian war, as reported by Richter, 33 cases of wound of the hip, treated by expectancy, furnished 31 deaths, and 21 treated by excision 18 deaths, while 11 hip-joint amputations all terminated fatally. From these facts the conclusion is fairly drawn that, in any case of un- complicated gunshot fracture of the hip-joint, primary excision should be preferred to any other mode of treatment. 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 what 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. 95), from a photograph, shows the condition of the bone in a case in which I performed (unsuccessfully) secondary amputa- tion 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, Gurlt, and Otis and Huntington. Cousin finds that 33 cases of total excision have given 5 recoveries and 28 deaths (85 per cent.), while 11 eases of partial excision have given but one recovery and 10 deaths (91 per cent.). Of the whole 44 cases, 38 proved fatal, a mortality of over 86 per cent. Chenu's figures, derived from the records of the Franco- fracture of Mp. Prussian war, show a still larger death-rate, 37 complete excisions having given 33 deaths (89 per cent.), and 65 partial excisions 62 deaths (95 per cent.), or the whole 102 cases 95 deaths, a mortality of over 93 per cent. Lotzbeck's and Kuster's statistics, though somewhat more favorable, are still sufficiently 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., while Gurlt's tables give 146 cases with 111 deaths, a mortality of 77.08 per cent. 1 Doubtful cases omitted in computing percentages. 12 178 GUNSHOT WOUNDS. Drs. Otis and Huntington tabulate in all 190 cases of knee-joint excision for gunshot injury, 57 derived from the records of the American war and 133 from other sources. The results may be seen in the annexed table:— Excision* Cases. Died. Recovered Doubtful. Primary . . Intermediate . Secondary Uncertain 69 67 41 13 49 58 25 8 18 8 15 4 2 1 1 1 Aggregate 190 140 45 5 73.1 87.8 62.5 66.6 75.61 The same authors give the death-rate of^gunshot fractures of the knee treated by expectancy as 57.3 per cent. In our own army, during the late war. it was 60.6 per cent. "When we compare the above figures with the death-rate of amputation in the lower third of the thigh (55 per cent, according to Legouest, 50 per cent, according to Macleod, 53.6 per cent, according to Otis and Hunting- ton), the conclusion is surely irresistible 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 war ; 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) were more successful, 47 cases having given 33 recoveries and only 14 deaths. Gurlt's figures embrace 150 cases with 51 deaths, a mortality of 34 percent. Drs. Otis and Huntington tabulate in all 183 cases, in 176 of which the results have been ascertained. Death occurred in 58 of these, showing a mortality percentage of 32.9—a death-rate considerably higher than that of either amputation or expectancy. Gunshot Fractures of Shafts of Long Bones very commonly require amputation. The preservation of a limb which is the seat of such an in- jury 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 following table taken from the second and third volumes of the Surgical History:— Excisions in Continuity. Died. Recovered. Undeter-mined. 28 Total. Mortality per cent. Humerus 191 4772 696 28.5 Bones of forearm 109 856 21 986 11.2 Metacarpal bones 10 104 2 116 8.8 Femur .... 116 51 8 175 69.4 Bones of leg 108 275 4 387 28.2 Metatarsal bones 18 75 4 97 19.3 Comparing these figures, when the number of cases is sufficiently large to justify their being used for statistical purposes, with the results of ampu- tations of the same parts, as given in previous chapters, we may conclude 1 Doubtful cases omitted in computing percentages. 2 In 1U4 cases bony union did not occur. AMPUTATION AND EXCISION IN GUNSHOT INJURIES. 179 that—(1) excision in the continuity of the bones of the forearm is permis- sible in favorable cases; (2) excision in the continuity of the humerus is more fatal than amputation of the corresponding parts, and is so often fol- lowed by non-union as to be in most cases an undesirable operation ; (3) excision in 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 may, therefore, be resorted to in selected cases ; (5) excision in the hand or foot is not an operation to be recommended. Judging from my individual experience, wThich is, of course, limited, I should say that, except in the case of the radius or ulna separately, and perhaps of the fibula, excision in the continuity of the long bones was an undesirable operation. Those cases of resection of the shaft of the humerus or tibia, which I have observed, have either required subsequent amputa- tion, or have preserved limbs of very questionable utility ; the case is very different from one of necro- sis or ununited fracture, and, I be- lieve, there is as yet no instance on record, of useful reproduction of bone, in a ease of excision in con- tinuity, for gunshot or other trau- matic injury. In the case of the separate bones of the forearm, however, most ex- cellent results may be obtained by excision. I have myself twice ex- cised considerable portions of the radius, in cases of gunshot fracture, one being a primary (Fig. 96), 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 excision 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 without operation. In the thigh, too, provided that the shaft of the bone only be involved, conserva- tion may be attempted in suitable cases, but in gunshot fractures involving the knee-joint, amputation is safer. These points will appear from the following table, condensed from two in the third volume of the Surgical History:— Statistics of Gunshot Fractures. Upper third of femur .... Middle " " " Lower " " " Knee-joint . . . . . . . .50 Fio. 96—Result of partial excision of radius for gunshot Injury. (From a patient in the Episcopal Hospital.) Mortali ty per cent. Amputatior . Expectation . 77.4 46.0 . 65.8 40.6 . 45.0 38.2 . 50.8 60.6 180 GUNSHOT WOUNDS. 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 the Surgical History, being but 13.8 per cent, under expectancy, and but 27.2 per cent. under all modes of treatment. Remote Consequences of Gunshot Injury.—There are certain indirect or remote consequences of gunshot wounds which may demand the attention of the surgeon. These are principally manifested in the bones, the vessels, and the nerves. Bones.—The vitality of a bone may be seriously impaired by a gunshot wound which, at first, is supposed to have inflicted no injury upon it. The subjects of contusion and contused wounds of bone, were ably investi- gated by the late Dr. John A. Lidell, wiio traced seven distinct conditions which may result from contusion of bone, and each of which is fraught with more or less danger to the patient; these are: 1. Ecchymosis of the osseous tissue; 2. Ecchymosis of the medullary tissue; 3. Simple osteo- myelitis (attended with the 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. Ne- crosis produced directly by 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, such as the brain, be adjacent, secondary visceral disease may ensue. Vessels.—Traumatic aneurism of the circumscribed variety, occasionally, though rarely, follows a gunshot injury; the diffused traumatic aneurism is a more frequent result of these wounds, and constitutes a most serious affection. I have seen one case of arterio-venous wound, resulting in aneurismal varix, produced by a musket-ball passing directly between the femoral artery and vein Xerves.—-Very curious nervous affections are occasionally observed as consequences of gunshot wounds. These affections may consist of paralysis of either motion or sensation, or both, of hyperesthesia, of choreic move- ments, etc. This subject has been particularly investigated by Drs. Mit- chell, Morehouse, and Keen, of this city, whose labors in this department will be again referred to in a subsequent chapter.1 Encysted. Balls.—Balls sometimes become encysted, that is, sur- rounded by a layer of dense cellular tissue, within which thev may remain without producing any irritation, for a very long period. There are well- attested cases on record in which encysted balls have remained harmlessly in the tissues for forty or even fifty years; in other eases, again, after a variable interval, they excite inflammation by acting as foreign bodies, and may produce serious or even fatal consequences. Especially Avhen 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 wound of the thoracic cavity, in which the ball remains lodged, will sooner or later cause death. 1 See also remarkable cases reported by Dr. J. H. Brinton (Am. Journ. of Mtd Sciences, Oct. Ib70, p. 435), and by Dr. B. Rhett (Ibid., Jan. 1873, p. 90). HEMORRHAGE FROM A WOUNDED VEIN. 181 CHAPTER IX. INJURIES OF BLOODVESSELS. Injuries of Veins. Subcutaneous Rupture of Veins occasionally occurs as a conse- quence of external violence, and is manifested by the extravasation of a large quantity of blood, which is, however, usually absorbed again in the course of a fewT days ; or the blood may coagulate, the clot subsequently exciting suppuration, or possibly becoming organized, as pointed out in Chapter VII. More rarely, the blood may become encysted in a fluid state, constituting w'hat is sometimes called a venous aneurism. Open Wounds ofVeins are not unfrequently met with in civil prac- tice, and occasionally give rise to most serious consequences. Hemorrhage from a Wounded Vein is marked by the even and rapid flowr, 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 accidents, eighty-five cases collected by Dr. S. W. Gross having been followed by death in no less than thirty-seven instances.2 Hemorrhage from superficial veins can usually be readily controlled by pressure, or even by position. Thus the most profuse bleeding, from rupture of a vein in a varicose ulcer of the leg, may often be checked simply by elevating the limb. The large superficial veins on the back of the hand are often wounded by accidents from broken glass; in such cases I have found it a good plan to transfix both ends of the bleeding vessel with a metallic suture, thus arresting the hemorrhage and closing the wound at one and the same time. In any case in which pressure cannot conveniently be applied, the surgeon should not 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 pyaemia, but now that modern researches have shown that there is no necessary connection between that process and inflammation of the veins, or phlebitis, the theoretical grounds for opposition are removed, and it is established by clinical observation that the risks of tying veins are much less than was formerly believed. The lateral ligature, which was first practised by Mr. Travers in a case of wound of the femoral vein, con- sists in pinching up the bleeding orifice, and throwing around it a delicate ligature, so as not to obliterate the calibre of the vessel; this plan, which has theoretical merits, is found in practice to be very apt to be followed by secondary hemorrhage, so that it is now generally abandoned, the vein being tied as an artery, above and below the bleeding point.3 It is usually recommended that in any case in which it is found necessary to tie the 1 Dr. H. A. Potter, of Geneva, N. Y., has observed in eight cases of spinal injury, that the blood drawn from a vein is of arterial hue; this observation has, however, not been confirmed by others. 2 Pilcher has successfully tied, at the same operation, both the internal jugular and the subclavian vein, both vessels having been wounded in removing a tumor from the neck. 3 Braun has collected twenty-seven cases of lateral ligature, of which nine are known to have proved fatal from hemorrhage or pysemia. 182 INJURIES OF BLOODVESSELS. principal vein at the root of a limb, the artery should also be tied so as to equalize the circulation ; I'ilcher judiciously advises that, if the femoral vein is tied in the groin, the superficial rather than the common femoral artery should be ligated. My own judgment is that the risk of gangrene is increased by tying the artery as well as the vein, and that the vis a tergo supplied by the arterial current is essential to prevent venous stag- nation. In one case in which I tied the femoral vein without the artery, the vitality of the limb was preserved, though death ensued from other causes; but in another case in which, in order to arrest hemorrhage, I was compelled to tie both vessels, mortification quickly followed. The process by which nature arrests bleeding from a vein is essentially that which will be presently described in speaking of wounded arteries, a clot forming in the vessel, and the cut edges subsequently uniting through the occurrence 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 liga- ture, which gradually cuts its way through, as in the case of an artery, though in a shorter time in proportion to the size of the vessel. Phlebitis may follow a wound of a vein, and was formerly supposed to be the cause of pyaemia, which occasionally occurs and proves fatal after such an injury ; this subject will be fully discussed in another part of the volume. Entrance of Air into Veins.—The most frightful and fatal conse- quence of venous wounds, though fortunately one which is rare, is the entrance of atmospheric air, and its transfer to the heart. This accident is principally met w ith 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 "dan- gerous region." It has, however, occurred in other parts of the body; thus, in a case of the late Prof. Mott's, serious though not fatal symptoms followed the entrance of air into the facial vein where it crosses the lower jawr, while this accident occurring in the femoral vein is supposed to have been the cause of death in a case of thigh amputation during the Crimean war. It is probable, also, as pointed out by Greene, of Dorchester, 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. The mode in which air is pumped into the veins is easily understood : during the act of inspiration, a vacuum is created in the thorax, to supply which air rushes through the trachea, or through any other opening into the in- terior of the chest; thus, in the case of wounds of the pleura, air is sucked in during inspiration, to such an extent as often to induce collapse of the lung and pneumothorax, and in the same way, if a large vein in the.neigh- borhood of the thorax be wounded, and be prevented from collapsing by the natural connections of the part, by the position of the patient, or by a, structural change in the vessel itself (to which the French give the name of canalization), the act of inspiration will mechanically'and necessarily pump air into the open vein, precisely as it does through any other aper- ture 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 wound. The constitutional symptoms are equally well marked. The patient cries out, impressed with a sense of certain and rapidly impending death, and falls almost instantly into a semi-collapsed ,-tate, moaning and perhaps struggling ; the pulse is almost imperceptible, the action of the heart tu- multuous but feeble, and the respiration difficult and oppres.-ed. Death may occur immediately, but more commonly after an interval varving ENTRANCE OF AIR INTO VEINS. 183 from a few7 minutes to an hour or more ; or, if the quantity of air intro- duced be but small, recovery may gradually ensue, partial paralysis some- times continuing for several hours or even a much longer time subsequent to the accident. The cause of death, in these cases is somewhat obscure; Mr. Erichsen believes it to be the frothy condition of the blood, produced by the action of the heart, which prevents the due transfer of the circulating fluid through the pulmonary tissue, and thus secondarily causes a deficient supply of blood to the brain and nerve-centres, inducing death by syncope. Sir Charles Bell believed that death was caused by the direct transference of air to the base of the brain, and, in confirmation of this view, Prof. Gross's observa- tion 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 dis- tention, while Mr. Moore maintained that death wras due to the entrance of air to the heart, impeding the action of the cardiac valves and thus stopping the circulation, a view 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 anaunia of the aortic system. Treatment.—As a preventive measure, the surgeon should exercise ex- treme 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 operation and the heart, and care should be taken not to place the veins in such a position as would prevent them from collapsing if wounded, whether by stretching the patient's head to the opposite side, by hastily elevating the shoulder, or by incautiously lifting a tumor from its bed. Mr. Erichsen recommends that the patient's chest should be swathed by a firm and broad bandage, as a precautionary measure, so as to limit as far as possible the depth of the inspirations. Should a large vein in the "dangerous region" be wounded during an operation, or should the surgeon find such a wound in a case of cut-throat, etc., measures should instantly be taken to prevent the entrance of air, by the application of ligatures above and belowr the aperture. When this alarming accident has actually occurred, the first indication for treatment is obviously to prevent any further ingress of air, by filling the wound with water (as advised by Treves), making instant compression, and then quickly applying a ligature. The lateral ligature was successfully employed in a case 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 pro- mising appear to me to be artificial respiration and the administration of stimulants. The patient should be in the recumbent position, with the extremities elevated, so as to retain as much blood as possible in the central organs; to accomplish the same purpose, Mercier advised the application of tourniquets and compression of the abdominal aorta. Artificial respira- tion may be practised with suitable bellows, or simply by the surgeon's mouth. Sylvester's or Hall's method would scarcely be applicable in these cases, on account of the situation of the weund. The administration of oxygen gas by inhalation is recommended by Walsham and Couty, the latter of whom also advises venesection. Various other plans have been suggested, among which may be mentioned—(1) an attempt to suck out the air by means of a canula introduced into the wounded vein, into the 184 INJURIES OF BLOODVESSELS. right jugular vein, or even into the heart itself; (2) bleeding from the right jugular vein or from the temporal artery ; (3) tracheotomy; and (4) the injection of warm water into the heart. I am not aware, however, that there are any cases on record which prove the efficiency of any of these methods. 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 disintegration, the fragments being carried to the right side of the heart and thence to the lungs, plugging the minute pulmonary arteries (embolism), and thus giving rise to the formation of what are commonly but incorrectly called metastatic abscesses. This condition, which is in no degree necessarily connected with phlebitis, will be again referred to in the chapter on pyaemia. On the other hand, a clot in a vein may undergo a process of gradual contraction, induration, and decolorization, becoming finally calcified, and constituting what is called a phlebolite, or vein-stone. These phlebolites, however, 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 lower extremities. Injuries of Arteries. Contusion of an Artery may exist without giving at first any evi- dence of its occurrence. The secondary results of arterial contusion depend upon the severity of. the injury ; if this have been very great, a portion of the wall of the vessel may slough, and cause secondary hemorrhage or extravasation ; if the violence have been less, the vessel may undergo oblite- ration, or in very slight cases may recover without evil consequences. The obliteration of an artery, occurring some hours or days after the reception of an injury, is usually attributed to the effect of inflammation ; I believe, however, that it is more commonly due to the plugging of the vessel, either by embolism (fragments of clot being carried from another part of the circu- lation), or more rarely to an actual thrombosis in situ, clotting taking place in the injured vessel itself. As a result of this obliteration, or infarctus as it is called by French writers, gangrene or serious visceral degeneration may occur according to the size and situation of the vessel. Thus, in two cases of injury in the lumbar region, Dr. Moxon found complete thrombosis of the renal arteries, with corresponding incipient degeneration of the kidneys. Rupture or Laceration of an Artery may be either partial or com- plete ; partial laceration generally occurs without external wound, and involves the two inner coats of the artery, the elasticity of the outer coat preserving it from injury. This accident may form the starting-point for the development of an aneurism at a subsequent period ; of 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, mav cause gangrene of the part below the seat of injury ; or, again, the lacerated inner coats may turn downwards, and by their mechanical valvular action pro- duce gangrene, by directly interfering with the circulation. Finally, a par- tial laceration may, after a longer or shorter interval, become complete, when death from internal hemorrhage may follow, as in a case of rupture of the external iliac artery observed by myself at the Episcopal Hospital. (Fig. 97.) Complete rupture may occur subcutaneously, or in an open wound. In the latter case, the nature of the accident mav be obvious from WOUNDS OF ARTERIES. 185 the profuse arterial bleeding, though in other instances, if the coats of the vessel are twisted upon themselves, there may be scarcely any hemorrhage, the artery, perhaps, hanging out of the wound and pulsating, and yet no blood escaping. When an artery is torn across subcutaneously, there may Fio 97.—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. be wide-spread extravasation, or the development of one or other form of traumatic aneurism, according to the size and position of the vessel. Hein- ricius records a case of spontaneous rupture of the ascending aorta, occur- ring during parturition. Wounds of Arteries—Non-penetrating wounds of arteries occasion- ally, 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 few days, wiien 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 with a tenaculum, secondary, if not primary, hemorrhage will almost certainly follow. Incised wounds of arteries bleed more or less freely, according to the size and direction of the wound ; thus, a longitudinal wound will, in consequence of the anatomical arrangement of the arterial coats, gape less, and consequently bleed less, than one which has an oblique direction, while a transverse wound will bleed more than either. An artery which is completely cut across bleeds less, other things being equal, than one which is only partially divided ; for the complete section of the vessel allows partial retraction and contraction to occur, and thus measurably lessens the size of the stream. A wound of an artery at 186 INJURIES OF BLOODVESSELS. the bottom of a narrow and tortuous passage through muscular or other tissue, approaches to the nature of a subcutaneous laceration, and exten- sive extravasation may then occur with very little external bleeding ; or the outer wound may actually heal, while the opening in the vessel remains patulous, in which case a form of traumatic aneurism may be developed. Hemorrhage from a Wounded Artery may usually be 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 artery always, I believe, presents the characters which have been described, but from the distal end, for at least an hour after the infliction of the wound, or until the collateral circulation has been established, the flow of blood resembles that from a wounded vein. In other cases, however, if the anastomosis be very free, as in the palmar arch, both ends of the cut vessel will bleed in jets, and pour out blood of a bright red color. The force of the jet varies with the size and position of the artery and the strength of the heart's action. A small branch wounded in close proximity to a main trunk, may bleed more furiously than a larger vessel divided at a more dis- tant 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 occurrence of syncope, or may be arrested by the natural processes of contraction and retraction which are set up in the wounded vessel. As already indicated, there may be profuse bleeding without any exter- nal 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 the 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 neighboring venous trunks, or, if circumscribed, may give rise to a form of traumatic aneurism. Constitutional Effects of Hemorrhage.—These are the same in kind, though differing in intensity, whether the bleeding proceed from arteries or veins, and whether the hemorrhage be apparent or concealed. The first effect of profuse hemorrhage is shown in the blanching of the surface; the cheeks and lips become pale, and the conjunctiva unnaturally white. The pulse becomes small and rapid, the heart endeavoring by increased action to compensate for diminished power. The patient feels languid ; the respiration assumes a sighing character ; the senses of sight and hearing are perverted, being sometimes preternaturally acute, but more often dull; 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 diaphrag- matic. Death may occur in this condition from a continuance of the hem- orrhage, but more commonly coagulation takes place in and around the mouth of the wounded vessel, and, when consciousness returns, the bleed- ing is found to have spontaneously ceased. Vomiting 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, which are rapidly absorbed into the depleted bloodvessels. Profuse or repeated hemorrhage, beside the symptoms which have been above described, often gives rise to distressing nervous phenomena, such as amau- rosis, delirium, convulsions, or even hemiplegia; I have known death attributed to a cerebral clot, which the autopsy showed did not exist the PROCESS OF NATURE IN ARRESTING HEMORRHAGE. 187 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 been not inaptly applied. The amount of blood which can be lost without serious consequences ensuing, varies greatly in different individuals. Infants and very old per- sons are, as a rule, more injuriously affected by hemorrhage than those in middle life. The amount of blood lost in ordinary childbirth might pro- duce serious consequences under different circumstances, while, on the other hand, the mental state of a patient, as of one who has attempted suicide, or who believes himself to be bleeding to death, may actually cause a fatal result after the loss of a really insignificant quantity of blood. Habitual or Periodic Hemorrhage may be met with in either sex. In the female it may take the place of, or alternate with, the natural men- strual flow, when it constitutes what is called vicarious menstruation. In the male sex bleeding from the hemorrhoidal veins sometimes occurs at certain periods of the year, and seems to be occasionally beneficial by re- lieving 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 subse- quently 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 Hdmophilie or Bluterkrankheit. Its chief manifestation, and that from which its name is derived, is a dis- position 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 in- flammations of the lungs. It affects almost exclusively persons of the male sex, the female members of a family, though transmitting it to their pos- terity, 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 con- tractility of the arteries and capillaries. P. Kidcl has observed, after death, great proliferation of the epithelioid cells lining the small vessels, with de- generation of their muscular coat. According to Wachsmuth, the sponta- neous 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 contraindica- tion 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 extraction 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 important operation, being in a case of lithotomy reported by Mr. Durham. Process of Nature in Arresting Hemorrhage__Before entering upon the subject of the treatment of arterial hemorrhage, it will be neces- 188 INJURIES OF BLOODVESSELS. sary to consider briefly the process adopted by nature in closing wounds of these vessels, a process which the surgeon endeavors to imitate by the appliances of art. The natural means by which arterial wounds are healed have been experimentally and very thoroughly investigated by Dr. J. F. D. Jones, whose monograph on the subject was published nearly eighty years ago, since which time comparatively little has been added to our information concerning the matter. The temporary means employed by nature to arrest hemorrhage 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 is greatly facilitated by the diminished force of the heart's action (one of the constitutional eftects of hemorrhage, as we have already seen), was first noticed and its importance pointed out by the cele- brated French surgeon Petit, in 1731. This distinguished writer described an external clot which he called couvercle, and an internal clot which he called bouchon. The internal clot is somewhat conical in form, its base adhering to the sides of the vessel near its cut extremity, and its apex reaching upwards, usually as high as the origin of the first anastomosing branch. It is formed gradually, and, having served its temporary pur- pose, undergoes contraction and partial absorption, and eventually appears to form a portion of the fibrous cord into which a closed artery is con- verted. 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 173(5, who did not deny, as some of his fol- lowers have done, that the formation of a clot is of temporary utility, though he clearly declared his conviction that the permanent closure of the vessel must depend upon the cicatrization of the artery itself. The retrac- tion of the vessel within its sheath allows the blood to come in contact with the irregular surface of the latter, and thus facilitates the formation of the external coagulum, while its contraction as regards its calibre di- minishes the size of the stream, and thus tends to assist the formation of the internal clot, of which it likewise determines the shape. This contrac- tion, as shown by Kirkland, extends to the origin of the nearest anasto- mosing branch. The permanent means by which a divided artery is closed, consist in the union of the cut edges by the development of local inflam- matory changes, the continued contraction of the walls of the vessel upon the internal coagulum, and the final conversion of the lower end of the vessel into a dense, fibrous, impervious cord, into the construction of which a certain portion of the internal clot appears usually to enter. The exact mode in which the cicatrization of the cut extremity of the vessel is effected, is variously described by authors, according to the several views entertained as to the nature of the inflammatory process. Most surgical writers, following Dr. Jones, have attributed the healing of divided arteries to the effusion of plastic matter from the vasa vasorum ; the ad- vocates of the cellular pathology consider the process to be one of cell pro- liferation from the vessel's walls, a view which 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 white corpuscles of the blood ; while Billroth (practically returning to the old doctrine of Petit), attributes the healing of wounds of both arteries and veins to the organization of the internal coagulum, through the multiplication of the white blood-corpuscles, aided, perhaps, by the entrance of wandering cells from the surrounding tissues. Dr. J. Col- lins Warren, on the other hand, looks upon the clot as a merely passive structure, which takes no part in the process of repair except as a protec- tive, and as furnishing a suitable medium in which the new tissue may TREATMENT OF ARTERIAL HEMORRHAGE. 189 germinate. Dr. Senn, too, regards the clot as an accidental formation, which never undergoes organization. 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 which injuries of other tissues are re- paired, by the same method, in all probability, are wounds of arteries united; and this method, as I have endeavored to show in previous chapters, is in all cases by means of that natural process which, for want of a better name, we call inflammation. We may, however, from what has been said, de- rive this practical lesson : that as the repair of an artery after injury ap- pears to require the co-operation both of the walls of the vessel and of the contained blood, no means of arresting hemorrhage can be looked upon as philosophical, wrhich ignores the efficiency and attempts to dispense with 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. The changes which have been above described are best marked in the closure of the proximal or cardiac end of a divided artery. Those which take place in the distal extremity are the same in kind, though less in de- gree ; especially is this the case as regards the internal coagulum, which in the distal 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 wiiich has long been recognized by surgeons, that secondary hemorrhage usually occurs from the distal extremity of a wounded vessel. In the case of partially divided arteries, the process is essentially the same ; a clot forms between the sheath and the vessel itself, and compresses 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 weunds, especially if longitudinal, may close without the cali- bre 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 al- most inevitably be converted into an impervious cord at the seat of injury, and it is probable that, in these cases, the healing process is assisted by the formation of an internal, as well as an external, coagulum. When such a wound heals without the obliteration of the calibre of the artery, the inner coats of the latter do not unite very firmly, and an aneurism is apt to be subsequently developed. In an artery as large as the axillary or fem- oral, 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 hemor- rhage, or give rise to a traumatic aneurism ; in the rare instances in which neither of these consequences ensues, the vessel will, in healing, be con- verted 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 stimu- lants 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 190 INJURIES OF BLOODVESSELS. 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 tinc- ture of iron or the acetate of lead, may lie administered, or ergot may be used, and may be conveniently combined with opium and digitalis. As a last resort transfusion of blood may be tried, in the manner and with the precautions recommended in Chapter IV. The statistics of this operation in cases of hemorrhage, as given by Landois, are very favorable, t)9 cases having afforded not less than ('5 recoveries, while II of the 31 fatal eases (the result in 3 was doubtful) were 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. With the same object, the blood may be driven from the extremities to the trunk by the application to the limbs of elastic bandages. 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 apparently in good health; or the debility resulting from hem- orrhage may act as a predisposing cause for the occurrence of tuberculosis or other morbid condition. The local treatment of arterial bleeding consists in the adoption of various measures, which may be either of a teni]>orary, or of a 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, which instru- ment have been sufficiently described in a previous chapter. In dealing with certain arteries, as the subclavian, to which a tourniquet cannot be applied, effectual pressure may be made with the handle of a large key (previously wrapped, so as to protect the skin), or other suitable imple- ment ; or if the clavicle be much displaced—as by an aneurismal tumor— Syme's plan might be employed, which consists in making an incision in the line of the arteiy, upon which direct pressure is then made by intro- ducing a finger through the wound. For the permanent arrest of arterial hemorrhage, the surgeon may have recourse to the use of—1, cold ; 2, posi- tion; 3, press-are; 4, styptics ; 5, cauterization; 6, torsion; 7, ligation; or 8, acupressure. 1. Cold is an efficient means of arresting hemorrhage from many ves- sels of small calibre. In some cases the presence of clotted blood in a wound appears to encourage further bleeding by acting just as a warm poultice would do, and the surgeon often finds that upon sweeping awray the clots and exposing the wound to the air, the hemorrhage ceases spontaneously. Hemorrhage from small vessels may often be arrested by pouring a stream of cold water over the part, or if the bleeding come from one of the mucous outlets of the body, as the mouth, nostrils, rectum, or vagina, by intro- ducing small pieces of ice. Care must be taken, however, in the use of cold, not to continue its application too long, lest injurious depression or even sloughing should ensue. The application of hot water has been success- fully 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 lower limb, the part should be elevated by means of pillows or an inclined plane, PRESSURE AND STYPTICS. 191 so that, by the laws 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 wounds of the upper extremity ; while in treating wounds of the arteries of the forearm or of the palmar arch, it will be found advantageous to forcibly flex the elbow—a modification of Hart's method of treating aneurism, which has afforded good results on more than one occasion. 3. Pressure, which, as we have seen, is the common mode of tempo- rarily checking hemorrhage, may also be 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 over a roller, or, in the case of bleeding from cavities, by plugging the part with lint or compressed sponge. Sometimes pressure may be efficiently applied by means of a weight, a bag of shot, or even loose shot, as was done in Dr. Smyth's remarkable case of successful ligation of the innominate artery, w*hich will again be referred to. The graduated compress is made by laying together a number of pledgets of lint of gradually increasing dimensions, so that when completed the mass has the form of an inverted cone about an inch in height; the apex of this cone is 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, while firm pressure is made upon it by means of a piece of cork or metal, secured with a bandage. In positions where the proximity of a bone gives a firm substance against which the vessel may be compressed, as in the case of wounds of the temporal arteiy, this will be found a very efficient mode of controlling hemorrhage. 4. Styptics.—These agents, when employed alone, are not of much use, except in checking capillary oozing or the bleeding from very small vessels. The simplest and most convenient is ordinary alcohol, pure or diluted, the employment of which in operations has already been adverted to. The st3Tptic of Pagliari, which has a good deal of reputation, particu- larly among French surgeons, contains alum and benzoin, and certainly seems in some cases to answer a very good purpose. Banks, of Liverpool, employs oil of turpentine. Dr. Wood speaks favorably of a drug named Pengawar Djambi. Among the more powerful styptics may be especially mentioned the perchloride of iron, in substance, in solution, or in the form of the muriated tincture, and the persulphate, or Monsel's salt.- The latter, in particular, is undoubtedly a very powerful agent, and, when properly used, capable of serving a very good end; its indiscriminate employment in all cases of surgical hemorrhage has, however, been productive of a great deal of harm, not only on account of its effect in hindering primary union, but because the rapidity of its action, and the facility with which it can be applied, have often induced inexperienced practitioners to neglect less easy but more trustworthy 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. Dr. J. M. Hollow*ay has advocated the employment of styptics, with pressure, in cases of consecutive hemorrhage from gunshot wounds, as often pre- ferable 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 few- exceptional cases met with by any individual, still the instances mentioned 192 INJURIES OF BLOODVESSELS. Si 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, Moreau recom- mends plugging the cavity With cotton saturated with tincture of benzoin, and compressed by means of a piece of cork fixed between 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 com- mand of the surgeon. Although the ligature was re-invented and power- fully advocated by the illustrious Pare, in the middle of the sixteenth century, it was not generally adopted for a long time afterwards, and we learn from the writings of Sharpe, of Guy's Hospital, two hundred years subsequently, that even in his time the cau- tery and styptics were still preferred to the ligature bv many surgeons, both on the Continent and in some parts of England. Although no surgeon at the present day, probably, would use the hot iron in any case in which a ligature could be applied, there are some circumstances under which the cautery must still be resorted to; in some operations about the jaws, and in other cases in which, from the position of the bleeding vessels, or from the condition of the surrounding tissues, other modes of controlling hemorrhage are not available, or fail upon trial, the hot iron is a valuable application. The various forms of the cautery have already been described and fig- ured in the chapter on Minor Surgery, and it will be sufficient to add here that when used for hemor- rhage, 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. (>. Torsion, as a means of controlling the hemor- rhage from cut arteries, was known to the ancients, but subsequently passed through a long period of oblivion, having been revived in the early part of this century, principally by the efforts of French and German surgeons, among whom may be specially named Amussat, Velpeau, and Fricke. Since then torsion has been occasional!}* used by surgeons, gen- erally in dealing with small arteries; but the prac- tice has more recently received a fresh impulse, and has been strongly advocated by several writers as a mode of treatment applicable to vessels of all sizes; this movement has been most actively partici- pated in by Prof. Syme, of Edinburgh, Prof. Hum- phry, of Cambridge, and Messrs. Bryant and Forster, of Guy's Hospital, London. Torsion may be prac- tised in several w*ays: Syme, Humphry, and Tillaux, following Amussat, draw the extremity of the artery out from its sheath, and twist it until it is twisted oft'; the surgeons of Guy's Hospital, on the other hand, adopt Velpeau's plan of leaving the twisted end attached, that it may give additional security by Hewson's tor- acting as a mechanical plug. Free torsion (that is, sum forceps. \\"ith a single pair of forceps) is recommended by LIGATION. 193 Bryant for vessels of moderate size, and for all vessels in the extremities- limited torsion (in which the vessel is grasped with one pair of forceps and twisted with another) for such arteries as are large and loosely con- nected. An ingenious torsion-forceps has been devised by Dr. Hewson, of this city (Fig. 98). When it is not intended to twist off the end of the vessel, the number of turns should vary from six to eight, according to the size of the artery. The mechanism of torsion is as follows: the inner and middle coats are 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 twisted into a cord, w*hich serves temporarily as a mechanical plug, and is eventually surrounded by lymph and incorporated with the adjoining tissues, or more commonly separated and thrown off by sloughing, just as the end of a vessel which has been submitted to the ligature. The artery is perma- nently closed by the inflammatory process, at the point at which the middle and inner coats have given way. Torsion has now been so often success- fully applied, even to large vessels, that it cannot, I think, any longer reasonably be doubted that it is an effectual mode of controlling hemor- rhage ; it is, according to Forster and H. Lee, even more applfcable to large vessels than to small. I do not see, however, that it is at all a better mode than ligation, nor, I think, does it equal the latter in safety; this point will be again referred to after I have described the remaining modes of 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 w*hich he calls Fig. D9.—Speir's artery constrictor. the "artery constrictor" (Fig. 99); its action somewhat resembles that of the ecraseur, and it is designed to sever the internal and middle coats of the artery, thus allowing their invagination within the external coat, which is corrugated but not divided. The instrument is removed as soon as this has been accomplished. 7. Ligation.—The use of the ligature, though apparently know*n to the ancients, was afterwards 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 were correspondingly unsatisfactory. The ligature, as now used, is, I believe, w*hen applicable, the very best method of checking arterial hemorrhage. The form and structure of the liga- ture, and its mode of application to the open ends of vessels, have already been described (page 101), 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. 100), or even an ordinary curved needle, or an eyed probe. The mechanism of the ligature in controlling hemorrhage is "now well under- 13 194 INJURIES OF BLOODVESSELS. Fio. 100—Aneurismal needle, armed with a ligature. stood (thanks to the investigations of Dr. Jones), and the rules for its application are 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 objects 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 within the noose. In trying the larger vessels, the giving way of the inner tunics of the artery is sometimes distinctly perceptible to the surgeon. The divided inner coats curl upon themselves, and assist the formation of an internal coagulum, while the artery is perma- nently sealed by the oc- currence of inflammatory changes, just as in the natural haunostatic pro- cess already described. The noose of the ligature, if this be of silk, is gradu- ally loosened by the pro- cess of granulation, and finally cuts its way through, or conies out bringing with it the constricted portion of the external arterial coat. The clot which is formed on the distal side of the ligature is usually smaller than that on its proximal side; in some cases one or even both clots may be absent, and yet the artery be securely closed, which shows 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. How*ard, of New York, has published some experiments to show that it is not invariably necessary to draw the ligature so tight as to divide the inner coats, but that mere narrowing of the arterial tube with a loose ligature is sufficient sometimes to secure obliteration of the vessel. This (which is a revival of the teaching of Scarpa) was indeed know*n from the cases of Hunter, who, as we have seen, did not tighten his ligatures in operating for aneurism ; but I am not aware of any clinical facts which show that a loose ligature has any superiority over a tight one, w-hile 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 which is tightly drawn. Unless in connection with the antiseptic method, the best material for a ligature is, as has been already said, ordinary tine whip-cord or silk. Vari- ous attempts have been made from time to time to substitute other materials which it has been supposed would produce less irritation and might become encysted or absorbed. Thus Sir Astley Cooper and Dr. Physick made use of animal ligatures, catgut or some similar substance, and this practice was afterwrards occasionally adopted by others.1 Carbolized catgut is generally employed with antiseptic dressings, but has not proved itself as absolutely certain a preventive of secondary hemorrhage as was at first anticipated. Its fault is, it seems to me, that it often disappears without dividing the external coat of the artery, and thus does not securely occlude the vessel— 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, Mr. Pollock, and Mr. Morrant Baker, have used carbolized ligatures made from the tendon of the kangaroo, as suggested by Mr. Girdlestone, of Melbourne: and Dr. Wyeth, of New York, has successfully tied the carotid with the sciatic nerve of a calf. Ishiguro suggests ligatures made from the sinew of a whale. LIGATION. 195 in this respect being open to the same objection as acupressure ; hence, unless primary union of the wound is expected, silk is, I believe, safer. Metallic ligatures were employed in a series of experiments on the lower animals by Dr. Levert, of Alabama, more than sixty years ago, and since then have been occasionally used in operations on the human subject. Dr. Levert found that wire ligatures tightly secured around the arteries of dogs, produced obliteration of the vessels, and that, w*hen both ends of the ligature were cut short, the loop became encysted, and remained in the wound an indefinite time without producing irritation. Similar results have been since obtained by Sir J. Y. Simpson and others. Dr. Howard, on the other hand, finds that wire ligatures if drawn tight, produce marked inflammation and suppuration around the seat of ligation, and therefore recommends the use of loose wire ligatures. Metallic ligature-threads have now been used a sufficient number of times in operations on the human subject, by Stone, Gross, Mastin, and other surgeons, to warrant the belief that they are safe agents, and may properly be applied in cases in which it is desirable to leave the noose in situ and close the wound over it, as in certain operations upon the abdominal cavity ; even in these cases, how- ever, I believe that the carbolized catgut or silk ligature will answer a still better purpose. Rules for Ligating Wounded Arteries.—In the application of ligatures to wounded arteries, there are certain rules w*hich should be indelibly im- pressed upon the surgeon's mind ; these are— 1. In cases of primary hemorrhage, no operation should be, performed upon an artery, unless it is at the moment actually bleeding. In cases of secondary hemorrhage, a different practice should be adopted, as will be presently seen ; but in dealing with a recently wounded artery, if hemor- rhage have ceased, the surgeon as a rule should not interfere, because (1) there is a fair prospect that the bleeding will not return ; (2) the proba- bility of discovering the source of hemorrhage is much less, when there is no stream of blood to point the surgeon's way, and (3) the incisions and manipulations which would be necessary in searching for the arterial wound would be a positive injury which would more than counterbalance any benefit that might probably 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 tremens, it might be proper to choose the lesser evil, and search for the weunded vessel, that it might be secured by a ligature. Under an}* circumstances the patient should be con- stantly watched, and if the w*ound were in an extremity, it would be right to apply a provisional tourniquet, so that, in case of secondary hemorrhage, all unnecessar}' 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 ope- rators. These are two principal reasons why this rule should be consid- ered invariable: (1) because it is often impossible to tell what vessel is wounded, until it is exposed in the wound itself; and (2) because, even if 196 INJURIES OF BLOODVESSELS. 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 wound of the axillary artery, when the hemorrhage really came from the long thoracic. Again, if the main trunk be tied, the col- lateral circulation being quickly established, secondary hemorrhage is ex- tremely apt to occur from the distal side of the arterial wound ; or if there be collateral branches given off between the point of ligation and the wound, bleeding may occur even from the proximal side of the latter, when, if a second ligature be applied in the wound, the double obstruction will (at least in the lower extremity) almost invariably cause gangrene of the limb. Still further, deligation of the main trunk exposes the patient 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, wiiich was directly connected with the operation, and entirel}* independent of the original injury. For these rea- sons, then, viz., that by this method only can the actual source of hemor- rhage be determined ; that thus only can probable security be afforded against secondary bleeding ; that if secondary 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 sur- geon should usually take the original wound as the guide for his incisions ; should, however, the wound be very deep, it may be more convenient to reach the source of hemorrhage by making a counter-incision in the course of the vessels, cutting upon the end of a probe introduced to the bottom of the wound. Hemorrhage during the operation should be guarded against by the use of a tourniquet, where this instrument is applicable, or by pres- sure made by an assistant on the main trunk ; in situations where this is impracticable, the surgeon should introduce one or two fingers into the wound, so as to compress the bleeding vessel while making the necessary incisions. This rule of tying an artery where it bleeds holds good for both primary and secondary hemorrhage; no matter what the condition of the wound 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 wounds that are swollen and granulating, but it is a proceeding that the surgeon should consider imperative when the occasion arises; and it is surely very reprehensible for any operator, in view of the vast accumulation of recorded experience on the subject from both civil and military practice, to persist in cases of arterial hemorrhage in tying the main trunk of a limb, merely because it is easier than to tie the vessel in the wound, or, still worse, because it enables him to perform what is considered a more important operation. 3. A third rule, and one closely connected with the preceding, is that two ligatures should be applied, one to each end of the artery if it be com- pletely divided, and one on each side of the wound, if the latter have not completely severed the coats of the vessel. The reason for this rule is obvious; in many parts of the body the arterial anastomosis is so free that a ligature to the proximal side alone will not even 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 LIGATION. 197 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 adjoining tissues, that it cannot be found even after long and careful search, the surgeon mav plug the wound with a graduated compress, the apex of which is imbued with the solution of the persulphate of iron, and good results may be hoped for from this pro- ceeding ; but, whenever it is practicable, the distal as well as the proxi- mal 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 to apply ligatures immediately above and below the origin of the branch, as well as on the distal side of the wound in the latter -,1 so, on the other hand, if a large branch be given off immediately above or below an arterial wound, it is proper, after tying the injured vessel in the usual way, to apply an additional ligature to the branch. If this should not be done, there would be risk of secondary hemorrhage from deficiency of the internal coagulum, which, as has been mentioned, 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 dis- tance from the wound, 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, which might well be called golden rules. 4. However desirable it may be to tie a bleeding vessel in the wound, in certain situations it is impossible to do so; thus, in the case of wounds which penetrate the floor of the mouth, dividing branches of the external carotid, or in cases of hemorrhage into the mouth from the internal carotid, or within the pelvis from branches of the internal iliac, it is manifestly impossible to reach the seat of the wound, and the surgeon's only resource is to tie the main trunk. Again, in cases of secondary hemorrhage from vvounds of the palmar arches, it may be necessary to deviate from the or- dinary rule, and to tie either the brachial, or the radial and ulnar arteries.2 Application of Ligatures in the Continuity of Arteries.—-In applying a ligature in the continuity of an artery, whether at the seat of wound or at a higher point, or in the Hunterian operation for aneurism, the surgeon is guided in making his incisions by the lines which he knows to corres- pond 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 Fio. 101.—Grooved director. 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 well, especially when the artery lies deep, to make the incision, as recommended by Hargrave and Skey, somewhat obliquely to the course of the vessel, which can thus be more readily found than if 1 Dr. T. B. Wilkerson, of North Carolina, has reported a case in which this plan was successfully carried out in a case of wound of the profunda femoris just below its origin. 2 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. 198 INJURIES OF BLOODVESSELS. the incision be 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 w*ith 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. 101), upon which the layer is then carefully divided from below upwards. When the sheath of the vessel is reached, the surgeon picks it up in the same way with forceps (Fig. 102, A), and makes an opening just sufficient to allow* the passage of the needle w'hich bears the ligature. This is then delicately introduced between the artery and the vein, and very cautiously brought around the former so as to include nothing ex- cept 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. 102. B), a process which may be facilitated by a gen- tle touch with the knife, one end of the ligature drawn out, and the other drawn backw*ards with the Fio. !0>.—A. Opening the sheath. B. Drawing needle, which must be withdrawn ligature around the artery. C. Tying artery. (Bry- as gently as it Was introduced. The ANT) operation is completed by tying the artery firmly and tightly with the reef-knot (Fig. 102, C), and bringing both ends of the ligature out of the wound, which is closed with sutures and lightly dressed. If catgut be used for the ligature, this should be tied with a surgeon's knot and reef-knot combined (Fig. 45), and both ends cut short. Some surgeons advise that in every case two ligatures should be applied, and that the artery should be divided between them ; but while I consider the double ligature indispensable in cases of wounded arteries, a single ligature will I think prove sufficient in cases of aneurism. If any small arterial branch should be cut during the operation, it should be twisted or tied, taking care to secure both ends; the chief precautions to be observed in passing the needle are not to wound the vein, and not to include the latter or any portion of it, or a nerve, in the noose of the liga- ture. Entanglement of the vein would be very apt to cause phlebitis or gangrene, w*hile 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 surgeon should either suspend the operatiou and apply pressure, or should extend his incision and reapply the ligature at a higher point. To allow a ligature to remain, which passed partially through a vein, would be equivalent to forming a seton through that vessel, and w-ould certainly expose the patient to the risks of phlebitis, thrombosis, gan- grene, and, possibly, embolism and secondary pyaemia. It is almost need- less to say that the surgeon should be careful not to miss the artery, and tie instead a nerve, or even a portion of condensed fascia, an accident which ACUPRESSURE. 199 has occasionally happened in the hands of the most skilful operators. If the artery be very superficial, the surgeon should be correspondingly care- ful not to go too deeply in his first incision, which some operators, indeed, prefer to make by pinching up a fold of skin, transfixing, and cutting from within outwards In dividing the deeper structures, the side of the knife should be used rather than the point, and the edge should alw*ays be di- rected away from the artery. After tying an artery in its continuity, the limb below should be kept warm until the collateral circulation is fully established; the ligature, if of catgut, will require no further attention; if of silk, it will usually drop between the first and third weeks, 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 hemorrhage by pressure with a needle or pin, was first introduced to the notice of the profession by Sir J. Y. Simpson, in December, 1859. 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 excited 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 wiiich arterial bleeding can be arrested. Acupressure may be practised in several different ways, of which Prof. Pirrie and Dr. Keith, who have published a monograph on the subject, enumerate seven, though for practical purposes the number might be reduced to four. In the first two of Pirrie's and Keith's methods, the vessel is compressed between a pin or needle and the soft tissues of the part; in the third, fourth, and sixth, between a pin or needle and a loop of fine flexible wire ; in the fifth (or Aberdeen method), the pressure is made by passing a pin or needle beneath the artery, which is then twisted upon itself by a quarter or half rotation of the pin ; and in the seventh, the vessel is compressed between the pin and any bony prominence which may be conveniently situated. The first method is thus described by Simpson : " It consists in passing a long needle twice through the flaps or sides of a wound, so as to cross over and compress the mouth of the bleeding artery or its tube, just in the same way as in fastening a flower in the lapel of our coat, we cross over and compress the stalk of it with the pin which fixes it, and with this view* pass the pin twice through the lapel.....When passing the needle in this method, the surgeon usually places the point of his left forefinger or of his thumb upon the mouth of the bleeding vessel, and with his right hand he introduces the needle from the cutaneous surface, and passes it right through the whole thickness of the flap till its point projects for a couple of lines or so from the surface of the wound, a little to the right side of the tube of the vessel. Then, by forcibly inclining the head of the needle towards his right, he brings the projecting portion of its point firmly down upon the site of the vessel, and after seeing that it thus quite shuts the artery, he makes it re-enter the flap as near as possible to the left side of the vessel, and pushes on the needle through the flesh till its point comes out again at the cutaneous surface. In this mode we use the cutaneous walls and component substance of the flap as a resisting medium, against w*hich we compress and close the arterial tube." The exact mechanism of the first method can be readily understood from the accompanying wood-cuts. (Figs. 103, 104.) In the second method, "a common short sewing-needle, threaded with a short piece of iron wire, for the purpose of aftenvards retracting and removing it, is dipped down 200 INJURIES OF BLOODVESSELS. 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. 105.) In the third method (Fig. 10C>), " the point of the needle is entered a few lines to one side of the vessel, then passed under or below it, and afterwards pushed 1' 'I ! ,ip ■ Fia. 103.—Acupressure ; first method ; Fio. 104.—Acnpressure ; first method ; raw surface. (Erichsen.) cutaneous surface. (Ekichsen.) on, so that the point again emerges a few lines beyond the vessel. The noose or duplicature of wire is next thrown over the point of the needle; Fio 10j.—Acupressure ; second method. Fin. 100— Acupressure ; third method. (Erichsen.) (Erichsen.) then, after being carried across the mouth or site of the vessel, and passed around the eye end of the needle, it is pulled sufficiently tight to close the vessel; and lastly, it is fixed by making it turn by a half twist or twist around the stem of the needle." The fourth method is identical with the third, except that a long pin is substituted for the needle, the head of the pin remaining outside of the wound, while the sixth, differs from the fourth merely in the way of fixing the wire, the ends of which are, in this method, "crossed behind the stem of the pin so as to embrace the bleeding mouth be- ^ tween them, . . pulled sufficiently tight to arrest the hemorrhage, there- after brought forward by the sides of the pin—one on each side—and finally fixed by a half twist in front of and Fig. 107-Acupressure ; fifth method. ploge down upon tfae pjn „ (pjrrje and ( richsen.) 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 w*hich the vessel is twisted upon itself, and then fixing the pin or needle by thrusting its point deeply into the tissues beyond. (Fig. 107). This method seems to me the best and most generally applicable; addi- tional security may be given by superadding the use of a wire loop, as in the preceding methods. The seventh and last method consists, according to Prof. Pirrie, " in passing a long needle through the cutaneous surface, pretty deep into the soft parts, at some distance from the vessel to be acu- ACUPRESSURE. 201 pressed—making it emerge near the vessel—bridging over and compressing ' the artery, dipping the needle into the soft parts on the opposite side of the vessel, and bringing out the point of the needle a second time through the common integument. In this method the soft parts are twice trans- fixed, and the artery is compressed between the bone and the middle portion of the needle in front of the integument, between the first point of exit and the second point of entrance." Mode of Repair of Arteries after Acupressure.—This subject has been fully investigated by several writers, the results of whose observa- tions may be stated as follows : There is no direct adhesion of the apposed walls of the vessel, as believed by Dr. Hewson and others, but, on the contrary, the sole process of permanent repair takes place at the cut end of the vessel; the end subserved by the needle is merely to remove the pres- sure of the blood current 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 vessel, then closure takes place at the line of this destruction, just as after the use of a ligature. The actual repair which goes on at the cut end of the vessel is due partly to changes in the walls of the vessel itself, and partly to changes in the contained blood, in fact to the same changes which we have already studied as taking place in the process of natural haemostasis. A clot forms above the needle, and rests upon without adhering to the contracted portion of the artery below. The time during which the acupressure needle should be allowed to remain varies from twenty-four to sixty hours, according to the size of the vessel. If it be removed before the repair of the cut end of the vessel is complete, there will be risk of dislodgment of the clot (which is not adherent), and of hemorrhage; w*hile 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. Cramp- ton's " presse-artere," and consists essentially of a bent probe and a wire, between which the vessel is compressed, and which are so arranged as to be withdrawn at will Dr. L'Estrange's apparatus for the same purpose consists of a double aneurismal needle, the blades of which close like the jaws of a lithotrite. Instruments of various kinds for the temporary occlu- sion of arteries have likewise been devised by Deschamps, Desault, Assalini, Durest, Richardson, of Dublin, Allis, of this city, 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, however, as shown by Simpson, an old mode of treatment, and, I may add, appears to be inferior to both acupres- sure and the ligature. It is practised by surrounding a vessel with a loop of wire, the ends of which are brought out separately through the flap or side of the wound, and twisted over a compress which serves to protect the skin. Uncipressure, or compression by means of a hook, is recommended by Vanzetti, of Padua, in cases of secondary hemorrhage from wounds 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, which consists in everting the cut end of an artery so as to invaginate the vessel within itsown extremity, and then fixing the parts by the introduction of a needle point or delicate metallic peg. 202 INJURIES OF BLOODVESSELS. Comparison between Acupressure, Torsion, and Ligature— From what has been said with regard to the mechanism by which each of these methods acts, and the pathological changes to which each gives rise, it will appear, I think, that the ligature is to be preferred, whenever the circumstances of the case allow the surgeon to choose between them. The objections urged against the ligature are, that (1) it acts as a seton, causing suppuration along its track ; (2) it confines a minute slough in the wound until it conies away itself; and (3) it may become prematurely detached and allow secondary hemorrhage. These objections, though theoretically just as regards the silk ligature, seem to me to be practically of little or no value, for (1) healing without any suppuration, when simple dressings are employed, is almost never met with (at least in this climate), in wounds of the size of those in which 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 ligature, in cases that do well, is so minute as to be really not worth notice, and in cases where there is extensive sloughing, there is no reason to attribute that sloughing to the use of ligatures ; and (3) though hem- orrhage 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 haemostasis, which, as we shall presently see, is quite as likely to occur with either torsion or acupressure as with the ligature. Torsion closes arteries just as the ligature does, and there is the same risk of hem- orrhage on the separation of the twisted extremity, if it has been twisted enough to impair its vitality, as on detachment of the ligature; while if it have been insufficiently twisted, there is the additional risk of the extremity of the vessel becoming untwisted, and thus allowing bleeding at an earlier period; if, on the other hand, the end be twisted off, the vessel is in the same 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 hemorrhage is an incomplete union at the cut end of the ves>el, and an unadherent clot above the point of constriction ; if it be allowed to remain long enough to cause inflammatory changes in the arte- rial coats at the point of constriction, it defeats its own object, and acts as a ligature which has been tied and subsequently removed. That both acupressure and torsion are able to control hemorrhage from even large arteries is abundantly proved; that either does so any better than the liga- ture is, it seems to me, not proved ; while to give the same security that is afforded by the ligature, either must be pushed so far as to be open to the identical objection which is urged against the ligature, viz., that of intro- ducing a foreign body into the wound, and, by so doing, impeding union by adhesion. Finally, by using the catgut ligature with antiseptic dress- ings, suppuration can usually be avoided, and the risks of the ligature are reduced to a minimum. I am not aware of any sufficiently extended statistics of torsion having yet been published, to warrant a numerical comparison of the results of this method with those of the ligature. The reports of Messrs. Syme, Humphry, Bryant, Foster, and Hill, have certainly been favorable, yet the experience of other surgeons who are equally eminent has been opposed to the general employment of torsion ; and it is to be observed that Mr. Syme only recommended it in connection with the antiseptic method, 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 acupressure, the most favorable series of cases yet published is that of Prof. Pirrie and Dr. Keith, and yet even this, when analyzed, shows at COLLATERAL CIRCULATION. 203 least no better results than are obtained by the use of the ligature. Thus twelve amputations reported by Prof. Pirrie gave three deaths, and yet in all but one case the operation was done for disease, and eight of the twelve patients were children. The theoretical assumption that acupressure guards against the common causes of death after operation is not borne out by fact:—erysipelas, sloughing, and pyaemia having occurred even in the very favorable experience of Messrs Pirrie and Keith ; while union by adhesion, except in Aberdeen, has been quite as rare with acupressure as with the ligature, and even in the few 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 w*hen 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 it therefore seems to me, although possibly safer than acupressure, to be even less desirable for general use. Collateral Circulation—In whatever w*ay an arterial trunk be oc- cluded, whether by disease or by surgical interference, the vitality of the parts below 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 balance 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 warmer than in its natural state. The action of the capil- laries is, however, but temporary, the true collateral circulation being estab- lished through the inosculation of anastomosing branches, derived some- times 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, while, after ligature of the common carotid, it is principally through the inferior thyroid and vertebral arteries that the circulation is maintained. Even after occlusion of the abdominal aorta, the collateral circulation is established 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. Stokes. In old persons, or in those whose arte- rial 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 accommo- date the increased flow of blood through them. On the other hand, in cases of chronic aneurism, the obstruction has sometimes gradually caused the establishment of the collateral circulation before ligation is practised, so that under these circumstances surgical interference may be even less resented than when employed for wounds of healthy arteries. This state- ment would appear to be contradicted by the well-known fact that gangrene is more frequent after ligature for aneurism than after that for traumatic causes, but, as will be seen hereafter, the gangrene in the former case is usually from venous, not from arterial obstruction. Not only does anastomosis take place between collateral branches, but 204 INJURIES OF BLOODVESSELS. an indirect communication is sometimes re-established between the divided ends of the obliterated trunk. Finally, the fibrous cord, which connects the divided extremities of the artery, occasionally becomes itself pervious, allowing a narrow but direct channel of communication between the proxi- mal and distal ends of the vessel. The establishment of the collateral circulation is sometimes at tended with pain, apparently from pressure of the enlarging vessels upon contiguous nerves; this is most marked in cases of aneurism, in which additional pressure is caused by the coagulation of the blood contained in the sac. Secondary Hemorrhage.—The most frequent accident after the use of the ligature or other artificial means of arterial occlusion, is unquestion- ably 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 doom1 slips off prematurely, when the knot has been carelessly made, when a large amount of extraneous tissue has been included in the noose of the ligature, so that this becomes loosened before the vessel is healed, or (which is especially apt to happen with acupressure) when the vessel has been compressed only enough to check bleeding while the force of the heart is diminished by shock or by the use of an anaesthetic, but not enough to occlude the artery when reaction has occurred ; (2) the giving off of a large collateral branch either immediately above or immediately below the point of occlusion, a circumstance which, though not necessarily a cause of sec- ondary hemorrhage, is very apt to be so, from limiting the extent of the internal coagulum in the proximal, and more especially in the distal end of the vessel; and (3) a diseased condition of the coats of the artery itself; this may cause hemorrhage directly, either by allowing the ligature to cut 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 hemorrhage may be said to be any conditions of system which interfere with the natural pro- cesses which we have seen to be essential for the closure of wounded arte- ries. Thus, a want of coagulability in the blood itself, the "hemorrhagic diathesis," visceral disease (especially of the liver), an unusually severe attack of ordinary traumatic or inflammatory fever, certain affections which are apt to occur after operations, especially erysipelas, pyaemia, hospital gangrene, or even ordinary sloughing, may all be considered as causes of secondary hemorrhage. In the case of pyaemia, the hemorrhage often consists of capillary oozing—the parenchymatous hemorrhage of Stro- meyer and Lidell—and is apparently due to mechanical obstruction, from thrombosis of the venous trunks of the part. J. II. Porter has described an intermittent form of hemorrhage, which he thinks is due to malarial influence. Occasionally a singly secondary hemorrhage may prove fatal, but more usually there are a number of successive gushes, of which the first may be comparatively slight, the patient being gradually reduced to a state of extreme anaemia, and dying rather from repeated losses of blood than from the quantity lost at any one time. When hemorrhage occurs after ligature SECONDARY HEMORRHAGE. 205 of an artery in its continuity, it is almost invariably from the distal ex- tremity 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 with its vasa vasorum, the distal end of the vessel is more exposed to sloughing than the proximal. Secondary hemorrhage may occur at any time after the application of a ligature, though it is most common about the period of separation of the latter; when it occurs earlier, it is usually owing to some defect in the mode of occlusion, to disease of the arterial tunics, or to some of the systemic conditions w*hich have been referred to. Secondary hemorrhage is occa- sionally 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 re-absorption, 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 condi- tion, are, I think, opium, digitalis, and ergot, which may be freely adminis- tered; special care should be taken to prevent any straining in defecation, or violent coughing : quinia should be given if there is any malarial compli- cation. The local treatment of secondary hemorrhage varies according as the bleeding proceeds from a stump, or from an artery ligated in its continu- ity. It should be premised that the rule not to operate on an artery which has stopped bleeding, does not apply in either of these cases. As Mr. Erichsen puts it, the surgeon in these cases may after the first, and must after the second bleeding adopt determined measures to prevent a return of the hemorrhage. 1. Secondary Hemorrhage from a Stump may, if in only moderate amount, be often checked by the judicious application of pressure, 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 with clots, the surgeon should without hesitation break up the adhesions, and search for the bleeding artery on the face of the stump itself, applying a fresh ligature to whatever vessel is found to be in fault. If, on the other hand, the stump 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, preferably, by acupressing the vessel by Simpson's first method; this is one of the exceptional cases in which acu- pressure seems to be particularly applicable, and there would be every reason to hope, under such circumstances, that the temporary occlusion of the artery by the pin would be sufficient to allow the completion of the natural process of repair at the cut extremity of the vessel. Ligation of the main artery of a limb, for hemorrhage from a stump, is in most situa- tions a bad operation, and should only be resorted to when prolonged search has failed to find the artery in the reopened wound (an event which may occur from the sloughing and disorganized condition of the part), and when the 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 would expose the patient to great risk of gangrene, 206 INJURIES OF BLOODVESSELS. and that it would superadd an operation, in itself serious, to the dangers already existing; hence, in some situations, even re-amputation 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 axillary for the upper, and the common femoral or external iliac for the lower extremity. 2. Secondary Hemorrhage from an Artery previously Ligated in its Continuity is an accident of the gravest nature. In its treatment the surgeon may properly first try the effect of pressure, adjusting accurately to the bleeding point a graduated compress, and keeping it in position with a ring tourniquet, or arterial compressor. In the case of some arteries, as the subclavian or iliacs, and generally in the case of vessels situated about the trunk, no other means are applicable, and the use of pressure should then be persevered in, though it must often prove ineffective. In the case ot the upper extremity, if pressure fail, the surgeon should treat the vessel as one primarily* wounded, cutting down and tying the vessel above and below the source of hemorrhage; if hemorrhage again recur, or if the bleeding vessel cannot be found or secured in the wound, a ligature may be applied with fair hope of success to the main artery at a higher point. Should this fail, amputation at the highest point of ligature should be resorted to. In the lower extremity the case is somew*hat 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 hemor- rhage, and this course will occasionally succeed, as in a case under my care at the University Hospital; though, as shown by Mr. Cripps's sta- tistics, carefully apjdied pressure is often the most promising remedy in these cases. The tibial vessels lie so deeply that it would be almost hope- less 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 gan- grene, and should not be attempted. Amputation at or above the site of ligature would be a safer operation, and should, I think, in this situation, undoubtedly be preferred. Gangrene after Arterial Occlusion, whether from disease or from surgical interference, is due to a deficiency in the collateral circulation ; it is most often met with in the lower extremity, and in Those whose arteries from age or other cause are in an inelastic condition, whether accompanied or not by positive degeneration. Among the exciting causes may be men- tioned 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, however, it assumes the character of dry- gangrene or mummification. These conditions have already been described, in discussing the subjects of inflammation and of mortification as a cause for amputation, 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 tem- perature and protect it from external injury, and by placing hot bottles or hot bricks under the bedclothes, though not in contact with the limb. Should there be much venous congestion, gentle but methodical friction from below upwards might be practised, so as to assist in emptying the TRAUMATIC ANEURISM. 207 superficial veins. Should gangrene actually occur, amputation must be practised through the site of arterial occlusion, unless wrhen, 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 94.) Remote Consequences of Arterial Occlusion.—Even when everything goes well after the ligation of a main artery, the limb is sometimes left for along while numb and weak. In the case of the lower extremity, it is often cedematous, aud apt to become inflamed from apparently slight causes. In such cases the limb should be warmly* clad, and supported with an elastic bandage, while care should be taken to avoid undue pressure, which might give rise to ulceration, or even gangrene. Traumatic Aneurism__Under this name are included several dis- tinct affections :— 1. The Diffused Traumatic Aneurism (so called), is, as Prof. Gross justly remarks, no aneurism at all, but merely a collection of arterial blood in the tissues of a part, differing from an ordinary case of wounded artery simply by there being no communication with the external air. This con- dition of affairs may result either from an originally subcutaneous lesion of an artery, or from the external wound healing before the arterial aper- ture itself is closed. It not unfrequentlv is a consequence of gunshot in- jury, the arterial wall being bruised though not severed by the contact of the ball, and giving way after an interval of perhaps several weeks, during which the external wound may have completely healed. The diagnosis of this condition can usually be made with tolerable facility ; there is an oblong, somewhat pyriform swelling, more or less elastic and fluctuating, and, if the arterial wound be tolerably free, accompanied by a distinct im- pulse, and often by a marked thrill and aneurismal bruit. The limb below is cedematous, and the pulse very feeble or completely absent. As the disease advances, the skin covering the tumor becomes tense, thin, and discolored, and, unless efficient treatment be adopted, the limb may become gangrenous, though more commonly the tumor will suppurate and open externally, allowing profuse secondary hemorrhage to occur. The treatment is the same as for an ordinary case of wounded artery. The circulation being temporarily controlled by pressure applied as already directed, the surgeon lays open the tumor, turns out the clots, and applies ligatures to both ends of the affected vessel; this is most conveniently done by intro- ducing a director into the mouth of the artery, dissecting it up for about an inch, and passing a ligature around it with an ordinary aneurismal needle. If the arterial wound be in such a situation that effective pressure cannot be made above it during the operation, the surgeon must proceed more cautiously, in the way recommended by Prof. Syme ; in this case the incision should be at first merely large enough to admit one or two fingers of the left hand, which may plug the wound as they are introduced, and thus 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 now enlarge his incision, turn out the clots, and, still keeping up pressure with the left hand, endeavor to pass a ligature with the right; in doing this, a mounted needle, eyed at the point (Fig. 81), or a short curved needle, held with suitable forceps, may prove of more service than the ordinary aneurismal needle. In some in- stances, 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 wrhen the brachial artery is wounded near its origin, the aneurismal tumor encroaching upon the axilla; under 208 INJURIES OF BLOODVESSELS. 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 which the extrava- sation is less extensive, and in which an adventitious sac has been formed by the condensation of the surrounding areolar tissue. This, which is, clinically speaking, a Circumscribed Traumatic Aneurism, commonly results from punctured wounds, and is rarely met with except in the course of the smaller arteries; it may be treated by laying open the sac and tying the vessel above and below ; or, if in a position where this operation would be undesirable, as in the palm of the hand, the main trunk may be ligated with the prospect of a favorable result. When met with in connection with a large artery, a proximal ligature may be applied as close as possible to the sac, without opening the latter. 3. Another form of circumscribed traumatic aneurism is that which has been called " Hernial," and which results from the protrusion of the inner coats of the vessel through a wound or laceration of the outer tunic. This form of aneurism is extremely rare, its existence indeed being doubted by many writers. 4. The True Circumscribed Traumatic Aneurism results from a punc- tured wound of an artery (generally a large one), which has healed, the cicatrix afterwards yielding, and a true sac being thus formed from the external coat of the vessel and its sheath. The treatment consists in com- pression or in ligation of the artery* at as short a distance as possible above the sac. Should, however (in any of these forms of circumscribed trau- matic 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 cont iguous vein are simultaneously wounded, the external wound healing, but a com- munication remaining between the two vessels. This accident most frequently follows upon punctures, as of the brachial artery in bleeding, though it may also result from a gunshot wound, as in a case to which I have already referred. The preternatural communication between an artery and vein may assume two distinct forms, known respectively as aneurismal varix and varicose aneurism. Aneurismal Varix consists in a direct communication between an artery and a vein, part of the arterial blood finding its way into the vein, which is dilated and somewhat tortuous ; the symptoms are the presence of a small, somewhat oblong, compressible tumor, with a jarring sensation com- municated to the hand, and a buzzing or rasping sound—sometimes a rustling or susurrus—rather than the ordinary aneurismal w*hir. 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 progres- sive, and requires, as a rule, no treatment beyond the support of an elastic bandage: should anything further be needed, the artery must be tied above and below its aperture. Varicose Aneurism.—In this form of arterio-venous aneurism, there is a distinct sac, which communicates also with a vein, which is itself always varicose. It differs from an aneurismal varix, in that the arterio-venous communication is indirect, through an interposed aneurismal sac. Its symptoms are a combination of those of aneurismal varix and of ordinary traumatic aneurism : the tumor gradually enlarges, and becomes more solid from the deposition of fibrin ; there is" a distinct impulse added to the LIGATION OF INNOMINATE ARTERY. 209 jarring sensation of the aneurismal varix ; and there is an aneurismal whir superadded to the rasping sound or susurrus heard in the former affection. The sac in this form of disease has two openings, one into the artery and one into the vein, and thereby is much in the condition of the sac of a traumatic aneurism which has become diffuse by rupture ; hence Fio. 108—A, aneurismal varix ; B, C, aud D, varicose aneurisms, a, artery, v, vein, s (Bryant.) the proper treatment consists in laying open the tumor and tying the artery above and below ; in doing this, it must be borne in mind*that the first incision (which opens the dilated vein) merely exposes the external orifice of the sac, and that this must be laid open by a second incision, when the aperture of the artery will be found more deeply seated. An- nandale advises that both artery and vein should be secured with double ligatures, and reports a case of traumatic popliteal arterio-venous aneurism successfully treated in this way ; Walsham has been equally fortunate in a case of varicose aneurism of the femoral artery and vein, but a similar case in the hands of Keyes, of New York, terminated fatally from pyae- mia. For the varicose aneurisms met with at the bend of the elbow, Vanzetti recommends simultaneous 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. My former colleague, Dr. W. Osier, now of Baltimore, showed me a remarkable case which I believed to be one of varicose aneurism of the axillary artery and vein, caused by a punctured wound inflicted by a sharpened lead-pencil. As the condition did not seem to be progressive, I advised against any operation. Lines of Incision for Deligation of Special Arteries. I have gone so fully into the discussion of the principles which should guide the surgeon in the management of arterial hemorrhage, and of the various accidents which follow arterial wounds, that I do not think it necessary or even desirable to recur to the subject in connection with each special artery. I purpose merely, therefore, in this place, to indicate as concisely as possible the lines of incision to be adopted in applying liga- tures 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 Brachiocephalic Artery.—This vessel may be reached by an incision at least two inches long, corresponding to the anterior edge of the left sterno-cleido-mastoid muscle, and extending in the form of an J across the top of the sternum, and in the line of the 210 INJURIES OF BLOODVESSELS. right clavicle (Fig. 109). Care must be taken to avoid the thyroid plexus of veins, the middle thyroid artery, and the pneumogastric and phrenic Fio. 109.—Ligation of the innominate artery. A. Innominate. B. Carotid. C. Subclavian. D. Inferior thyroid vein. E. Sterno-mastoid muscle. F. Sterno-hyoid and sterno-thyroid muscles. (Skeit.) nerves. The needle should be passed behind the artery, from without inwards, so as to avoid the innominate vein which lies on its outer side. Common Carotid__This vessel may be tied either above or below the point at which it is crossed by the omo-hyoid muscle (Fig. 110). In Fia. 110.—Ligation of carotid and facial arteries. (Bryant.) 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 (which is the best, LIGATION OF SUBCLAVIAN ARTERY. 211 when practicable) extends from near the angle of the jaw to a little below the cricoid cartilage; for the lower operation, from a little above the cricoid cartilage, about three inches downwards, along the edge of the sterno-mastoid muscle. The ligature should be passed from without in- wards, avoiding the jugular vein and pneumogastric nerve. In opening the sheath, care should be taken to avoid the " descendens noni" nerve, which, however, it is said, has been occasionally divided in this operation, without unpleasant consequences resulting. External Carotid.—This vessel may be reached by an incision parallel to, but half an inch in front of, the inner edge of the sterno-mas- toid muscle, and extending from near the angle of the jaw to a point cor- responding to the middle of the thyroid cartilage. Internal Carotid__Should it be thought proper in case of a w*ound of this vessel to attempt its ligation rather than that of the common trunk, an incision 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 have tied the common carotid and both its branches for gunshot injury. Vertebral Artery—This vessel may be reached by an incision cor- responding 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. Fenger has successfully tied this vessel between the atlas and the occiput. Direct compression proved effectual in two cases of wounded vertebral artery recorded by Kuester, and in a third observed by* Dr. J. H. C. Simes. Superior Thyroid—This vessel may be reached either by an incision across the upper part of the neck, from the side of the hyoid bone, obliquely outwards and downwards to the edge of the sterno-mastoid muscle, or by an incision of about tw*oinches along the inner border of the latter muscle. Lingual Artery__This may be tied through an incision an inch long, made in a direction downwards and forwards, immediately behind the cornu of the hyoid bone (Fig. 113). The superior laryngeal nerve should be carefully avoided in passing the needle. Podraski and Hueter recom- mend an incision along the upper border of the hyoid bone. The platysma myoides being divided, and the submaxillary gland turned upwards, the artery is found immediately beneath the fibres of the hyoglossus, in the so-called triangle of Lesser. The Facial Artery is most easily secured w*here it crosses the lower jaw (Fig. 110); the Occipital, as it emerges from beneath the splenius muscle, behind the mastoid process of the temporal bone (Fig. Ill) ; and the Temporal, immediately above the zy-goma (Fig. 112). 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 impracti- cable, though, if it be attempted, the same incision (reversed) should be employed. This 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 surgeon's operation being indeed not strictly a ligation, but an attempt to cure a subclavian aneurism by* exposing the vessel and tempo- rarily compressing it with torsion forceps. Either subclavian may be tied in the third part of its course, or exterior to the scaleni muscles, by an incision about three inches long, corresponding to the upper border of the clavicle, the shoulder being drawn down, and the head turned to the oppo- 212 INJURIES OF BLOODVESSELS. site side ; in dividing the superficial fascia, care must be taken not to wound the external jugular vein. After cutting through, if necessary, some of the Fig.Ill— Ligation of the occipital artery. (Skey.) Fio. 112—Ligation of the temporal artery. (Skey.) fibres of the sterno-mastoid muscle, the surgeon cautiously w*orks his way down to the outer edge of the scalenus muscle, in the angle between which Fig. 113.—Ligation of the subclavian and lingual arteries. (Bryant.) and the first rib, the vessel lies; the needle should be introduced from below upwards. The artery may be tied in the second part of its course,1 by the same incision, the anterior scalenus muscle being cautiously divided upon a grooved director; the parts to be specially guarded from injury in this operation are the phrenic nerve, the jugular vein, the thyroid axis, and 1 A successful instance of this operation lias lately been recorded by Dr. Middleton Michel, and an unsuccessful one by Dr. G. H. Bridgeman. LIGATION OF ULNAR ARTERY. 213 the pleura. Mr. Skey recommends for ligature of the subclavian in its outer part, an arched incision which " is commenced about two and a half or three inches above the clavicle, upon, or immediately on, the outer edge of the mastoid muscle wards towards the acromion, and then curved inwards along the clav- icular origin of the mastoid muscle." Axillary Artery__This vessel may be tied either below the clavicle or in the axillary space. For the former operation, an incision either straight or semilunar (in which case it must be convex upwards) is made below the clavicle from near its sternal end to near the attachment of the deltoid muscle. The fibres of the pectoralis major require divi- sion, and care must be taken to avoid the cephalic vein and acro- mial thoracic artery. The needle is passed from below upw*ards. To secure the artery* in the axilla, an incision of about three inches is made along the border of the latis- simus dorsi muscle, though many surgeons prefer an incision more oblique to the course of the vessel; the ligature may be passed from within outwards, between the roots of the median nerve, which, in this position, lie on either side of- the artery. Brachial Artery__This ves- sel may be tied in its upper part by an incision along the inner edge of the coraco-brachialis muscle, or in its middle and lower parts by an incision corresponding to the ulnar edge of the biceps. The artery lies very superficially in its whole extent carried slightly outwards and down- Fig. 114.—Ligation of the brachial, radial, and ulnar arteries ; also of the palmar vessels. (Mil- ler.) and is perhaps more easily tied than any other in the body. The ulnar nerve lies to its inner side, while the median nerve, which above is to the outside of the vessel, crosses in front of it at about its middle. In operating upon the brachial artery, its occa- sional high division must be borne in mind. 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 in- wards, to a point half-way down the forearm, and thence parallel to the 214 INJURIES OF BLOODVESSELS. 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 mayr 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 pro- cess of the ilium, the length of the wound being about six inches. The various structures being divided down to the peritoneum, this membrane is cautiously pushed backwards, the sur- geon tracing up the common iliac to its bifurcation, about an inch above which the ligature should be applied; the needle is passed around the aorta from left to right, and from behind forwards, special care being taken not to injure the vena cava, which lies to the right, nor the filaments of the sympathetic nerve, which lies in front of the vessel. Common and Internal Iliaes. —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 whichever vessel is to be secured. In tying the internal iliac, the surgeon must be specially cautious not to wound the external iliac vein, which lies in the angle formed by the bifurcation of the common artery. Gluteal and Sciatic Arteries.—The former vessel may be reached by an incision in a line from the posterior superior spinous process of the ilium, to a point midway between the tuber ischii and the great trochanter; the latter, by a similar incision, about an inch and a quarter below the position of that already* described. External Iliac.—This vessel may be tied by Liston's modification of Abernethy'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 downwards, to an inch and a half above the middle of Poupart's liga- ment; the wound, which is convex downwards, should be three or four inches long. All the tissues being carefully divided down to the perito- neum, the latter is cautiously pushed and held out of the way, while the artery is secured by passing the needle from within upwards. Cooper's incision (Fig. 116) is about three inches long, parallel to and a little above Poupart's ligament, and reaching from near the anterior superior iliac spine, to a point above the inner border of the abdominal ring. The external oblique tendon being divided, the spermatic cord appears, and Fig. 115.—Ligation of the common iliac. TON.) (Lis- LIGATION OF FEMORAL ARTERY. 215 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, Aberne- thy 'sis the best incision, especially as it can very easily be extended up- wards, so as to allow the common trunk to be reached, if that should be found necessary. Fig. 117.—Ligation of the pop- liteal at it3 upper and lower parts, a. The popliteal vein. 6. The popliteal artery, c. The posterior saphenous vein. The popliteal nerve, on the outside of the artery, has been omitted in the diagram. (Miller.) artery can be readily reached by an incision made directly downwards 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 pre- ference 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. 116); the incision for this operation should be three or four inches long, beginning about two inches below Poupart's ligament, mid- way between the anterior superior iliac spine and the symphysis, and car- ried downwards 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 within outwards. The femoral artery may also be tied at a lower point, where the sartorius muscle will still be the guide for the surgeon's incision, the vessel, which at first lies inside of this muscle, afterwards crossing be- neath it, and finally being external to it. Decjifaseta SarC'erins mitsrlcf Cord. 2/onp. Sa/i/iena nerve Fig. 116.—Ligation of the external iliac and superficial femoral arteries. (Bryant.) Femoral Artery.—The Common Femoral 216 INJURIES OF BLOODVESSELS. The Profunda, or Deep Femoral Artery, mayi>e 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 circumflex branches. 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. 117). The vein in the former situation lies to the outer, and in the latter to the inside of the artery; in either case the needle should be introduced between the two vessels. Anterior Tibial.— This artery maybe found, in its upper third, in the space between the tibialis anticus and extensor communis muscles. The Fig. 118.—Ligation of the anterior tibial at various parts. The wonnds are supposed to be held asnnder. The ligature is under the vessel. (Miller.) Fig. 119.—Ligation of the posterior tibial at various parts. The wounds are supposed to be held asunder. The ligature is under the vessel. (Miller.) incision is made rather more than an inch outside of the spine of the tibia, and should be about three inches long: In its lower half, the artery may he found just outside of the extensor proprius pollicis tendon, which, in thb situation, is the guide for the surgeon's incision. Care must, of course, he exercised in passing the ligature, to avoid the venae comites and the ante- PUNCTURED WOUNDS. 217 rior tibial nerve. On the dorsum of the foot this artery may readily be found between the tendons of the extensor pollicis and extensor brevis digi- torum. 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, w*hen the wound must be made the guide for the in- cision, which should be in the direction of the fibres of the gastrocnemius, and about four inches long. Above the ankle, the artery may be easily reached by a semilunar incision, concave forwards, about three-fourths of an inch behind the inner malleolus, and from two to three inches in length; the needle should be passed from behind forwards, so as to avoid the accompanying nerve. Peroneal Artery—If this vessel should require ligation, which can only be in case of wound, an incision must be made similar to that recom- mended for ligation of the posterior tibial in its upper third, except that in this instance it will, of course, be on the outer or fibular side of the calf. The artery will be found lying in a groove between the fibula, flexor pollicis muscle, and interosseous ligament. CHAPTER X. INJURIES OF NERVES, MUSCLES AND TENDONS, LYMPHATICS, BURS^, 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 distribu- tion 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 instances, to a distressing form of neuralgia; or the neuri- lemma 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. Dislocation of a nerve (the ulnar) is a rare form of injury which has been observed by* Dr. Lange, of New York. Laceration or Rupture of nerves sometimes occurs as a subcuta- neous injury*, as in cases of dislocation, w*hen the lesion may be a direct result of the injury*, or may be caused by the force used in attempts at reduction. Paralysis sometimes exists in these cases from the first, or may come on several weeks subsequently, and be attended with muscular atrophy; according to Duchenne, sensation is less impaired in these cases than motion. The treatment should consist in the use of electricity, douches, and suitable gymnastic exercises. H. "\V. Drew reports a remarkable case in which avulsion of the lower extremity with the sciatic nerve and part of the cauda equina, was followed on the eighth day by a free flow of cerebro-spinal fluid. Punctured Wounds of nerves usually result from the pricks of needles, or of the lancet in venesection. Partial paralysis and neuralgia may result, and may affect not only the parts supplied by the injured nerve, but adjoining parts as well, as in cases recorded by Graves and others. In some 218 INJURIES OF NERVES. instances genera] convulsions have been oliserved, 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, by Dr. Middleton Michel, by M. Nicaise, and by other writers. 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 appear- ance, loss of hair, incurvation of nails (Fig. 120), and the occurrence of Fig. 120.—Trophic lesions (glossy skin, ulceration, and turtle-shell nails) following wound of median nerve. (From a patient in the University Hospital.) eczematous eruptions or ulcerations ; subacute, rheumatoidal, articular inflammations (arthropathies) ; absence of perspiration from the affected part; the whole accompanied in many cases by a peculiar and very distressing burning pain. In some rare instances the tem- perature of the affected part is absolutely higher than the nor- mal 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 peripheral bulb, and to pass through certain degenerative changes which have been par- ticularly studied by Waller and by Ranvier, and in this country by Dr. R. M. Bertolet.and which are subsequently followed by a process of repair, the nuclei of the neurilemma undergoing pro- liferation, and the continuity of the trunk being ultimately restored by means of delicate fibres projected from either segment, and by the coales- Fiq. 121.—Wallerian degeneration of median nerve ; 180 diameters. (Bertolf.t.) TREATMENT OF WOUNDED NERVES. 219 cence of spindle cells in the intermediate cicatricial portion. In some cases neighboring nerves appear to act vicariously for those trunks which are divided, thus presenting a condition somewhat analogous to the collateral circulation in cases of arterial obliteration. If 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 circumstance, requiring surgical interference, which has been successfully applied in such cases by Warren, Oilier, Busch, Whitson, Trelat, Beauregard, Israel, Puzey, Hunter, Ger- ster, and other surgeons. Treatment of Wounded Nerves__It is proper, I think, to unite the cut extremities of divided nerves by means of" sutures, and numerous cases have been reported in which this has been done with favorable results. Bowlby, Polaillon, Surmay, Cavazzani, and others, believe that union "by first intention" may sometimes be thus secured, but according to Mitchell, who has paid particular attention to this subject, there is no reason to be- lieve that immediate union of a cut nerve can ever be obtained, though the use of a suture may hasten restoration of function. When this plan is resorted to, the ends of the nerve may be brought together with a delicate wire secured by passing its extremities through a perforated shot or Galli's tube (as was done by Nelaton), or a fine pin or acupressure needle and wire loop may be used as in the hare-lip suture. Bakowiecki recommends sutures of catgut passed through the neurilemma only, and this is the plan now generally adopted. In a number of instances nerve-suture has been resorted to long after the occurrence of the injury, and, usually', with good results, 39 cases collected by Weissenstein and Markoe having given at lease 29 successes, and 67 cases collected by Bowlby having given 27 complete and 24 partial successes, and only 16 failures. Bergmann, in order to facilitate the operation, did not hesitate to resect two inches of the uninjured humerus. Letievant and Tillmans splice the nerve by cutting strips from either segment, leaving them attached to the lower end, and fastening them together with stitches. Gluck and E. G. Johnson have reported several successful experiments in nerve-grafting, in the lower an- imals, but the operation has failed in the human subject (Vogt, Albert). Gluck also finds that by* stitching both ends of a nerve from w*hich a por- tion has been lost, to a decalcified bone drainage-tube, reproduction of the nerve-tissue will be effected. The same observation has been made by Vendoit, of Liege. If the proximal end of a cut nerve cannot be found, its distal end may be stitched to a neighboring nerve, as suggested by Letievant and Despres. The pain attending nerve wounds may be allevi- ated by the application of warmth or cold, according to the feelings of the patient, and especially by the hypodermic use of morphia. Repeated blis- tering is recommended by Dr. Mitchell and his co-laborers, for the burning pain of nerve injuries (causalgia)—and for the muscular atrophy, faradi- zation with 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, Nussbaum afforded relief by exposing and forcibly stretching the nerves which supplied the affected part, and similar operations have been since reported by the same surgeon, and by Billroth, Gartner, Callender, Palmer, Peterson, T. G.Morton, Jos. Bell, Byrd, Higgins, Amboni, Blum, Duplay, Bartleet, Andrews, Panas, M. H. Richardson, and others. I have myself stretched in one case the 220 INJURIES OF MUSCLES AND TENDONS. musculo-spiral, and in another the median nerve, for traumatic neuraliria of the hand; in the latter case with permanent, but in the former with only temporary advantage. I have also in two cases stretched the nerves of the brachial plexus with decided relief to the patient, but in another ease in which I stretched the sciatic nerve, the gain was somewhat doubtful. 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 writer, the production of complete myesthesia is necessary to insure success. Subcutaneous nerve-stretch- ing, by forcibly flexing the thigh and extending the leg, has been practised on the sciatic nerve by Billroth and others, and in some cases with good results. Reflex Paralysis, resulting from injuries of nerves, is a very inte- resting subject, but belongs more to the domain of physiology than to that of practical surjrery ; it has been specially studied bv Prof. Brown-Se'quard, by Dr. Mitchell, of this city, and by Dr. Eeheverria, of New York. Injuries of Mrscijas and Tendons. Strains and Sprains of muscular tissue are of very frequent occur- rence, and vary in severity from the slighest stretching to absolute rup- ture 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 administration (in cases occurring to patients of a rheumatic ten- dency) of Dover's powder with colchicum or iodide of potassium. Corri- gan's button cautery may be applied if the pain be very persistent, while the atrophy and paralysis, 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 parturition, 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 induration 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 known to give way in elderly gentlemen 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 acci- dent are efficiently evident. The patient experiences a sudden shock, attended with a sharp pain (coup de fouet), and sometimes an audible snap; the power of using the part is lost; and usually a distinct depres- sion or hollow can be felt at the line of rupture. If the part be the seat of varicose veins, thrombosis and milk-leg may follow, as pointed out by Verneuil. Effusion into the neighboring 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 will relax the affected muscle or ten- don, and allow its divided extremities to be approximated as closely a- possible. Repair in these cases is effected, as shown by Paget, Adams, and Demarquay, by the development of a new tissue between the divided INJURIES OF THE LYMPHATICS AND BURS2E. 221 extremities, which in the case of a tendon gradually assumes the character of the original structure, but in the case of a muscle remains permanently as a fibrous band.1 Rupture of the tendo Achillis may be conveniently treated by an apparatus consisting of a collar placed above the knee, with a cord which pulls up the heel of a slipper applied to the foot, so as to keep the gastrocnemius muscle thoroughly and constantly relaxed. Rupture of the extensor muscles of the thigh, or of the ligamentum patellae, should be treated by keeping the limb in an extended position and somewhat ele- vated ; after recovery, a posterior splint should be worn for some time, to prevent sudden flexion of the knee. Dr. Sands cut down upon a ruptured ligamentum patellae, and brought the ends together with sutures. 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 taken to avoid gaping of the part by placing the limb in a suitable position, and by the use of sutures to approximate the cut extremities, if this should seem necessary. If the proximal extremity of the cut tendon should be retracted out of reach, its distal end may be attached to a neigh- boring tendon, as advised by Denonvilliers, Tillaux, Duplay, and Hager. Annandale has successfully pared and reunited the tendo Achillis more than two months after its division. Gluck has induced reproduction of lost tendons- by grafting them with catgut, and Peyrot has filled the gaps in retracted tendons by transplanting portions of tendon taken in one case from a dog, and in another from a cat. Luxation of a Tendon from its sheath is occasionally met with, particularly 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 redisplace- ment by the use of a compress and bandage. Injuries of the Lymphatics. These present, ordinarily, no features requiring special comment; in some cases, however, in which there is a varicose state of the ly*mphatic trunks (a condition usually associated with one of the varieties of Ele- phantiasis Arabum), wounds of the affected part are followed by a copious and sometimes troublesome flow of a milky fluid, constituting a traumatic form of w*hat is known as lymphorrhcea. Such wounds are difficult to heal, and sometimes degenerate into obstinate fistula?. 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 bursae heal with oblite- ration of the sac. Should suppuration occur in a bursa, without external wound, the part should be freely opened, and treated as an ordinary ab- scess. Injuries of bursas sometimes result in chronic structural changes which will be described in another part of the volume. 1 According to Demarquay, however, under favorable circumstances actual regene- ration of muscular tissue may occur. 222 INJURIES OF BONES AND JOINTS. Injuries of Bonks. Besides fractures, which will be considered in a separate chapter, bones may be subjected to contusion and to alteration of shape (bending), without solution of continuity. Contusion of bone has already been referred to in the chapter on gun- shot wounds, as a consequence of which injuries it is not un frequently met with. It may also occur, how ever, 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 con- tusion, 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 which may be required by the after-consequences of this form of injury will be referred to in another place. Bending of Bone, apart from fracture, can only be met with in very- early life, or under the influence of some morbid condition which 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, w'hich 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 isnotunfrequently 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 followed by osteo-myelitis of the humerus, with suppurative disorganization of both eibow 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, with leeches if necessary; and, in the later stages, in affording support by means of an elastic band- age, and in the use of methodical friction and of the cold douche. Sprains—A joint is said to be sprained, when, as the result of a twist or other external violence, its ligaments are forcibly stretched or torn, without the occurrence of either fracture2 or dislocation. The 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 recog- 1 Prof. Humphry, of Cambridge, denies the correctness of the theory thai shortening 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 sam« locality. WOUNDS OF JOINTS. 223 nized. The position assumed spontaneously by the part is that in which there is least tension, the hand being slightly flexed and inclined to the ulnar side in the case of the wrist, and the foot being extended ("pointed toe") in the case of the ankle. The joint presents the usual evidences of inflammation, the swelling and heat being 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 subsi- dence of acute symptoms. The articulation sometimes becomes the seat of chronic rheumatism, while more rarely, if the patient be strumous, suppurative disorganization of the part may ensue. The treatment in the acute stage consists in keeping the joint at entire rest, and in making cold or warm applications, as most agreeable to the patient. I have often, by the use of warm spirituous fomentations, such as the tincture of opium or tincture of arnica, succeeded in dispersing the swelling, and relieving the other sy*mptoms 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 with a soap plaster and bandage, or an elastic stocking, and subjected to methodical kneading and friction (massage), and the use of the cold douche. 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 with sprained ankle is unable, from the nature of his avocations, to stay at home and keep the part at rest, it may advantageously be sup- ported with a plaster-of-Paris bandage, which will allow of a certain amount of exercise without injury to the joint. Should the surgeon have the opportunity of seeing the case at an early period, before the occur- rence of inflammatory symptoms, it might be proper to completely sur- round the joint with long and broad adhesive strips, superadding a gypsum bandage—a mode of treatment which has occasionally succeeded in pre- venting the occurrence of inflammation and its troublesome sequela?; 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 with 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 w*ound itself, and the constitutional condition of the patient. Wounds of the smaller joints, such as of the fingers and toes, are commonly recovered from without difficulty, although anchylosis of the articulation usually results. Small incised wounds of even large joints may terminate favorably under expectant treatment, while lacerated wounds of the same joints, especially if complicated with dislocation or fracture, almost inevitably require excision or amputation. Again, in a strumous patient, a comparatively slight wound may give rise 224 INJURIES OF NERVES. to such disorganization of a joint as would not ensue in the case of a per- fectly healthy person. Treatment.—In the case of a simple, uncomplicated wound of even so large a joint as the knee, the surgeon should make an attempt to save the limb. If a portion of the instrument which has caused the injury remain in the wound (as often happens in cases of needle puncture), it should be carefully extracted, and the wound then hermetically sealed with gauze and collodion, or 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 with patients in adult life, the whole joint may become acutely inflamed, that condition being then developed wiiich is known as traumatic arthritis. This differs from the ordinary forms of arthritis, which constitute the " white swellings" so often met with in practice, in that, in them, the disease often originates in the ligaments or the bone itself, while 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-wound, the treatment above directed should be somewhat changed; the use of cold may be abandoned, and warm fomen- tations or cataplasms substituted, while a few leeches may be applied to the neighborhood of the joint, and calomel and opium exhibited internally. At the same time the strength of the patient must be sustained, by the ad- ministration of concentrated food, and even stimulants if necessary. Any abscesses which form around the joint should be opened as soon as they are detected, while, if suppuration occur within the joint itself, the question of excision or of amputation 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 worse than useless—and should be so situated as to allow of perfect drainage ; it is not, however, necessary to slit up a joint from side to side, and it should not be forgotten that, as Mr. Holmes puts it, these incisions, ''if they do no good, will certainly do harm." The object and the sole object of opening a suppurating joint is to secure free drainage, and this object can be better accomplished by an incision of moderate size judi- ciously placed, than hy 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 a coil of fine wire, as recommended by Mr. Robert Ellis. Drainage-tubes are usually pieces of India-rubber tubing, from one-sixth to one-third of an inch in diameter, with numerous lateral apertures made by notching the tube with scissors. Decalcified bone tubes are employed by some surgeons, and Weeks recommends a tube made from the artery of the ox. Glass tubes are less well adapted for joints than for the abdominal cavity. Treves recommends irrigation by means of a constant stream of water passing through a drainage-tube, and continued, if necessary, for several weeks. Should this treatment prove successful, the inflammatory 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 im- prove after opening the joint, the surgeon should not hesitate to resort at OPERATIONS IN CASES OF JOINT-WOUND. 225 once to amputation, or, in some cases, excision, for although the progno- sis 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 opera- tive treatment be required, either as a primary procedure or in a subsequent stage on account of the occurrence of suppuration within the articulation, the choice between amputation and excision will depend in a great decree upon the particular joint concerned. In the upper extremity, amputation can rarely be required, except for special circumstances connected with the constitutional condition of the patient, and excision, either primary or secondary, should be preferred, in cases which require any operation at all. In the lower extremity the case is somewhat different; the hip-joint is so deeply seated that it is scarcely ever wounded except by gunshot injury, in which case, for reasons already given, primary excision is the mode of treatment to be adopted. Wounds of the knee-joint are among the most serious injuries met with in civil practice; if complicated with fracture or dislocation, they should, I think, be considered as cases for amputation, although exceptional instances do undoubtedly occur in which recovery without operation follows, even under these unfavorable circumstances. Excision of the knee-joint, for traumatic causes, is not a very promising operation ; still, in a young and healthy person, if the destruction of parts were comparatively slight, it might be at least a justifiable procedure. M. Spillman, who rejects knee-joint excision in military surgery, yet considers it a suitable operation as applied to cases of injury met with in civil life. Eleven such cases which he has collected, excluding gunshot wounds, gave six recoveries, three deaths, and two consecutive amputations. Five cases of total excision for compound fracture, collected by Penieres, gave four deaths and but one recovery, Avhile six operations for joint-wound, without fracture, gave but one death and five recoveries ; as justly observed, how- ever, by this writer, these cases might, perhaps, equally well have recov- ered without operation. Culbertson's tables include 28 cases, with 17 re- coveries and 11 deaths. When an attempt has been made to save the knee-joint, but without success, amputation should be unhesitatingly per- formed, as offering the only remaining chance of preserving life. One point worthy of notice in connection with wounds of the knee, is the frequent occurrence of suppuration above the joint, abscesses being formed which dissect up the muscles of the thigh to a considerable extent, before giving evidence of their existence. It is this deep-seated destruction of the tis- sues of the thigh which constitutes one of the chief dangers of wounds 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 required 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 with more or less useful limbs, two recovered after amputation, and thirteen died (two of these having been likewise previously amputated); the mortality of the operation is, accord- ing 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. Two cases in my own hands both terminated successfully. In the conservative treatment of these injuries, it is of great importance to support the foot, so that the patient after recovery mav be able to walk 226 FRACTURES. properly, and may not be left with an extremity* anchvlosed in the posi- tion 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 followed ligation under these circumstances, but no sufficient evidence has been adduced to show that the good result was in any degree due to the operation, which, beside being unphilosophical in conception, evidently adds an additional risk, without 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 practice as it is unscientific in theory. CHAPTER XI. FRACTURES. Fracture is the most common form of injury* to which the bones are exposed, and, as such becomes a subject of the deepest interest to every practising surgeon. Moreover, no injuries require more care and judg- ment in their treatment than fractures, and no cases contribute, more than these, to establishing the fame or the discredit of the surgeon. A man who gets well with a crooked or shortened limb, is very apt, whether rightly or wrongly, to lay the blame of it upon his doctor, and though cases do undoubtedly occur in which the most skilful and attentive surgeon may- fail in obtaining a satisfactory result, there can be no question that a great many bad cures of fracture are directly traceable to ignorance or neglect upon the part of the practitioner. Causes of Fracture. These may* be divided into the exciting and predisposing causes. Exciting Causes—The exciting causes of fracture are external vio- lence 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, while fracture of the clavicle from a fall on the shoulder, or of the radius from a fall on the hand, may* be taken as illustrations of the injury as pro- duced 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, w*hich 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 w*as applied, but at a point more or less opposite. Familiar examples of fractures 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 understood as denoting merely a variety of injury from indirect violence, the mechanism of which is explicable by simple and well-understood physical laws, depending entirely upon the structure and connections of the bones and other parts involved. PREDISPOSING CAUSES. 227 2. Fracture by Muscular Action is not of very unfrequent occurrence, though the eases in which fracture is produced by* pure divulsion, or tear- ing asunder the fragments, are rarer than is commonly supposed. Indeed, the only instances of the kind with which I am acquainted, are those rare cases in which fracture of the sternum has occurred during the acts of par- turition, vomiting, etc. In the more commonly quoted instances of frac- tured 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. Predisposing Causes.—The predisposing causes of fracture may per- tain to the bone itself, or to the general condition of the patient. Thus, the situation of a bone influences its liability to fracture; the clavicle is much oftener broken than the scapula, and the lower than the upper jaw. Again, the function of a bone may predispose it to fracture ; the bones of the lower extremity, which support the.trunk, or those of the upper extremity*, wrhich are constantly engaged in the active employments of life, are more liable to fracture than the vertebrae or sternum, the functions of which are different. The following table, condensed from the statistics of Lonsdale, Xorris, and Malgaigne, will exhibit the relative frequency of fracture in different parts of the body, in the Middlesex Hospital, Pennsylvania Hos- pital, and Hotel-Dieu:— Seat of Fracture. Skull...... Nasal bones .... Upper jaw and malar . Lower jaw .... Sternum..... Ribs and costal cartilages Vertebrae..... Pelvis, sacrum, etc. Clavicle..... Scapula (or shoulder) . Lons- dale. ) years, 48 13 1 32 2 357 273 18 Norris. Mai gaigne. 10 yrs. 11 yrs. 46 53 3 12 19 27 5 1 46 263 8 11 6 9 84 225 10 12 Seat of Fracture. Lons-dale. Norris. Mal-gaigne. Humerus . . 6 years. 118 10 yrs. i 11 yrs. 310 Radius . . . Ulna . . . 197 96 (-252 160 38 Radius and ulna 93 I 107 Hand, etc. . . 116 9 71 Thigh . . . Patella . . . 181 38 133 16 303 45 Tibia . . . 41 ) 29 Fibula . . . 51 ^295 108 Tibia and fibula 197 ) 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 which attends advancing age, and which renders the entire frame less elastic and yielding, and there- fore 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 foetal life.1 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 adult early 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 vio- lence. 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 women; for a similar reason, the right side of the 1 Depaul, however, believes that supposed intra-uterine fractures are really cases of defective ossification, and not of injury. 228 FRACTURES. 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 exerci.-es a powerful influence in this way, as do osteo- malacia, cancer, syphilis, scrofula, gout, locomotor ataxia, and general paralysis of the insane. Some very remarkable cases are on record illus- trating the fragility of bones under certain conditions; Gibson, Arnott, Tyrrell, Lonsdale, and H. Thomson have described such cases, but the most remarkable of all is that published in the Journal des Savants for 16i>0, and which appears to be the same as one quoted by Malgaigne from Saviart, in which an apparently healthy young woman 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 eases union readily took place, but in one mentioned by Stanley, and in that of II. Thomson (in which, indeed, the bones are described as separating rather than breaking), the fractures appear to have remained ununited. Varieties of Fracture. Fractures may be Complete or Incomplete ; these names suf- ficiently express their own meaning. The form of incomplete fracture usually met with in civil life is the partial or "green-stick" fracture, in which some of the bone-fibres have given way, w*hile the rest have yielded to the force, bending but not breaking. In military practice, incomplete fractures are occasionally produced by blows from sabres, but more often by gunshot wounds, 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 fracture, in which a piece is fairly punched out from the centre of a bone. These terms (com- plete and incomplete) are principally used in reference to the long bones; in the case of flat bones, as of the skull, many of the fractures met with in civil life are incomplete. The most usual and the most important division of fractures is into simple and 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, which seems to me to correspond with the niean- iug usually attached by* surgeons to the term simple frac- ture, 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 subcu- taneous character, while the latter regards merely the ab- sence of external wound, without reference to the number of fragments. The classification adopted by Mr. Hornidge, in Fm. i22.-Par- Holmes's System of Surgery (which would make this form ti«i fracture, the " simple, single fracture"), is perhaps the most strictly correct, but is almost too complicated for common use. Compound Fractures are fractures which, communicate with the external air through a wound : this wound is usually, though not neco- " I have myself met with a case in which, without apparent reason, seventeen frac- tures had been sustained by the bones of the rifjht lower extremity; when I saw the patient, multiple enchondromata had been developed in the foot and ankle. DIRECTION OF FRACTURE. 229 Fig. 12:!.— Coinmin. uted fracture of the patella. sarily, an external or cutaneous wound ; a fracture of the jaw may be com- pound 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 with each other and occupying the same general position as regards the bone affected. A multiple fracture, on the other hand, is one in which the bone is the seat of two or more distinct fractures not necessarily* connected with each other; thus the radius may be broken just below its head and again above the wrist, or the tibia through the malleolus and again just below* its tuberosity. A double fracture is a multiple fracture in which the solutions of continuity* are but two in number. Comminuted and multiple fractures 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 frac- ture alone is used, it is understood that there is no communication with an external wound; if there be such communication, the injury becomes a compound comminuted fracture. Complicated Fractures are fractures which are accompanied by some other serious injury of the same part. Thus a fracture may be com- plicated by dislocation of a neighboring joint, by rupture of an important artery, or by a severe flesh wound which does not communicate with the seat of fracture. Some authors speak of fractures being complicated (in this technical sense) by any* of the various lesions to w*hich the human frame is subject, but this, it seems to me, is incorrect; thus it would be w*rong to describe a fracture of the right thigh as complicated by a dislocation of the left shoulder, or a fracture of any of the extrem- ities as complicated by a wound of the pleura or lung, though the latter lesion, if produced by* the sharp fragments of a broken rib, w*ould be a-techni- cal complication of that injury, which would then be properly called a complicated fracture of the rib. Impacted Fractures are those in which one fragment is driven into and fixed in the other. Intra-periosteal Fracture is the term ap- plied to a fracture unaccompanied by laceration of the periosteum; it is a form of injury* rarely* met with except in certain flat bones, as those of the skull, and, indeed, the creation of this subdivision seems.to me to be of very little practical utility. Direction of Fracture___Fractures are also classified in accordance with the direction in wiiich the separation of the bony fibres occurs; thus fractures are said to be transverse, oblique, or longitudinal. A Transverse Fracture is one in which the general line of separation is transverse, or in a plane at right angles with the long axis of the bone. A perfectly transverse fracture in a long bone is very rarely met with, the line of separation being almost always more or less oblique; a variety of the transverse is the serrated fracture, in which the fragments present cor- responding indentations which render it comparatively easy to maintain them in apposition. Transverse fractures usually result from direct vio- lence or from muscular action. mi Fiu 124.—Impacted frac- ture thf-ough the trochan- ters of the femur. The upper fragment is wedged into the lower. 230 FRACTURES. The Oblique Fracture is the form most commonly met with 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 which the line of separation runs in the general direction of the long axis of the bone. This form of fracture is comparatively rare in civil life, but is frequently met with as a result of gunshot injury, especially since the general introduction into warfare of the improved conoidal ball. Longitudinal fractures commonly, occur in the shafts of long bones, and usually do not extend beyond the epiphyseal lines though occasionally* thev pass through the epiphyses into the neigh- boring joints. Several other divisions are made by French writers, accord- ing to the peculiar form of the fracture, but the above are sufficient un- practical purposes. . Separation of Epiphyses.—This is a form of injury which may fairlv 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 ex- tremity of the radius; it is also frequently seen in the case of certain bony pro- cesses, as the acromion and olecranon; while in certain flat bones, as the sternum and os innominatum, simi- lar injuries are met with, consisting in a separation of the osseous structure into its original constituent parts, in the lines of cartilaginous junction. Epiphyseal sepa- ration can of course only occur before complete ossifi- cation has taken place; hence, in the long bones it is not met with beyond the age of twenty or twenty-one, though in other situations, as in the acro- mion, it may occur at a much later period. The direction of an epiphy- seal separation is transverse, and from the proximity of the epiphyseal lines to the articulations these injuries are liable to be confounded 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, while 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. Epiphy- seal injuries are apt to be followed by arrest of growth of the affected bone,1 and thus sometimes cause great deformity, as shown in Fig. 125. Fig. 12V—Deformity resulting from injury of radial epi- physis in childhood. (From a patient in the Episcopal Hos- pital.) 1 Whether, in any particular case, separation of an epiphysis will or will not inter- fere with the subsequent growth of the bone, appears to depend upon the amount of DEFORMITY. 231 Symptoms of Fracture. Deformity.—The most prominent, and one of the most characteristic symptoms of fracture, is deformity or displacement. The Causes of Dis- placement, in cases of fracture, have been the subject of much dispute among systematic writers. Without entering into a minute discussion of this matter, I may say, in general terms, that the causes of displacement are fourfold, viz : 1, the force that produces the fracture; 2, the action of sur- rounding muscles; 3, the weight of the limb below the seat of fracture; and 4, the natural elasticity and resiliency of the ligaments and other soft tissues above the seat of fracture. 1. Deformity from the influence of the fracturing force is seen in cases of depressed fracture of the skull, in cases of partial fracture of the clavicle with inward angular deformity, and in cases of impacted fracture generally. 2. Muscular action is the most common cause of displacement in cases of fracture. It is seen in the shortening which accompanies almost all fractures of the extremities, and in the rotatory displacement common in fractures of the femur, radius, etc. It is the chief if not the sole cause of displacement in cases in which the fracture itself has been caused by mus- cular action, as in fractures of the patella or olecranon. Beside the ordinary contraction of the muscles around the seat of fracture, there is often a spas- modic condition induced by the irritation caused by 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 pro- ducing eversion of the limb, 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 powerful of the femoral muscles are those on the back and inner side of the limb. This is the form of displacement met with in partial or " green-stick" frac- tures, 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 cases 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 with joints, as in splitting fractures of the condyles of the humerus or femur. injury inflicted on the " spongy layer"—no longer cartilage, but not yet bone—which unites the epiphyseal cartilage to the diaphysis. If this spongy layer, as usually happens, be torn off with the cartilage, and accurate reduction be not promptly effected, the growth of the bone in length will be arrested ; but if, on the other hand, this layer should remain attached to the shaft, or if prompt and accurate reposition should enable it to resume its normal function without hindrance, the bone may con- tinue to grow as before the injury. 232 FRACTURES. 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 fracture, which allows one fragment to slide upon the other as upon an inclined plane. When the shortening is so great that the upper end of the distal fragment is drawn above the lower end of the proximal fragment, there is said to be overlapping, and the more prominent fragment is said to ride the other. The overlapping often amounts, in fracture of the thigh, to several inches. Another form of shortening is due to impaction ; this is often seen in fracture of the cervix femoris, the shortening being principally in the direction of the axis of the neck of the bone, not of its shaft; hence the deformity in such a case is comparatively slight. The form of longi- tudinal displacement which consists in lengthening, is chiefly seen in cases of fractured patella, fractured olecranon, fractured calcaneum, etc., in which the fragments are often widely separated by muscular action ; it is, how- ever, as pointed out by* Malgaigne, occasionally met with in fractures of the articular extremities of the long bones, as of the fibula, when it is a secondary condition dependent on antecedent rotatory displacement. 4. Rotatory displacement consists in one of the fragments being twisted upon its own axis; this form of displacement may be due to muscular ac- tion, or to the weight of the limb below the seat of fracture. The displace- ment is constantly seen in fracture of the upper part of the femur, when the lower fragment is rotated outwards by* the powerful external rotator muscles of the thigh ; in fracture of the bones of the leg, by the action of the same muscles, the upper fragments, moving with the femur, are sub- jected to rotatory- displacement. So in fracture of the radius, particularly if above the insertion of the pronator radii teres, the upper fragment is usually rotated outwards by the biceps and supinator brovis. Displacement in cases of fracture may be confused with deformity from other causes ; thus a periosteal node or an exostosis may closely simulate angular dir-placoment; shortening may result from old joint-disease, or from contracted tendons ; the position which a joint assumes when the seat of >prain, may be mistaken for rotatory displacement; while the trans- verse, or, indeed any of the varieties of displacement may be due to dislo- cation and not to fracture. Hence the surgeon, in making his diagnosis, must not rely upon the appearances presented to the eye, or even upon mere tactual examination. The limb involved should be carefully and re- peatedly measured between known fixed points, and compared with the corresponding unaffected limb; and in cases of doubt, not only the injured limb, but the bone itself should be accurately measured and compared with its fellow of the opposite side. Mobility is often a striking and easily recognized symptom of 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 manifestation of this symptom; again, in serrated, and especially in impacted fractures, there will often be no undue mobility ; or the swelling of the soft parts may be so great as to render the mobility of a fracture, especially if near a joint, difficult of recognition. On the other hand, dislo- cation, which is usually characterized by immobility of the affected joint, may, if there be much destruction of the articular ligaments, be accompa- nied by positive increase of mobility, and thus simulate fracture. But in the continuity of a bone, at a distance from its articular extremities, mo- EXTRAVASATION AND ECCHYMOSIS. 233 bilitv, 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 presence of fracture. Crepitus or crepitation is the grating sensation pro- duced by rubbing together the rough ends of the fragments. It \sfelt as well as heard, and is usually recognized without difficulty ; it must not be mistaken for the grating produced by moving diseased joints, nor for the crackling due to effusion in the tendinous sheaths, nor yet for the crepita- tion of traumatic emphysema, each of which conditions may, under certain circumstances, closely simulate the true crepitus of fracture. The diagnosis might, perhaps, be aided in such cases, as suggested by Lisfranc, 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 ab- sence may be due to several causes : thus, the fragments may overlap to such a degree that their rough ends are not in contact—a condition often met with in fracture of the thigh, when it is necessary for an assistant to make extension before the fragments can be brought together and crepitus produced; or the fragments may be widely separated—as in cases of frac- tured patella ; or a portion of muscular tissue may be caught between the fragments, and prevent crepitus. In partial fracture, there is no crepitus ; nor in impacted fracture, 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, however, persistent localized tenderness is a sign of some value, especially in cases of partial or impacted fracture, in which the more characteristic symptoms are absent. Loss of Function used to be considered an important symptom of fracture. Yelpeau, however, showed that a fractured clavicle interfered with raising the arm to the head, merely by the pain caused by the act; and Gouget, a French army surgeon, hasshowai the same thing as regards the power of w*alking, after fracture of the patella. I have myself known a man with fracture of both bones of the leg, to walk about the ward, when under the influence of mania a potu, using his fracture-box as a boot, and apparently* not feeling any inconvenience from his injury. Muscular Spasm is 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 pro- duced by simultaneous injury, or subsequent compression, of neighboring nerves. Extravasation and Ecchymosis, to a greater or less extent, occur in almost every case of fracture : the degree of ecchy*mosis is often much greater after a few days, than when the injury is first received, and may then (especially if accompanied by much vesication, as it is apt to be if the soft parts have been much bruised) be mistaken by a hasty observer for incipient gangrene. When extravasation proceeds from a ruptured artery, giving rise to a traumatic aneurism, it constitutes a very* serious complica- tion of fracture. When the extravasation reaches to the neighboring joints, intraarticular effusion results, as pointed out by Gosselin, from irritation of the outer surface of the synovial capsule; this symptom is, therefore, usually met with some hours or even days after the occurrence of the fracture. 234 FRACTURES. Diagnosis of Fracture. The diagnosis of fracture can usually be made without much difficulty by attending to the symptoms above enumerated, the first three of which, when coexisting, may indeed be considered as pathognomonic. In cases of partial and of impacted fracture, the surgeon has not the evidence fur- nished by crepitus and mobility, and must rely upon the other signs of fracture, especially deformity and localized tenderness. Again, in cases where but one of several bones is broken, as in the hand or foot, the diag- nosis is more obscure, especially if there be much swelling of the soft parts. In such a case, the surgeon carefully explores the surface, by making firm but gentle pressure upon each part in succession, and is thus enabled to detect any abnormal prominence, and often to elicit crepitus which could not otherwise be obtained. If the metacarpus or metatarsus be involved, each bone should be successfully grasped by its extremities, and so mani- pulated as to render evident any fracture which may be present. As it is of great importance in any cast1 of suspected fracture that the surgeon should arrive at a correct diagnosis, his examination should always be made deliberately and systematically. The deformity, mobility, impair- ment of function, pain, etc., should be successively noted, before proceed- ing to the manual examination which is to determine the existence or non- exi>tencc of crepitus. In this final part of the investigation, preliminary extension being made by an assistant, if necessary, the surgeon grasps the limb above and below the suspected seat of fracture firmly—so that he controls the bone as well as the flesh, and gently moves his hands in various directions, so that if there be a fracture, the ends of the frag- ments 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 renew this evidence, thus appearing more anxious to make a clinical demonstration for himself or for the bystanders, than to relieve the sufferings of his patient. The 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 fracture until the swelling has subsided, when, if there be really no bone broken, at least no harm will have been done by the delay. Or, if for any reason it were important to ascertain the nature of the case at once, the plan recommended by Rizet, a French army surgeon, might be tried. This plan consists in endeavoring to 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 would be justifiable, in order to facilitate the diagnosis (see page 73).1 In any case of doubt, it is safe to presume that the worst has occurred, 1 Grossich declares that in every case of fracture (or other bone-lesion), the urine contains an excess of indican, and suggests that this should be looked for in an-" doubtful case. PROCESS OF UNION IN FRACTURED BONES. 235 and to treat the case as one of fracture It is remarkable what severe inju- ries 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, was not detected until the eighth day, and I can myself recall a case in the Penn- sylvania Hospital, in w*hich the swelling of the part prevented the recog- nition of anything further than that the patient had a fracture of both tibia and fibula, and yet in which (death taking place soon after from mania a potu) an autopsy showed that the bones were broken into at least a dozen fragments. Process of Union in Fractured Bones. In order to understand the process of repair after fractures, it will be necessary to pause for a few moments to consider the natural process of growth and maintenance of bone in its normal condition. This subject has been most thoroughly and carefully studied by Oilier, of Lyons, to whose elaborate and admirable Treatise on the Regeneration of Bone's I would respectfully refer the reader for a detailed exposition of the w*hole subject of bone pathology. Bone grows in length by the development of bone-cells from the epiphyseal cartilages, or cartilages of conjunction, and in thickness by the development of bone-cells from the inner or osteo-genetic layer of the periosteum ; while this peripheral thickening is going on, there is a simultaneous conversion of the innermost layers of bone into medulla or marrow, and hence the medullary cavity enlarges as the bone grows. Turning now to consider the effects of any"traumatic irritation upon the constituents of bone, we find the various nutritive and formative changes which were described as parts of the inflammatory process (see Chap. I.), taking place in the periosteum, the bone-tissue proper, and the medulla! Direct irritation of either periosteum or medulla is apt to result in giving rise to what was described as the second formative change of inflammation, the formation of pus, or suppuration: indirect irritation, however, w*hether 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 propa- gated traumatic irritation is to cause a hyperplasia of the deep or osteo- genetic layer, manifested by swelling, and ultimately resulting in an increased production of new bone; in the marrow, the irritation, if not excessive, results in induration and a local retrograde metamorphosis into bone. Finally the bone-tissue itself responds to the stimulus, and becomes medullized (assuming the character of granulations), proliferation of its cells takes place, and hypertrophy, temporary or permanent, results, with (if the irritation continue) the various changes which will be hereafter considered under the head of osteitis. These are not mere theoretical views, but have been adopted by Oilier after numerous carefully conducted and often repeated experiments upon the lower animals, as well as after extended clinical observation.1 1 It is but right to say that a different explanation is given by Billroth ; according to this distinguished surgeon and pathologist, the periosteum possesses no peculiar osteo-genetic power, and the formation of callus is due not to proliferation of pre- viously existing cells, but to an accumulation of wandering cells, which, following Cohnheim, he looks upon as white blood-corpuscles escaped from the vessels. The same difference of opinion, in fact, prevails with regard to the pathology of inflamma- mation and repair in the osseous tissues, that has already been noted witli 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 236 FRACTURES. Taking now the simplest case of fracture—an in/ra-periosleal fracture, so called—the process of repair can be seen at a glance. The traumatic irritation propagated from the broken bone causes swelling of the perios- teum, active proliferation, and formation of a sheath of new bone around the seat of fracture; this is the "ensheathing" or " ring callus" of surgi- cal writers. At the same time the medulla feels the effect of the irritation, becomes hardened and partially ossified ; this constitutes the "interior" or "pin callus." Lastly, the osseous tissue itself undergoes cell prolifera- tion, and union of the fragments takes place, mutatis mutandis, precisely by the same process that we have already studied in considering wounds of the soft tissues. The new material which is thus developed between the* fragments themselves, constitutes what Dupuytren called the intermediate, permanent, or definitive callus, in contradistinction to the ensheathing and interior forms of callus, which are temporary or provisional. This explanation is applicable to the process of repair as seen in every variety of fracture. The new formations from the periosteum and medulla gradually disappear, the ensheathing callus is partly absorbed and partly incorporated in the bone, in the process of its normal maintenance, while the ossified medulla, or interior callus, undergoes rarefaction and medul- lization, 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 unaccompanied by displacement, the periosteal and medullary new* formations may lie so small in amount, and so temporary in duration, as to escape observation ; this is seen in certain serrated, impacted, and partial fractures, and is often spoken of as union by intermediate callus alone. On the other hand, the fragments 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 displacement, 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 them- selves widely 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 week 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 wiiich will be con- sidered hereafter, bony union does not take place, and the fragments are connected by fibrous tissue only. In cases of compound fracture, the pro- cess of union, though the same, is much slower in its progress, being delayed by the occurrence of granulation, of suppuration, and often of necrosis, and presenting similar differences to those wiiich are observed in the heal- ing of open, as compared with that of subcutaneous wounds. Cartilage differs from the connective and medullary tissues, but is of an embryonic character analogous to that met with in foetal life, and probably results from a direct "gene- sis." Dr. H. 0. Marcy believes that the periosteum is destroyed at the seat of frac- ture, and that repair takes place by exudation of " plastic or germinal material" and the formation of a new periosteum. J. Greig Smith believes that true hone is devel- oped, in cases of fracture, by the medullary structure, but that the change in the periosteum is rather calcification than true ossification. TREATMENT OF SIMPLE FRACTURES. 237 is occasionally met with in callus; it is, however, but a temporary con- stituent, due to excess of irritation. Separated epiphyses unite as frac- tured bones: the part usually* remains permanently thickened, while, from the injury to the cartilage of conjunction, the growth of the bone in length may be permanently interfered with. (See Fig. 125.) For further infor- mation 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 prevent a recurrence of displacement; and 3, to see to the well-doing of the part affected, and to look after the constitutional condition of the patient. I shall first consider the general principles which should guide the surgeon in the treatment of simple fractures, then the modifications of treatment required by the principal complications of simple fracture, and finally* the treatment of compound fractures. Treatment of Simple Fractures.—Fractures are often met with at a distance from home, and in localities where no surgical appliances are at hand, and where no treatment can be satisfactorily carried out. Under such circumstances, it becomes necessary for the surgeon to attend, in the first place, to the transportation of his patient. If the fracture be in the upper extremity, 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 lower extremity, it will be necessary for the patient to be carried upon a sofa, or litter extemporized from boards, a window-shutter, etc. If a mattress cannot be obtained, the patient's head and the broken limb may be supported on any old cloths that can be procured, or upon straw. Temporary splints may sometimes be formed from the bark of trees, or made by laying together three or four thicknesses of folded straw or rushes. The limb should be laid in as easy a position as possible, and the litter borne deliber- ately, but with a firm step; it is usually recommended that the bearers should be instructed to step off with alternate feet, as it is said that thus less vibration is communicated to the litter. Before the patient is removed from the litter, the surgeon should see that a suitable bed has been pre- pared. Various fracture-beds have been invented by surgeons, amongst the most ingenious being those of Daniels, Burges, Coates, and Hew son, but, for practical purposes, I know of nothing better than a simple, per- forated, hard mattress, with a pad accurately fitting the perforation, and a pan which slides in a frame-work beneath a corresponding opening in the bedstead ; the latter should be provided with strong weoden 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 per- forated, and should be secured to the mattress so as not to form ridges under the patient's body. If a fracture-bed be not at hand, an ordinary bedstead with a hard mattress may be satisfactorily used, in which case a bed-pan must be employed to receive the fecal evacuations. These preliminary matters having been attended to, and the patient being in bed (if the fracture be in the lower extremity), the surgeon removes the clothing as gently as possible, and exposes the injured part and the 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 238 FRACTURES. 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, with Prof. Hamilton, that it is only in exceptional cases that the displacement of fracture can be entirely overcome. Reduction should be effected as soon as possible, for the reason that it is much easier to the surgeon, and much less painful to the patient, if done before the development of inflammation ; if, however, the patient is not seen until a later period, or if displacement should, from any cause, have recurred, the surgeon need not hesitate at any stage of the case to effect as perfect reduction as he can, for the slight addi- tional irritation thus produced will be of much less consequence than tin- evils which would result from continued displacement. Reduction should be effected by the hands alone; no mechanical contrivance should be used to give increased force, lest serious mischief to the already 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, when the bones will fall into position of them- selves. Even in fracture of the femur, in which extension is commonly necessary to effect reduction, it is a good rule that no more force should be used than can be applied with the hands alone. In cases in which one or both fragments are embedded in the muscular tissue, or in which, from any other cause, there is great muscular resistance, it may* be justifiable to employ anaesthesia as an aid to reduction. 2. To Prevent the Recurrence of Displacement, the surgeon makes use of various forms of apparatus, splints, bandages, etc. It is often very dif- ficult to maintain reduction during the first few days, on account of the spasmodic action of the muscles constantly reproducing the deformity; but the tendency to spasm gradually* passes off, so that by constant attention and careful dressing during the early stage of the treatment, it is almost alw*ay*s possible to obtain such accurate apposition of the fragments, as will secure a well-shaped and useful limb, though probably not one absolutely free from deformity. The different forms of bandage used by surgeons, and their modes of application, were considered in the chapter on Minor Surgery; the splints and special apparatus employed, will be described in discussing fractures of the several bones. Suffice it to say* here, that the surgeon should aim to use as simple apparatus as possible ; plain and light splints of wood, pasteboard, wires,1 or thin metal, such as can be made by any carpenter or blacksmith, are, I think, in every way preferable to the elaborate and complicated appliances which have been, from time to time, recommended for the treatment of fractures. Straight and angular splints, made of smooth half-inch boards, for the upper extremity, straight splints and plain fracture-boxes with soft pillow's for the lower extremity, a roll of cotton-w*adding or of tow for padding splints, or bags filled with bran or sand for the same purpose, a few pieces of binder's board, a half dozen or a dozen roller bandages, a few yards of adhesive plaster, and two or three bricks for use in making " weight extension," constitute an armamentarium sufficient for the treatment of almost all cases of fracture. The general principles to be observed in the use of splints and other apparatus may be stated as follows :— (1)' They are to be used as means of retention only, not of reduction or 1 Surgeon-Major Porter, of the Medical School at Netley, suggests that, in military practice, splints might be readily made from abandoned telegraph wire. Mr. Pyle recommends splints made from corrugated paper. TREATMENT OF SIMPLE FRACTURES. 230 extension ; these are effected by the surgeon's hands, and splints and band- ages 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 with which they come in contact, while at the same time the padding must not be so bulky as to render the splints clumsy or unmanageable. (3) Circular compression is to be carefully avoided, as swelling is inevitable after a fracture, and the risk of gangrene from this cause is by no means only theoretical. Hence, as a rule, in the early stages of frac- ture, no bandage should be applied beneath the splints. (4) In treating fractures of the shaft of a bone, the nearest joints above and below should, if practicable, be fixed by the splints used; if the fracture involve an articulation, the shafts of the bones which form the joints should themselves be so fixed. (5) When a fracture is properly "put up," unless the patient suffer so much pain as to render it probable that displacement has recurred, or that the splints are pressing unevenly, the dressing should not be disturbed more than absolutely necessary. It is a good rule to leave the fingers or toes exposed, so that the surgeon can by them judge of the condition of the cir- culation in the injured limb; and if they appear unduly congested or swollen, the dressings should be at once removed, and reapplied with addi- tional precautions against gangrene. If a case do well, every other day is quite often enough to renew the bandages during the first fortnight, the interval between the dressings being gradually lengthened after that time to half a week, and finally to a week. At the same time, while in. no class of cases is meddlesome surgery to be more reprobated than in this, fractures should be invariably looked upon as cases requiring careful and continual watching, and a patient with a broken bone should receive from his sur- geon at least daily visits, until after the subsidence of all inflammatory symptoms. 3. The third indication for treatment (see p. 237) brings up the consid- eration of the various accidents which may* arise during the management of a case of fracture. Muscular spasm and extravasation are such con- stant accompaniments of fracture, as to entitle them to be considered as symptoms, under which head they have been referred to. Spasm is best controlled by the free use of opium; moderate compression with a firm bandage is often recommended, but is a somewhat hazardous 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 w*hich its use would be justifiable. Extravasation, if moderate, may be disregarded ; if there be much contusion and vesication, the limb should be simply laid on a pil- low, protected by* oil-cloth, while evaporating lotions are applied until the subsidence of inflammation; if large vesicles or bullae form, they should be opened with the point of a lancet. The formation of vesicles in more than ordinary abundance, or the presence of oedema in connection with a frac- ture, renders it probable that union of the bone will be delayed. If extravasation proceed from the rupture of a large artery, the case will require special treatment, which will be considered under the head of complications. Embolism by particles of fat is an occasional complication of simple fracture, which has been already referred to at page 144. Gangrene is the most serious accident which can be met with in the treatment of a simple fracture, and may be due either to arterial obstruc- tion at a point above the seat of fracture, to venous obstruction, due to swelling 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 240 FRACTURES. bandage may seem sufficiently* loose when applied, and yet in a few hours may become the cause of great constriction from subsequent swelling of the limb; hence the importance of not applying a bandage beneath the splints; it is, as remarked by Mr. Erichsen, almost invariably to a neglect of this rule that the occurrence of gangrene from the pressure of a bandage is due. Especially is this true in the case of the forearm, in fracture of w'hich part this accident most often occurs. It should not be forgotten, however, that this accident may be partly or entirely due to arterial ob- struction, which is, of course, an unavoidable occurrence; hence we should not be too hasty in accusing a fellow-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 Fiu. 126.—Gaugrene from tight bandagiug. (Bei.i.) 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 bandage, when possibly the patient may escape with superficial sloughing. If complete gangrene have occurred, amputation, of course, becomes necessary; if the disease shows a disposition to self-limitation, the surgeon may await the formation of the lines of de- marcation and separation ; but if the gangrene be of the rapidly spreading traumatic variety (p. 155), immediate removal of the limb must be practised at a point above the farthest 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 which many years since I amputated at the shoulder-joint, for spreading gangrene following a badly treated fracture of the forearm. The other accidents which occur during the treatment of fractures, can- not 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 pul- monary 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 carefully held by an assistant, keeping up firm extension so as to prevent spasm of the muscles, which would cause pain by driving the sharp ends of the fragments into the soft tissues, and to avoid any recurrence of dis- placement while the splints are off; it is well at each dressing to gently rub the affected limb with soap liniment or dilute alcohol (carefully drying TREATMENT OF COMPLICATED FRACTURES. 24.1 the part afterwards), so as to keep the skin in a healthy state. The pa- tient'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 con- viction is very clear that it should not, as a rule, 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 com- plicated by various conditions which will require special modifications of the general course of treatment above described. Thus the extravasation, although proceeding from vessels of moderate size, may produce so much swelling as to give rise to great congestion or even strangulation of the tissues, and consequent gangrene, demanding amputation ; or the contusion and subsequent inflammation may be so great as to cause suppuration and sloughing, resulting in the conversion of the case from one of simple, into one of compound fracture. Rupture of the Main Artery of a limb is a very serious complication of fracture. This accident is principally met with in connection with 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 pul- sating tumor—a diffuse traumatic aneurism in fact—forms in the ham ; and, unless promptly treated, will inevitably cause gangrene. If the pos- terior 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 compression or ligation of the superficial femoral, in Scarpa's space. The reason for not treating the case as one of ordinary wounded artery is, that by so doing, even if the opening in the vessel could be found, which would be doubtful, the injury would be converted into a compound fracture of the worst kind, w*hich would almost inevitably require ampu- tation ; while there would be a chance, though not a very brilliant one, that by* the use of the proximal ligature the arterial wound might heal, and allow the preservation of the limb. If, however, the temperature of the leg and foot continue to sink, and no pulsation can be detected in the anterior tibial, gangrene appearing imminent, it becomes almost certain that the popliteal artery is ruptured ; and, under such circumstances, ampu- tation should be at once performed. So, also, if after an attempt to save the limb gangrene should occur, amputation would be necessary7. In any case of doubt, I think that the safety* of the patient would be consulted rather by removing the limb, while he was yet in good general condi- tion, 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. In the upper lfi 242 FRACTURES. extremity, these cases are more hopeful; thus Fenwick has recorded a case in which the axillary artery was successfully ligated in a case of fracture of the surgical neck of the humerus complicated by rupture of that vessel. 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 Xerve, as the mus- culo-spiral or median, is a very troublesome and annoying complication of fracture, causing loss of power or permanent impairment of the 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 occurred, not discovering the existence of paralysis until the splints were finally removed, when the limb dropped helplessly by the patient's side. The treatment of such a case is not very satisfactory ; it should be conducted on the principles laid dow*n in the last chapter, in discussing injuries of the nerves in general. A very Severe Flesh Wound, even if not communicating with the seat of fracture and thus rendering it compound, may seriously complicate the progress of the case, and may occasionally necessitate amputation. Unless, however, the injury to the soft tissues were, in such a case, in itself suffi- cient to condemn the limb, a fair trial should always be given to conserva- tive treatment before resorting to amputation. The Implication of a Joint in the line of fracture, will very often give rise to a certain amount of stiffness, if not to absolute anchylosis, after recovery*; or, in a strumous constitution, may cause disorganization of the articulation, and thus eventually render amputation imperative. In every case of fracture involving a joint, the treatment should be conducted with great caution, and the prognosis should be extremely guarded. Dislocation of an Adjoining Articulation is not an unfrequent compli- cation of fracture. In such a contingency the fracture should be tempora- rily put up with wooden splints and firm bandages, so that the limb may be used as a lever in effecting reduction of the dislocation, the patient being, of course, etherized. The fracture is then to be treated in the ordinary manner. If the dislocation be not recognized until a later period of the case, the surgeon must wait until firm union of the fracture has occurred, and then, applying splints, make an effort to reduce the dislocation, a feat which, under these circumstances, may be very difficult to accomplish. A fracture in a limb which is the seat of an old Unreduced Disloca- tion, or of a Previously Anchylosed Joint, presents no peculiar difficulties of treatment, though it may require a modification in the form of the splints used, to adapt them to the existing deformity of the parts. Fracture of the bone in a Stump, or into* the site of a Previously Ex- cised Joint, is occasionally met with, but requires no special treatment be- yond the necessary modification of apparatus. Chorea, affecting a limb which is the seat of fracture, is a very serious complication : in a case of simple fracture of the humerus complicated with chorea, reported by Dr. Wm. Hunt, of this city, it was found 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 without 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, which might readily induce sloughing. TREATMENT OF COMPOUND FRACTURES. 243 Treatment of Compound Fractures.—The first question to be determined with regard to any case of compound fracture, is w*hether 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 amputation have not been done before the setting in of the inter- mediate or inflammatory stage, it must be, if possible, further postponed until suppuration is freely established. Amputation for Compound Fracture.—No universal rules can be laid down as to what cases of compound fracture should be submitted to pri- mary amputation, 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 circumstances w*hich usually call for amputation in these cases are the following :— 1. Extensive and severe laceration of the muscular and other soft tis- sues.—A compound fracture in which the wound is made by the fracturing force, is a more serious injury than one in w'hich the wound is made by the fragments perforating the skin, for the reason that in the latter case the soft tissues are comparatively little injured, while in the former they are apt to be greatly torn and bruised, or perhaps completely pulpefied. Hence compound fractures from railway and machinery* accidents, especially in the lower extremity, are almost invariably* cases for amputation; in the upper extremity it is often possible to save the limb, even in these unfavorable circumstances, and if the age and general 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 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, wiien, if other circumstances are favorable, an attempt may be made to save the limb. If, however, the wounded vessel cannot easily be secured, and if the part injured be the lower extremity*, immediate am- putation should be unhesitatingly resorted to. In the upper extremity such extreme measures may* not be required, and if the bleeding vessel can neither be controlled by pressure, etc., nor secured in the wound, a ligature may be applied to the brachial artery, which has been several times suc- cessfully tied under such circumstances. 3. Great comminution of the bones themselves may be a cause for ampu- tation in cases of compound fracture. In the upper extremity much may be done in the wray 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* andsecondary sequestra will leave a gap in the continuity of the bone, the resulting limb, even if it could be preserved, would scarcely have sufficient firmness to be useful, and hence in such cases primary amputation is to be recommended. An exception should, perhaps, be made in cases of compound fracture in the upper third of the thigh, in which position primary amputation is so fatal an operation that the surgeon is loath to resort to it under any* circumstances ; but, indeed, these injuries are very apt to terminate in death under any mode of treatment. 4. Compound fractures into large joints often require amputation. In the case of the shoulder or elbow, provided 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 gun- 244 FRACTURES. shot wound, or from some crushing injury which necessarily proves fatal from visceral complication ; when the accident does occur, however, pri- mary excision is, I think, the correct mode of treatment, and it has been successfully employed, under these circumstances, by P. A. Harris, of New Jersey. Compound fractures of the wrist, ankle, and knee-joints are usu- ally cases for amputation. Especially should this rule be considered im- perative as regards the knee-joint; much as I admire the operation of excision, and strenuously as I would advocate the practice of conservative surs-erv, I cannot but believe that in the immense majority of instances theliest interests of the patient will be promoted by primary amputation in cases of compound fracture of the knee-joint. 5. A compound fracture, which would of itself require amputation, may be complicated by the existence of a simple fracture in the same limb, but at a higher point. In such a case, should the amputation be done at the seat of the upper fracture, or below ? In my own experience, such cases, when an attempt has been made to save the limb, have 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 the highest lesion. Still, if it were certain that the soft parts between the two fractures were healthy, and quite free from in- jury, it might be right to remove only the part that was irretrievably hurt, and to make an attempt to save the rest of the limb; as it happens, how- ever, these cais, and Gay has observed the same phenomenon as a result of compression of the subclavian artery. SPECIAL FRACTURES. 251 fragments subcutaneously with 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 with the instrument at such a point as to enable it to be carried through the ends of the fragments, to wound their surfaces, and to transfix whatever tissue may be placed between them. After having transfixed them in one direction, it is withdrawn from the bone, but not from the skin, its direction changed, and another perforation made, and this operation is repeated as Fig. 129.—Gaillard's instrument for ununited fracture. often as may be desired." The late Prof. Gaillard's method consists in pinning together the fragments by means of a gimlet-like instrument, pro- vided with a movable silver sheath, a handle, and a brass nut (Fig. 129) : 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 apposition than merely wiring together the fragments, as practised by Rodgers, Flaubert, X. R. Smith, and others. The operation employed by Prof. Bigelow, of Boston, is almost identical with that inde- pendently suggested by Oilier, of Lyons, and is probably the surest method of treating ununited fracture; it consists in making a subperiosteal resec- tion of the ends of the fragments, the freshened extremities being then held together by a wire suture. Dr. Bigelow has thus treated eleven cases, with but one failure, and that from disease of the bone, which subsequently required amputation. 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 conducted 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 fracture 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; 252 SPECIAL FRACTURES. 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 writings of Hamilton, Malgaigne, Cooper, Smith (of Dublin), Lonsdale, Stimson, Packard, etc., and to the chapter on Fractures in Dr. Wales's Mechanical Therapeutics, which contains a very good account of the different forms of apparatus devised for the treatment of broken bones. Fractures of the skull, and of the vertebras, are principally interesting on account of their involving respectively the brain and spinal cord; hence their consideration will be postponed till we come to speak of injuries of those parts of the body. Fractures of the Face. Any of the facial bones mav be broken by direct violence, and especially by gunshot wound ; the nature of the injury is usually recognized with facility, and the treatment should be particularly directed to the lesion of the soft tissues. Nasal Bones___These are not unfrequently broken, and the injury may escape detection from the rapid swelling of the soft parts. The treatment consists in removing the displacement (if there be any), by inserting a broad director or a pair of polypus forceps into the nostrils, and moulding the bones into their proper places ; the parts may then be supported by means of a compress on either side, and a few strips of adhesive plaster, 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 way, the shape of the nose being pre- served by plugging the nostrils, if necessary. Occasionally the whole nose is split off, as it were, from the face, hanging by the alae in front of the mouth. In such a case, in which the injury was produced by a blow from an iron pan, I kept the nose in place by numerous sutures, the patient making a good recovery. Sometimes the whole nose is driven inwards, fracturin,'- the ethmoid bone, and involving the brain. Under such circum- stances, the nose should be gently drawn forwards with forceps, and the case treated as one of fracture at the base of the skull. Profuse hemor- rhage may require plugging of the nares. W. Adams and R. F. Weir have devised special apparatus for forcibly straightening the nose when deformity has ensued, and for subsequently keeping the parts in position. An inge- nious nasal splint has also been devised by Gamgee, of Birmingham. Blandin and Steele employed cutting instruments to perforate the septum and thus facilitate its replacement. Ingalls excises a wedge-shaped piece of the cartilage, and Bos worth removes the projecting part with a fine saw. Mv own practice has been to effect the same object by using a small gouge. Roberts, when the deflection is cartilaginous and not bony, simply pushes the septum into place and secures it by transfixion with a pin. Fracture of the Lachrymal Bone may cause obstruction of the nasal duct, and consequent epiphora; or emphysema of the subcutaneous tissue mav 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 masti- cation, by the impaction of splinters in the temporal muscle ; in such a case, the surgeon should cut down and remove the offending fragments. Upper Maxilla.—Fractures of the upper jaw* are sometimes attended with such profuse hemorrhage as to require plugging the antrum, or even LOWER MAXILLA. 253 ligation of the external carotid. If the malar bone be thrust in upon the antrum, it should be drawn out with atirefond, or screw* elevator (Fig. 94), 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 wire. The vascular supply is so free in this part, that necrosis rarely follows, even in cases of gunshot injury; the fetid discharge is, however, a source not only of annoyance, but of constitutional depression, and hence free use should be made in such cases of detergent and disinfectant washes. Some- times all the bones of the face are crushed and separated from their attach- ments by* explosions, violent blows, or falls. Such cases are attended with great shock, and usually prove fatal from hemorrhage or cerebral compli- cation. Lower Maxilla.—The lower jaw is more frequently broken than any other bone in the face. The fracture, which is usually caused by direct violence, may be in any part of the bone, the most usual seats being, how- ever, near the s\*mphysis, and about the position of the mental foramen. The lower jaw is often broken in two or more places at once, and its frac- tures are frequently rendered compound by laceration of the mucous mem- brane. Fractures near the symphy*sis are more or less transverse, while those further back are almost invariably oblique from before backwards, allowing considerable displacement, which is evidenced by shortening of the alveolar border, and depression of the chin. In fractures near the angle of the bone, the dental nerve is occasionally involved, an accident which causes temporary paralysis, or more rarely convulsions. The displacement, mo- bility, and crepitus, which accompany fracture of the jaw*, render its diag- nosis usually easy : in cases of fracture below the condyle, there are, besides, embarrassment in the motions of the jaw, and pain, felt especially on open- ing or shutting the mouth. Fractures of the lower jaw commonly unite without much difficulty*, and with little deformity. Treatment.—For the treatment of an ordinary case of broken jaw, nothing is required except a compress to support the chin, and a roller bandage. Yelpeau, 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- ficent rest was insured to the fragments by the inevitable occurrence of pain upon any attempt at motion made by the patient. I am in the habit of treating these fractures in the manner recommended by Dr. J. Rhea Barton, of this city, with the superaddition of a few oc- cipito-frontal turns of the roller, as in Gibson's bandage. The following description of Barton's bandage is taken from Sargent's Minor Sur- gery:—" Composition: A roller five yards long, and two inches wide; suitable compresses. Ap- plication: Place the initial extremity of the roller upon the occiput, just below its protube- rance, and conduct the cylinder obliquely over the centre of the left parietal bone, to the top of the head ; thence descend across the right temple and zygomatic arch, and pass beneath the chin," which should be supported by* a compress, " to the side of the face; mount over the left zygoma and temple to the summit of the cranium, and rejoin the starting-point at the occiput, by tra- versing obliquely the right parietal bone: next, wind around the base of the lower jaw on the left side to the chin, and thence return to the occiput along the right side of the maxilla;" to these three turns, I add a fourth, Fio. 130.—Barton's bandage fractured jaw. 254 SPECIAL FRACTURES. around the head just above the ears, making an occipito-frontal turn, which being pinned at its intersection with the others, serves to prevent slipping. The same course is to be continued until the roller is exhausted, and addi- tional security may be furnished hv sealing the bandage (as it were) with a few strips of adhesive plaster. Gibson's bandage consists of a compress beneath the chin, with turns of a roller passing from that part to the top of the head, from the occiput to the forehead, and from the nape of the neck to above the mental protuberance, the whole being held in place by a short strip passing from the forehead, backwards to the nape along the median line of the head. Many surgeons prefer to treat fractures of the jaw with an external splint, moulded from pasteboard or gutta-percha, and held in place by a simple sling of four tails, two of which are tied on the top of the head and two behind the neck (Fig. 16), or with an ingenious apparatus composed of a leathern sling, with strong linen webbing straps, devised for the treatment of these cases by Prof. Hamilton; wiring together the teeth on either side of the fracture is often recommended, but I confess to have seen very little advantage from the practice : a better plan is the application of clasps of ivory, silver, steel, or other material, as practised by Lonsdale, M utter, N. R. Smith, Nicole, Wales, Bullock, and others, or of interdental splints of gutta-percha or vulcanized India-rubber, as ingeniously applied by Dr. Cunning, of New York, and Dr. Beans, of Atlanta, Ga. In a case of frac- ture of both rami of the jaw, Annandale 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 employed by Buck and Hamilton, of ]Vew York, and by Kinloch, of Charleston, and I have myself adopted it with good results, when 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 necro- sis and to consequent non-union, which accident is, in this position, I be- lieve, more apt to result from tight bandaging than from the bandage being too loose. Gunshot fracture of the lower jaw is sometimes attended with so much splintering as to require partial resection of the bone. The period required for the cure of a simple fracture of the jaw is usually from three to six weeks. Fracture of the Hyoid Bone is a very rare accident. Hamilton has collected ten cases, of which three were caused by hanging, three by grasping the throat between the thumb and fingers, three by direct blows or falls, and one by muscular action. Dr. La Roe reports a case in which the injury was caused by gaping. The accident is attended with great pain, sometimes with hemorrhage, and with difficulty in opening the mouth, in swallowing, and in speaking. The diagnosis can be made by observing the mobility of the fragments, and the inward angular displace- ment, with or without crepitus. The treatment consists in reducing the deformity, by pressure from within the mouth, and in keeping the parts at rest by use of a pasteboard or leather collar, with the enforcement of quiet, and the hypodermic administration of opium. Of thirteen cases collected by Dr. Gibb, two proved fatal. FRACTURES OF THE RIBS. 255 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 w*ay like an over-bent bow, at the weakest part.1 The ribs are occasionally broken by muscular action (as in parturition), or, according to Malgaigne, even by* the impulse of the heart. The middle ribs, from the fourth to the tenth, are those most ex- posed to fracture, and the usual seats of injury are near the junction of the costal cartilages, and in the neighborhood of the angles. The direction of the fracture is commonly transverse or slightly oblique; occasionally a rib is comminuted, or broken in more than one place. These fractures are rarely compound, except as the result of gunshot wounds. The displacement in cases of fractured rib is usually slight; if the result of a direct blow, there will probably be some inward angular deformity, while if from indirect violence, the projection will be outwards; if a number of ribs on the same side be broken, there may be a slight tendency to overlapping. The diag- nostic signs are deformity*, mobility, and crepitus, which is sometimes readily perceived, but at other times can only be elicited by careful and prolonged manipulation, by compressing the chest from before backwards, or by auscultation. There are, besides, pain and localized tenderness, with a sharp stitch, if the pleura be wounded, and, possibly, haemoptysis, pneu- mothorax, or emphysema, if the lung be involved. The pain is much in- creased by movements of the chest wall, and the breathing is therefore shallow, and to a great extent diaphragmatic. The prognosis is favorable; except in cases complicated with thoracic or other severe injury, it is very rare for death to follow fracture of the ribs. Union commonly takes place in from three to five weeks, with very little deformity, and by means of a well-marked ensheathing callus. False-joint is occasionally met with in this situation, while, on the other hand, the production of new bone is some- times excessive, causing coalescence between adjacent ribs. Treatment.—In the treatment of fractured ribs, the surgeon may* dis- regard any existing deformity, which 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 screw elevators. The chief indication in any case of frac- tured rib, is to put the affected part in a state of complete rest, and this may best be done by surrounding the side of the chest w*hich is involved with numerous overlapping broad strips of adhesive plaster, each reaching a little beyond the median line, both behind and before. This mode of treatment, which appears to have originated with Dr. Hannay, of England, is, according to my experience, much superior to any other which has been proposed. The strips, which should be about two inches wide, are laid on in circular layers, beginning from below, each strip overlapping its predecessor by about one-third of its width. As the dressing becomes loosened, it may be renewed, or other layers of strips may be tightly applied immediately over the first, so that the chest is kept constantly fixed by a stiff and firm splint of adhesive plaster. The patient will usually be most at ease in a sitting posture for the first day or two. Thoracic com- plications must be met by appropriate treatment, and in any case opium 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. 25u' SPECIAL FRACTURES. may be freely administered. The dressing may be removed at the end of three weeks, when union is commonly sufficiently firm to enable the sur- geon to discontinue his attendance. If, in any case of injury of the chest, it is uncertain whether a rib be broken or not, the dressing above described should be applied, as it will afford great comfort, even in cases of contusion without fracture. The emphysema which sometimes accompanies fracture of the ribs requires no special treatment, usually disappearing spontaneously in the course of a few days or weeks. Rupture or laceration of an intercostal artery, which proved fatal in a case recorded by* Amesbury, could scarcely be recognized unless the fracture were compound. Under such circum- stances 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 spicula should be carefully removed, and the after-treatment conducted with reference to the condition of the thoracic viscera, on the principles which will be laid down in the chapter on Inju- ries of the Chest. The Costal Cartilages are occasionally broken, either at their junction with the ribs or through their middle. The causes are the same as in the case of fractured ribs ; but, as the violence required is greater, there is more apt to be serious visceral complication. The symptoms are the same as those of fractured ribs, except that crepitus is rarely perceptible. The direction of the fracture is commonly transverse, the anterior fragment usually* projecting in front of the posterior. Union takes place by the pro- duction 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 treatment 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 with, and is a less 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 observed, commonly a diastasis, or, according to Maisonneuve, Brinton, and Rivington (who have repeatedly observed a true joint in this position), a dislocation. It is a matter of some importance, as regards the prognosis, to be able to say in any individual case whether the lesion be a true fracture or a diastasis, for in the latter case, the posterior ligament being intact, the patient usually escapes visceral complication. In true fracture, the lung or even the heart may be torn, and, even if these dangers be avoided, there is considerable risk of the subsequent formation of abscesses in the mediastinal space. The following may be looked upon as evidences of true fracture, viz., the presence of crepitus, the injury being below 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 pro- duce true fracture, while when exerted upon the gladiolus it almost never produces dia.-ta^is. In cases of injury from indirect violence, if the marks ' See interesting papers by Dr. E. H. Bennett, in the Dublin Journal of Medical Science for March, 187G, and October, 1877. FRACTURES OF THE PELVIS. 257 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 various surgeons, including Hamilton, Martin, Billard, Mauriceau, Gallez, Annandale, Polaillon, and Rinonapoli. In making the diagnosis of fractured sternum, the possibility of a con- genital deformity being mistaken for the result of violence, must not be overlooked. The detection of crepitus and mobility* may be facilitated, as suggested 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 counter-stroke may, according to Hewett, be aided by noting the occurrence of ecchymosis some days after the reception of the injury. The prognosis 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 displace- ment, attempts at reduction may be made, by straightening the spine and drawing the shoulders backwards. Opium will usually be required, and any thoracic complications must be met by suitable remedies. Mediastinal abscesses should be opened at the side of the sternum, when pointing occurs ; they have been evacuated by Gibson and others by the use of the trephine, but the results of the operation do not warrant its repetition. Annandale reports a case in which persistent vomiting appeared to be caused by pressure on the stomach from displacement of the ensiform car- tilage, and was relieved by reposition of the bone after abdominal section. Pelvis.—Fractures of the pelvis are chiefly interesting on account of the liability to implication of the adjacent viscera. One of the Ossa Inno- minata 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 sacroiliac 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 sacroiliac symphyses. Fractures of the pubis and ischium assume a somewhat oblique direction, while those about the sacroiliac junction correspond pretty generally to the line of the symphysis. The diagnosis of fractured pelvis can usually be made without much difficulty. There is great pain, aggravated by motion, and especially* by* an 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 be readily detected. These inju- ries are commonly caused by great violence of a crushing nature, such as the fall of a bank of earth. In one case, which was under my care, the crest of the ilium w*as knocked off by a sharp blow resulting from the fall of a stove-pipe. The pubis has sometimes been fractured as the result of muscular contraction, as in a remarkable case recorded by M. Letenneur, while diastasis of the pubic, and occasionally* of the sacroiliac, symphysis may occur in the process of parturition. Fracture 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, while 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 17 258 SPECIAL FRACTURES. of the acetabulum may consist merely in a separation of its posterior lip, or in a destruction of its floor, attended sometimes with impaction of the head of the femur in the pelvic cavity. The latter form of injury is com- monly attended with such severe visceral lesions as to prove fatal. Sepa- ration of the lip of the acetabulum is marked by the signs of dislocation, the displacement being readily reduced with crepitus, but as readily repro- duced when extension is discontinued. The great danger in cases of fracture of the pelvis is from rupture or laceration of the bladder or urethra. Hence the surgeon's first step should be to pass a catheter, with a view of ascertaining the condition of those organs; if they are found to have been injured, prompt treatment must be employed, according to the principles which will be laid down in speaking of Injuries of the Pelvic Yiscera. The treatment of fractured pelvis consists in the first place in restoring the displaced fragments to their proper position, if this can be done with- out violence; in the case of a woman, reduction may be assisted by intro- ducing one or more fingers into the vagina. The pelvis should be sur- rounded by broad adhesive strips, a padded belt, or a firm and broad roller, so as to keep the parts at perfect rest, while the hip-joint of the affected side is fixed by means of a pasteboard splint or a sand-bag, as in cases of fractured thigh. The patient should lie on his back, on a hard mattress, with the knees slightly* Hexed, and supported by pillow's. Compound fractures of the pelvis are usually fatal accidents, though I have seen re- covery 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 transverse, and the lower fragment pressed inwards upon the rectum. Richerand gives one ea^e of longitu- dinal fracture of the sacrum. These injuries are rarely met with except in connection with other severe pelvic lesions, and are then apt to prove fatal; the treatment would consist in endeavoring to effect reduction by pressure from w ithin the rectum, and in the application of a padded belt. Bernard, a French surgeon, plugged the rectum with a lithotomy tube, in order to maintain reduction, but I should prefer, with Hamilton, to dis- pense with such an instrument, and to rely upon keeping the parts at rest and administering opium. Fracture of the coccyx sometimes results in the development of a very painful neuralgic 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 which has been successfully resorted to by numerous surgeons, including Dr. Burn- ham, 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 osseou- connection between the trunk and the upper extremity. It may be broken by direct violence in any part of its length, but is much oftener fractured by indirect violence (such as a fall or blow on the shoulder), and then usually gives way near the outer end of its middle third, where the bone is weakest. Partial fracture from indirect violence is usually situated towards the inner end of the middle third, and is characterized by slight FRACTURES OF THE UPPER EXTREMITY. 259 angular projection. Partial fracture from direct violence 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 the inner third of the bone ; the immediate mechanism of the accident in some cases may be, as suggested bv Dr. Fio. 131.—Attachments of outer end of clavicle ; showing branches of coraco-clavicular ligament. (Gray.) Packard, the bending of the clavicle over the first rib, which acts as a ful- crum. 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 backwards, and from without inwards. Fracture of the sternal end of the clavicle, within the fibres of the costo-clavicular ligament, is usually attended with but little displacement, though, 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-clavicular ligament, but if the fracture be outside of the trapezoid branch of that ligament, the displacement, according to the same surgeon, is quite marked. According to A. Gordon, however, even the existence of the last-named variety of fracture is doubtful. Frac- tures of the middle of the clavicle, especially such as are produced by indi- rect violence, are accompanied with great and very constant displacement. This consists in a tilting upwards of the inner fragment, and a dropping 260 SPECIAL FRACTURES. of the outer fragment, which is also rocked imvards and somewhat back- wards by the action of the powerful muscles attached to the scapula, par- ticularly" the rhomboidei, trapezius, levator anguli scapula-, pectoralis minor, and some fibres of the serratus magnus. The diagnosis of fractured clavicle can usually be made without difficulty; if the middle of the bone be involved, the displacement is in itself sufficiently characteristic, while crepitus can readily be elicited in any position of the fracture, on account of the sub- cutaneous character of the bone in its whole length. In cases of partial or partially impacted fracture from direct violence, an accident of not unfrequent occurrence among quite young children, persistent tender- ness over the point of injury will be found a valuable diagnostic sign. The attitude of the patient, in cases of complete fracture, is peculiar, and often significant of the nature of the injury ; the head is bent towards the affected side, so as to relax the mus- cles, while the elbow* and forearm are supported in the opposite hand, so as to diminish the dragging sen- sation produced by the weight 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 Fiu. 132.-Complete oblique fracture of clavicle is, without deformity---is Very rarely- near its middle. (Gray.) obtained, at least in oblique frac- tures of the middle of the bone. Comminuted fracture of the clavicle is sometimes a serious injury, from concomitant laceration of the subclavian vein or plexus of nerves. Com- pound fracture of this bone is rare, except as the result of gunshot injury, when it is apt to prove fatal from thoracic complications ; I had, however, under my care, some years ago, a case of multiple fracture of the clavicle from direct violence, which became secondarily compound by the occur- rence of suppuration ; slight necrosis followed, but the patient eventually • made a good recovery. Fracture of both, clavicles is an accident of rare oc- currence, but presents nopeculiarities, except that of course it requires sonic 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 fornn of apparatus. The deformity, as we have seen, depends (1) on the tiltinjr up of the inner fragment, by the resiliency of its ligamentous attachments and the action of the sterno-cleido-mastoid muscle; (2) on the falling of the shoulder with the outer fragment, due to the weight of the arm; but (3) chiefly on the rocking inwards and backwards of the outer fragment, by the action of the powerful muscles attached to the scapula. Hence the indications for treatment are, (1) to relax the sterno-cleido-mastoid muscle. (2) to prevent the weight of the arm from dragging down the outer frag- ment, and (3) by fixing the scapula, to carry the attached external frag- ment outwards and forwards, and thus restore the shape of what has been FRACTURE OF THE CLAVICLE. 261 not inaptly called the "shoulder-girdle." These indications may all be met by position alone. For this purpose the patient should lie flat on his back, on a firm hard mattress, with the head slightly elevated, and the arm flexed and carried across the chest, so that the hand rests on the sound shoulder—the position commonly known as the " Yelpeau position," from its having been employed by that distinguished surgeon in the treatment of these and other injuries (see Fig. 134). The elevation of the head (by- means of a single pillow, which must not touch the shoulders) relaxes the sterno-cleido-mastoid muscle, and thus obviates the tendency to upward tilting of the inner fragment; the position of the arm across the chest makes the weight of the limb act, if at all, in an upward direction, and thus effectually prevents any downw*ard displacement; while the weight of the chest, together with the firm and even counter-pressure of the mat- tress, serves to fix the scapula, and thus prevents that rocking of the bone around the chest which causes the inward and backward displacement of the outer fragment. By this simple mode of treatment the deformity can, at least in the immense majority* of cases, be completely reduced, and"could the patient be trusted to remain quiet for a sufficient length of time (three or 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, while the arm is fastened in the " Yelpeau 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 in the form of the " third roller of Desault,"1 with additional circular turns to fix the arm in the required position. The same indications may be met by using Fox's apparatus (to be pre- sently described) or any of its modifications, taking care to apply the pad, not as^ an axillary fulcrum, but simply as a scapular compress. The posterior figure-of-8 bandage, recommended by some authors, is defective in that its force is exerted on the acromial part of the scapula only, and not on the entire bone; the same objection applies to most of the back splints devised for these cases, though a back splint, such as that devised by Dr. Staples, of Minnesota, broad enough to fix both scapula?, might be made a useful adjuvant to the compresses already described. Yacher, of Birkenhead, has modified the figure-of-8 bandage by applying metallic caps to both shoulders, and drawing them backwards by means'of a posterior strap and buckle, while O'Connor, of Limerick, relies upon a splint of plaster-of-Paris, moulded to fit both shoulders, and an ordinary bandage. The apparatus introduced by Dr. George Fox, of thiscitv, is thus described by Sargent: " The apparatus consists of a firmly stuffed pad of a wedge shape, and about half as long as the humerus, having a band attached to each extremity of its upper or thickest margin ; a sling to suspend the elbow and forearm, made of strong muslin, with a cord attached to the 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 forming two triangles, one in front and the other behind the chest; the firmness of tlie bandage may be much increased by making additional circular turns as recom- mended m the text. 262 SPECIAL FRACTURES. humeral extremity, and another to each end of the carpal portion ; and a ring made of muslin stuffed with cotton to encircle the sound shoulder, and serve as means of acting upon and securing the sling.'' Fox's appa- ratus has undoubtedly produced a great many excellent cures; it has (lone so, however, I believe, by fixing the scapula more or less perfectly, and not by affording leverage to the humerus, as it was originally intended to do. Indeed, the wedge-shaped pad, if used as a fulcrum, pro- duces so much pain that few patients can en- dure 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 bv Dr. Levis, Prof. Hamilton, and others, and any of these forms of the sling and pad dress- ing may be used with good results, provided that they are accurately adjusted and carefully watched by the surgeon.1 Moore, of Roches- ter, and Sayre, of New York, believe that the point of most importance is to render tense the clavicular fibres of the pectoralis major muscle, and thus draw* the inner fragment downwards ; the former surgeon accomplishes this purpose by forcing the entire arm back- wards, and fixing it with a shawl 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; while Prof. Sayre employs two broad adhesive strips, one of which fixes the arm and acts as a fulcrum, while the other forces the shoulder backwards by drawing the elbow forwards, at the same time supporting the forearm, as shown in Fig. 133. 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 within three weeks, but the dressing should be retained, as a matter of safety*, at least a couple of weeks longer. In a case in which fracture of the clavicle had united with great deformity, Folker excised the ends of the fragments, after separating them with an elevator, and then applied a wire suture. Scapula.—The scapula may be broken through its body, through itsneck, 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 produced by muscular action. If the spine of the scapula be involved, the line of fracture can commonly be detected with facility by palpation, and in other cases crepitus can generally be elicited by pressing firmly on the scapula with one hand, while the other moves the shoulder in various directions. The treatment consists in attempting to reduce the 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 elbow being supported in a suitable sling. If the lower angle have been Fio. 13:1.—^ayre's dressing for frac tured clavicle. (Hamilton.) 1 See a full and able discussion of the principles of treatment of fractured clavicle, and of the comparative merits of different forms of apparatus, by the late Dr. Edward Hartshorne, in the 2d volume of the Pennsylvania Hospital Reports, pp. lng-142. FRACTURES OF THE SCAPULA. 263 separated from the rest of the bone, it may be secured, as advised by Boyer, by the additional application of a firm compress. Fracture of the Neck of the Scapula (in the anatomist's sense of the term) is an accident the possibility of which has never been established by dissection, and which, if it have ever occurred, except when complicated with 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, however, means fracture through the supra-scapular notch, and in this position the lesion has unquestionably been met with, though very* rarely. I have myself seen one example, in a child five years old. The amount of displacement depends on the degree of integrity of the various ligaments of the part, especially* the coraco-tiavicular and coraco-acromial. If these be ruptured, the glenoid cavity and head of the humerus fall into the axilla (where the latter may be sometimes felt), causing a depression beneath the acromion, as in dislocation of the shoulder, though not so deep ; crepitus is elicited by laying one hand on the shoulder, so as to touch the coracoid process, and with the other hand moving the arm in various directions. 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 when support is removed, and the coracoid process can be felt moving with the humerus, instead of with the acromion. The treatment consists in fixing the scapula by placing a thin pad or folded towel in the axilla, fastening the arm to the 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 comminu- tion of the glenoid cavity. Fracture of the Acromion is probably a rarer accident than epiphyseal separation of that process. When the line of fracture is through or behind the acromio-clavicular articu- lation, the shoulder drops forwards, inwards, and dow*nw*ards, as in cases of fractured clavicle; if, how- ever, the fracture be in front of the acromio-clavicular ar- ticulation, there will be little or no displacement, and the diagnosis must be made by the detection of mobility and crepitus. Union occurs with- out much deformity, though rarely, according to Cooper, except by fibrous tissue. The treatment consists in fixing the arm and scapula by an axillary pad and bandage, and in supporting the elbow with a sling. This, as well as fracture of the body or neck of the scapula, may be also efficiently* treated with the bandage known as Yel- peau's, the application of which can be seen from the accompanying illustration. Fracture of the Coracoid Km. 134 — Velpeau's bandage. 264 SPECIAL FRACTURES. P)-ocess, a rare injury of which R. W. Johnson has collected '21 cases, is usually the result of direct violence. There is seldom any displacement, and no treatments required beyond the use of a sling, with perhaps a U'W turns of a roller around the arm and shoulder. A ease of epiphyseal sepa- ration of the coracoid is recorded by Bennett. Two or more of the various forms of scapular fracture may coexist in the same case, or any one of them may be complicated by fracture or disloca- tion 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 with reference to its own 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 deformity, which, how- ever, fortunately seldom proves much of an impediment to the usefulness of the arm. The time required for treatment, in cases of fractured scapula, is usually* from three to four weeks. Fracture of the Humerus__Fractures of the humerus are divided by Hamilton into eleven classes, of which four are fractures of the upper extremity (head, neck, and tubercles), one of the shaft, and six of the lower extremity. 1. Fractures of the Upper Extremity of the Humerus__(1) The fracture may pass through the Head and Anatomical Xeck of the bone, being chiefly intra-eapsular, and may or may not be impacted, accord- ing to circumstances. If the fracture be entirely intra-eapsular, bony union cannot well occur, and the detached head of the humerus is apt to become carious or necrosed, requiring an operation for its removal. Frac- ture of the anatomical neck is attended with but little deformity, nor does it much interfere with the motions of the part. There may be slight short- ening, 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 with in old persons. (2) Fracture through the Tubercles of the humerus differs from the preceding variety merely in being completely extra-capsular. Bony union takes place in these cases, but the motion of the joint is apt to be impaired by the irregular masses of callus which are formed. Crepitus may be de- tected by grasping the tubercles with one hand, and rotating the arm with the other ; there is rarely much displacement, though, if the fracture be im- pacted, there may be slight shortening. The signs of this injury are very ob- scure, and in many cases the diagnosis cannot be positively* made during life. (3) Longitudinal Fracture of the Head and Neck, or Splitting of <>j the Greater Tubercle, produces a marked increase in the antero-posterior diameter of the upper end of the humerus, and, while there is some depres- sion under the acromion, a smooth, bony prominence can be felt under the coracoid process ; crepitus can be usually elicited by pressing together the tubercles and rotating the arm, while the mobility of the limb is unimpaired. Union takes place by bone, or by fibrous tissue, according to the amount of separation between the fragments. (4) Fracture of the Surgical Neck of the humerus, under which head may be included separation of the upper epiphysis, is the most frequent form of injury met with in this region. The surgical neck is that part of the humerus which extends from thelineof epiphyseal junction to the place of insertion 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. 135) is. an accident of early life, but true fracture, though FRACTURES OF UPPER EXTREMITY OF HUMERUS. 265 met with in children, is more frequent among adults. Crepitus can be readily elicited, unless either impaction or overlapping have occurred ; in the latter case the diagnosis can be easily made from the deformity, which is characteristic, and which consists in the upper end of the lower fragment Fiu. 13.*).—Separation of upper epiphysis of humerus. (From a patient in the Episcopal Hospital.) Fig. 136 —Fracture of the surgical neck of the humerus. (Gray.) being drawn upward, inwards, and forwards, while the upper fragment is rotated outwards. Reduction is often difficult and sometimes impossible in these cases, in spite of which, union commonly occurs without material impairment of the usefulness of the limb. Treatment of Fractures of the Upper Extremity of the Humerus.— Compound fractures of these parts, especially* if resulting from gunshot injury, usually require either excision or ampu- tation. The treatment of simple fractures of the upper end of the humerus may be con- ducted 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 ap- plied while the elbow* is in a flexed position. A thin pad, compress, or folded towel is then to be placed in the axilla, so as to fill up the hollow of that part and afford a firm basis of support to the humerus. This pad may be held in place by a bandage or by adhesive strips. The arm is then brought to the side, with the elbow a little forwards, so as to ob- viate the anterior angular projection, and sufficient extension made to reduce the frac- Fio. is7.-Dre.«n* for fracture of ture. The arm is to be securely fastened to the surgical neck of the humerus. the chest with circular turns of a roller, or (Ferhcsson.) 266 SPECIAL FRACTURES. adhesive strips, and the forearm secured across the chest, somewhat as in the "Yelpeau position," or merely supported by a sling, as may be found most convenient. After a few days, when swelling has subsided, a moulded pasteboard or gutta-percha cap may be applied to the shoulder and upper half of the humerus, and will give additional security and firmness to the dressing. This simple mode of treatment, which is very similar to that recommended by Fergusson (Fig. 137), 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. Erich- sen uses a pad, a leather shoulder-cap, and a sling, while Hamilton employs a simple outside splint of gutta-percha without any pad. Welch's shoulder-splint may be also used in the treatment of these injuries. 2. Fracture of the Shaft of the Humerus is an accident of fre- quent occurrence, and may result from either direct or indirect violence. The seat of the fracture is more often below than above the middle of the bone, and its line usually somewhat oblique, from above downwards and outw*ards. The displacement consists in the drawing upwrard and inward of the lower fragment, with some eversion of the upper fragment, and an anterior angular projection, due to the weight of the forearm. The diag- nosis is easy, the increased mobility and crepitus rendering the nature of the injury almost unmistakable. The treatment consists in the application of a bandage up to, but not above, the seat of fracture (until after the subsidence of swelling), and the use of a short internal splint, with an outside splint moulded from pasteboard or gutta-percha, the arm being fastened to the chest in the way already described. If the anterior angular deformity- give any trouble, a short anterior splint may be used with the moulded pasteboard splint, while the forearm is laid across the chest, and fixed by a broad bandage, or merely supported by a short sling around the wrist. Various plans of making permanent extension have been proposed, but are all of questionable utility, sufficient extension being afforded by the weight of the elbow, which for this purpose should be unsupported, or, at least, not ]»ressed upwards. When the internal splint is used, care must be taken that it does not make pressure on the axillary vein ; the length of the sling may be varied at different dressings so as to avoid stiffness of the elbow. 3. Fractures of the Lower Extremity of the Humerus.— (1) Of these, the first to be considered is the Fracture at the Base of the Condyles not implicating the joint, under which head may be properly included separation of the lower epi- physis of the humerus. This form of fracture usu- ally results from indirect violence exerted upon the extremity of the elbow, and its line is generally oblique, upwards and back- wards. This injury is fre- quently confused with dislo- cation of the elbow back- wards, but the diagnosis can be made by observing that in fracture there is increased mobility, crepitus, shortening of the humerus, but no change in the relative position of the olecranon and condyles, and that the deformity, while easily Fiq. 138.—Fracture at the base of the condyles. (Grat.) FRACTURES OF LOWER EXTREMITY OF HUMERUS. 267 reduced, instantly recurs on the removal of extension. In dislocation, on the other hand, there is immobility, no crepitus, no shortening, but an obvious projection of the olecranon behind the line of the condyles, and the displacement when reduced does not return. (2) Fracture at the Base of the Condyles, complicated by a Splitting Fracture between them, is a somewhat rare accident; it is marked by the same symptoms as the preceding variety, with the addition of increased breadth of the lower end of the humerus, and of crepitus between the 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 Outer Epicondyle, though I am not aware that the existence of this lesion has ever been demonstrated by dissection. The diagnosis of these varieties of fracture can usu- ally be made by the detection of mobility and crepitus, elicited by grasping the arm firmly with one hand, and moving either condyle successively in various directions, or by pressing and rubbing the condyies 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 conveniently and efficiently treated by means of a simple internal rectangular splint (Fig. 140), the forearm being in a semi-prone position with the thumb pointing upwards, or by means of an anterior angular splint (Fig. 141), the forearm being supine. The Fig. 139.—Fracture at the base of and between the condyles. (Erichsen.) Fio. 140.—ehysick's elbow splints. Fm, 141.—Hartshorne's elbow splint. latter is, I think, the better appliance in the early* stages of the injury. The splints should be well padded, and no bandage should be applied be- neath the splint, until after the subsidence of inflammatory swelling. In- deed, 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 especially mentioned 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 268 SPECIAL FRACTURES. of dressing above recommended ; whatever plan may be adopted, great care must be taken to avoid undue or uneven pressure, which might pro- duce excoriation or even gangrene. Great difficulty is sometimes experi- enced in maintaining reduction from the action of the powerful muscles at the back of the arm ; by careful bandaging, however, and the judicious use of compresses, this difficulty* can usually be overcome.1 As already men- tioned, if the elbow-joint be involved in the fracture, there will always be great risk of anchylosis ; hence, it may be proper to resort to passive motion at a comparatively early* period in these cases, as soon sometimes as the end of the third or fourth week ; or the patient may be directed to swing a flat-iron, as recommended in the last chapter. Compound fracture of the elbow-joint is a very serious injury, and usually requires excision or amputation. The time required for the treatment of a fractured humerus is commonly from five to eight weeks, according to the age of the patient, and other modifying circumstances. Fracture of the Olecranon is usually produced by direct violence, such as a fall on the point of the elbow. It may also be caused by indirect violence—a fall on the hand, etc. ; or even by muscular action, through the powerful contraction of the triceps extensor'muscle. In t he 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 detached process will be drawn a considerable distance up the arm, giving rise to marked displacement. In the majority of instances, however (at least according to my own experience), there is little or no separation, and the diagnosis must then be made by noting the existence of abnormal mobility and of crepitus. Crepitus can commonly be elicited simply by seiz- ing the olecranon and rubbing it laterally against the extremity of the shaft of the ulna, or, if there be any displacement, by grasping the forearm just below the elbow, so that the forefinger rests upon the point of the ole- cranon, which it draws down in contact with the shaft, when crepitus may be brought out by flexing and extending the forearm with the other hand. Union occasionally takes place by bony deposit, but is more often ligamen- tous merely. The utility of the arm may, however, be preserved even with considerable retraction of the upper fragment. The treatment consists in fix- ing the olecranon in apposition with the shaft (which may be conveniently efiected by means of a compress and adhesive strips), and keeping the joint at rest in an extended position for four or five weeks, or until union has occurred. Surgeons are divided as to the comparative advantages of cow- plete or of partial extension, many agreeing with Sir Astley Cooper and Prof. Hamilton, in recommending the former, while the majority of French surgeons. Air. Erichsen, and others, prefer the latter. I am niyself in the habit of using a simple obtuse-angled splint, well padded, and applied to the inside 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 elbow assist in fixing the olecranon. This position—one of slight flexion__is less irk- some to the patient, and is at least as effective in obviating deformity as that of complete extension, which sometimes causes an angular depression at the seat of fracture. In cases of compound fracture of the olecranon, 1 Dr. T. Blanch Smith reports a case in which, other 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 the extended position in the treatment of these injuries. FRACTURE OF THE NECK OF THE RADIUS. 269 or of any compound fracture about the elbow-joint, in which an attempt is made to preserve the limb, the arm should be flexed to an angle of from 100° to 120°, which will be found the most useful position should anchy- losis ensue. Wiring the fragments of the broken olecranon has been practised by MacCormac, Jessop, Caselli, and other surgeons. Fracture of the Coronoid Process of the Ulna has been sup- posed to be a frequent complication of backward dislocation of the elbow- joint. I have, however, 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), while only three of nine specimens described by authors appear to give satisfac- tory evidence as to the existence 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 diag- nosis would have to be established principally by exclusion. The treat- ment would consist in fixing the elbow on a rectangular splint, and in practising passive motion after three or four weeks. Fractures of the Forearm—Both bones of the forearm are fre- quently broken through their shafts, either by direct, or more frequently by indirect, violence, w*hile by direct violence either the radius or the ulna may be fractured separately. If only one bone be broken, the other acts as a splint, and prevents the occurrence of much displacement, in spite of the obliquity of the fracture ; but if both bones have given w*ay, there is marked shortening, which, with the mobility and crepitus, renders the nature of the case evident. The treatment consists in reducing the defor- mity by extension and manipulation, and in fixing the limb so that the line of the bones is maintained, 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 prona- tor radii teres, the upper fragment is supinated by the action of the supinator brevis and biceps muscles, and therefore, unless the lower frag- ment be also supinated by the surgeon, union with rotatory deformity will almost inevitably ensue. Two 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 elbow to beyond the fingers ; the dorsal from just below the olecranon to just above the styloid process of the ulna. They* should be well and evenly padded, the object being not to thrust the bones apart as by a wedge, but to fix them in the position which they have assumed under the surgeon's manipulations. No bandage should be used underneath the splints, and the dressing should be renewed at least every other day during the first fortnight. For the fracture of both bones, the splints should be retained for from five to seven weeks, but for fracture of the shaft of either bone alone, four weeks will usually suffice. A per- fect cure of a fracture of both bones of the forearm is perhaps rarely ob- tained ; but I believe that the surgeon will secure better results by this mode of treatment than by any other. Fracture of the Head "of the Radius is a rare form of injury which 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 rarelv met with except when complicated with other lesions. The diagnostic signs are slight an- terior displacement, with localized pain, mobility, and crepitus. The treat- 270 SPECIAL FRACTURES. ment consists in the use of a well-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 acci- dent of very frequent occurrence, its nature and pathology have been made the subject of special study by Colles, K. W. Smith, Erichsen, (Joy- rand, Voillemier, Xelaton, Barton, Gordon, Moore, and Pilcher, of New York. There are two varieties of this form of fracture which are known gen- erally in this country as Colles's and Barton's fractures. (Utiles's frac- ture, w*hich is by far the more 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's a very oblique fracture, extending from the articulation upwards and backwards, separat- ing and displacing the whole or a portion of the posterior margin of the articulating surface. It is a very rare accident, constituting probably not more than one or two per cent, of the whole number of fractures in this locality. The cause of these injuries is almost invariably a fall upon the palm of the hand, the position of over-extension causing the bone to give way, as pointed out by Gordon, by what mechanicians call a "cross-break- ing strain;" the displacement is very constant, the lower fragment being drawn somewhat upwards and backwards, while the upper fragment pro- jects downwards and forwards ; the hand at the same time inclines some- what to the radial side, though if, as sometimes happens, there be also a fracture of the styloid process of the ulna, this symptom may not be pre- sent. In some cases, according to Moore, of Rochester, the styloid process is dislocated and caught beneath the annular ligament, from which position it must be released before reduction can be accomplished. The so-called " silver fork''deformity, which usually characterizes this injury, is well seen in the accompanying illustration (Fig. 142). The diagnosis of this Fio. 142—Fracture of the radius near its lower end. (Lisro.v.) fracture is generally easy. Beside the peculiar displacement, there is pain, greatly increased by motion and especially by attempts to rotate the wrist, while crepitus can be readily elicited by drawing down the hand and rub- bing together the fragments. In some rare cases the fracture is completely impacted, w*hen crepitus will be absent, and reduction very difficult, if not Fio. !43.—Bond's splint. impossible. The treatment connsts 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 FRACTURES OF THE HAND. 271 Fig. 144.—Gordon's splints for fracture of the lower end of the radius. (lower fragment), and one over the palmar prominence (upper fragment). Two straight splints may be applied over these compresses (as recom- mended by Dr. Barton), or, which I prefer, the well-known splint of Dr. Bond (Fig. 143) may be used, or one of the ingenious modifications of Drs. Hays, Hamilton, and others. To any of these a short dorsal splint may sometimes be advanta- geously added. Bond's splint consists of a piece of wood, of the shape indicated in the figure, with a curved block to support the hand and fingers, and side strips of leather or pasteboard. It is prepared for use by placing it in a layer of cotton wad- ding or folded lint, and ad- justing upon this the palmar compress in such a position that, when the splint is ap- plied, it will press accurately upon the lower end of the upper fragment. The splint is laid on the fractured limb, so that the hand folds lightly over the block (which should fit the hollow of the palm), and the dorsal compress is then adjusted to the lower fragment so as to maintain the reduction wiiich has hitherto been kept up by the surgeon's hands. The dressing is completed by the appli- cation of a roller band- age, firmly, but not tightly, for fear of gan- grene. Another effi- cient, but, as it seems to me, unnecessarily complicated apparatus, is that employed by Dr. A. Gordon, of Belfast, which like the splints devised by Dr. Carr, Dr. Coover, and Dr. Levis, employs a curved instead of a plane surface for the support of the broken bone. The semi-prone position is that usually re- commended for the treatment of this injury, but I myself prefer the posi- tion of supination, which I have already advised for fractures of both bones of the forearm. When Colles's fracture is complicated with Fracture of the Styloid Process of the Ulna, the case should be treated with two straight splints, as an ordinary fracture of the forearm, with the addition of compresses to combat the " silver-fork" deformity, if required. From five to seven weeks are usually* necessary for the treatment of these cases. Fractures of the Hand. —Fracture of the carpus or metacarpnsshould betreated Oil a broad palmar Splint, fIo< H6.—Agnew's splint for fracture of metacarpus. Fig. 145.—Coover's splin 272 SPECIAL FRACTURES. which is so padded as to fill up the hollow of the hand, and afford firm sup- port to the injured member; fractures of the phalanges commonly require, in addition, a small pasteboard splint, applied immediately to the injured finger. The u.-e of apparatus may be dispensed with after two or three weeks. In the treatment of all fractures of the upper extremity, the limb should (unless fastened to the chest) be supported in a sling, which may, within reasonable limits, be lengthened or shortened according to the patient's preference or 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 within the capsule, (2) of the neck without the capsule, (3) of the neck, partly intra- and partly extra- capsular, (4) through the trochanter major and base of the neck, and (5) of the epiphysis of the trochanter major. The terms intra-eapsular and extra-capsular have, however, as justly remarked by Prof. Bigelow, not much practical significance, for the reason that the attachment of the cap- sule varies in different individuals, so that, apart from the difficulty of diagnosis during life, it is often impossible, in looking at a specimen which shows bony union, to say whether the fracture was originally inside or outside of the capsular ligament. Hence, this distinguished surgeon divides these injuries merely into the impacted and non-impacted varieties of frac- ture. The old classification, however, is at least unobjectionable, and may properly be retained, as being more familiar than any other. 1. Intra-eapsular Fracture of the Neck of the Thigh-bone is an acci- dent of frequent occurrence, being met with principally in those of advanced life, and in women oftener than in men. It is predisposed to by the ordi- nary senile change in the structure and shape of the cervix femoris, which is, in old age, often less obliquely attached to the shaft than in earlier life.1 This form of fracture results, usually, from indirect violence of an appa- rently 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 walk, shortening, and eversion of the foot. Alteration in the shape of the hip is evidenced by flattening of the trochanter, which may also be observed to rotate in an arc of abnormally small radius, the reason being that the 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 flac- cidity of the tensor vaginae femoris and gluteus medius muscles is regarded by Bezzi and Lagorio as a sign of pathognomonic value. Pain is markedly increased by any motion of, or pressure on, the joint, and is sometimes so intense as to render the use of auaesthesia 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 wanting in which patients have walked a short distance 1 This is denied by Prof. Humphry. FRACTURES OF UPPER EXTREMITY OF FEMUR. 273 after the accident before falling, probably from the fracture beimr at first incomplete, or partially impacted. The attitude of the limb, as shown in the accompanying illustration (Fig. 147), is often characteristic, and some- times 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 or an inch ;' it subsequently, and often suddenly, increases by the giving aw*ay 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. To determine whether or not the shortening is, in any particular case, in the cervix femoris, Mr. Bry- ant 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. "Nelaton's line" is one drawn from the anterior-superior spinous process to the tuber ischii; in the normal limb this line crosses the tip of the trochanter major, but in fracture of the cervix femoris, with shortening, passes below it. 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 patella;, and can be "smoothed out" by* making extension. 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 few cases inversion has been observed, and is attributed by Mr. Erichsen to paralysis of the external rotator muscles from concomitant injury. Pirrie reports a case in which inversion was accompanied by abduction and great flexion, the deformity thus closelv resembling that of dislocation downwards 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 Bigelow, it may be "best indicated by a comparison of the extent to which the two limbs can be inverted." Impaction with absolute inversion has been observed by W. J. Conklin, of Dayton, Ohio. The diagnosis between intra-eapsular and extra-capsular fracture will be considered when we come to speak of the latter form of injury. The prognosis of unimpacted intra-eapsular 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 whether bonv union ever occurred 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 Fig. 147. — Fracture of the neck of the femur. (Ferocsson.) 274 SPECIAL FRACTURES. impacted intra-eapsular fracture, however, bony union may undoubtedly occur. As these injuries are commonly met with in those of advanced age, the shock and general constitutional disturbance are often considerable ; old persons, too, bear confinement badly, and, in such, these injuries not un- frequently prove fatal, through the occurrence of congestion or inflammation of internal organs, the formation of bed-sores, etc. Under more favorable 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-eapsular variety. It is, like the latter, usually, though less exclusively, met with 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 poste- rior inter-trochanteric lines, and the inner almost invariably penetrates the outer fragment, in such a way as to split and comminute it into several portions. Either trochanter may* be completely detached, and the fracture may involve the summit of the shaft itself. Occasionally the fracture is completely impacted. The s;/mjttoms are much the same as those of the intra-eapsular form of injury, the chief differences being that the trochanter moves in an arc of still shorter radius, that the pain is acuter arul more superficial, and that the crepitus is more distinct, the fragments being sometimes felt loose under the skin; the shortening (unless incases of im- paction) 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 differetdial diagnosis between intra-eapsular and extra-capsular fracture may in many cases be made by attention to the above-mentioned peculiarities, taken in connection with the history of the case, the age of the patient, etc. In cases of impacted fracture, the diagnosis is much more difficult, and in such cases the surgeon must be very cautious in his exam- ination, lest he inadvertently remove the impaction, and thus seriously complicate the condition of the patient; for in any fracture about the neck of the femur, impaction is a most desirable circumstance, limiting the amount of shortening, and favoring the occurrence of bony union. Severe contusion of the hip may cause temporary eversion and immobility, and thus simulate fracture ; if the joint be also the seat of rheumatoid arthritis, there will be superadded shortening and false crepitus. The diagnosis, under such circumstances, must be made by careful inquiry into the his- tory of the case and the previous condition of the patient. The prognosis of extra-capsular fracture, unless the patient die from shock or general constitutional disturbance, or from some concomitant injury, is usually* favorable. Bony* union readily occurs in these cases, the amount of callus, on account of the comminution of the fracture, being very large, forming stalactitic projections or osteophytes, which are most abundant along the posterior inter-trochanteric line. 3. The neck of the thigh bone may be broken partly within and partly without the capsule; the symptoms would, of course, be essentially those of the previously described varieties, and the chances of bony union pro- portional to the degree in which the fracture was extra-capsufar. 1 According to Gordon, of Belfast, extra-capsular is more common in extreme old age than intra-eapsular fracture. FRACTURES OF UPPER EXTREMITY OF FEMUR. 275 4. Fracture through the Trochanter Major and Base of the Neck.—The line of fracture in this injury, which is sufficiently described by its name, separates the femur into two segments, the upper of which 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 authen- tic case on record. The diagnosis, I should suppose, could only be made during life by observing displacement of the epiphysis, without the ordi- nary signs of fractured femur. Treatment of Fractures of the Upper Extremity of the Femur.—I have no hesitation in expressing my preference for the treatment of these injuries by means of the straight position with moderate extension, when- ever that mode of treatment is applicable. In cases of impacted fracture, anv but slight extension is (for reasous already indicated) undesirable, and such cases ma}* be treated by position alone, the joint being fixed by means of the long splint, in any of its varieties, or simply supported by means of heavy sandbags placed on either side of the injured member, the extension afforded by* a weight of three or four pounds being sufficient to steady the limb and prevent muscular spasm. If the fracture be unimpacted, the same treatment should be employed, with the addition of more decided extension. For this purpose, Liston's splint, or that of Desault (as modi- fied by* Physick and others), may be conveniently* used ; or the surgeon may employ Hagedorn's apparatus, as modified by Gibson, or the less cum- brous 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 length- wise and well stretched) is prepared, 2i to 3 inches wide, and 3| 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 Fio. 148.—Adhesive-plaster stirrup for making extension in cases of fracture of the lower extremity, etc. this, again, is placed another adhesive strip of the same width, and 1^ to 2 feet in length ; the block, which 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 ex- tension 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. 148). The apparatus is fixed 270 SPECIAL FRACTURES. by two or three broad strips passed circularly around the limb, which is finally surrounded with an ordinary spiral bandage. The malleoli should be protected by a layer of cotton, to prevent 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, which plays over a pulley fixed at the foot of the bed, and which carries the ex- tending weight, which, for fractures of the neck of the femur, need not usually exceed ten or twelve pounds. Counter-extension may be made by means of a perineal band, or broad adhesive strips applied to the lower part of the trunk and fastened to the head of the bed, or, which I think preferable, simply by elevating the foot of the bed, thus utilizing the weight of the body itself as the counter-extending force. The sand-bags are merely long bags, like the "junks" used with Physick's splint, except that they are filled with clean sand instead of bran ; the outer should reach from the axilla to the sole of the foot, and the inner from the perineum to the in- ternal 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-eapsular fracture in old persons, in which no apparatus can be borne, and in which even confinement to bed is fraught with dan- gerous consequences; under such circumstances, the injured limb should be simply laid across pillows, as recommended by Sir Astley Cooper, until the pain and inflammation which attend the injury* have, subsided, the patient being then allowed to get up in a chair or on crutches ; bony union, under such circumstances, cannot be hoped for, and the general rather than the local condition of the patient should be the object of attention. In some of these cases, a moulded leather or pasteboard splint, or a 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 frac- ture is marked by* mobility, shortening, eversion, and crepitus, which are so manifest that the nature of the injury can scarcely be mistaken. With regard to the prognosis of fracture through the shaft of the femur, I have no hesitation in saying that I have never seen a perfect cure, either in my own practice or in that of others ; by this I mean that I have never seen a cure without shortening. Without entering upon a discussion as to the possibility of such a result (for a full and candid consideration of w*hich question I would respectfully refer the reader to Prof. Hamilton's excel- lent treatise), I will merely say that I have seldom 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 satisfac- tory result in adults.1 It is to be observed, however, that fracture of the thigh in children may even cause temporary lengthening, from increased growth due to the irritation transmitted to the epiphyseal cartilage at the lower end of the femur. The treatment of fractures of the shaft of the femur is most conveniently conducted with the weight-extension apparatus already* described, substituting, however, for the sand-bags, long splints (either padded or provided with bran junks), which have the effect of fixing both hip and knee, a very important consideration in the management of 1 The question of 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 ascertained by measurement that an inequality in the length of the lower limbs is often congenital. FRACTURE OF THE SHAFT OF THE FEMUR. 277 these injuries. (Fig. 149.) The chest and pelvis should both be secured to the external splint by broad and firm bands, while the splints themselves should be kept in position by similar bands, passing at intervals across the affected limb. In fractures of the upper part of the shaft, there is frequently —ii Fio. 149.—Weight-extension with long splints for treatment of fractured thigh; counter-3Xtension made by raising foot of bed. seen an anterior angular projection, which is generally attributed, and is probably usually due, to the tilting forwards of the lower end of the upper fragment; though that it is occasionally due to the projection of the lower fragment, is shown by several specimens described by* Mr. Butcher. What- ever be the cause of the projection, it may require the application of a third, anterior splint, which should reach from the groin to above the knee, and should be well padded to prevent excoriation. After several weeks, when union is pretty well advanced, short moulded pasteboard splints may be applied immediately around the seat of fracture, 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 which I am in the habit of employing in cases of fractured thigh, and Fio. 150.—N. R. Smith's anterior splint, applied to a fracture of the thigh. I have found it to be as efficient as it is simple. Excellent cures may, how- ever, doubtless be obtained by the use of other means, such as the various 278 SPECIAL FRACTURES. forms of apparatus already mentioned (page '275), or the *' suspension splints" of the late Profs. X. K. Smith, of Baltimore (Fig. 150). and J. T. Hodgen, of St. Louis. Compound Fractures of the Thigh may be con- veniently treated with the weight-extension apparatus, with the bracketed long splint (Fig. 151), with a simple long fracture-box (particularly useful Fio. 151 — Compound fracture of shaft of thigh-bone ; treatment by bracketed long splint. (Eriohsbs.) when the bran dressing is to be employed), or, in some rare eases, with the old-fa.shioned double-inclined plane, which was so popular at the end of the last and the beginning of this tentury.1 3. Fracture of the Condyles of the Femur—Either condyle may be broken off separately, or there may be a splitting fracture between them, complicated with a more or less transverse fracture through their base. The symptoms are mobility, crepitus—elicited by rubbing the con- dyles together—and, if the fracture extend through their base, shortening; there is also an increase in the breadth of the limb around the condyles, which persists after recovery. These accidents may result from direct violence, or from falls on the knee (the patella, as remarked by Willett, acting as a wedge in splitting: the condyles asunder), and are often followed by secondary inflammation of the knee-joint, which may run on to suppura- tive disorganization, endangering either the limb or the life of the patient. The treatment consists in placing the limb at rest in a straight or almost straight position, in a long fracture-box with a firm but soft pillow, and in making moderate extension if there be much shortening ; recovery will usually be attended with more or less anchylosis. Separation of the Lower Epiphysis of the Femur would require the same treatment as fracture of the condyles. Compound Fracture of the Femur, involving the Knee- joint, should, almost invariably, be considered a case for amputation. The time required for the treatment of a fractured thigh may be said to be from eight to ten weeks; even if union appear firm before that time, the patient should not be allowed to bear any weight on the limb, for fear of consecutive shortening, which I have known to occur after apparently com- plete recovery. Patella—Fractures of the patella are usually met with in male adults, and are commonly produced by muscular action, the patella being broken as an over-bent lever across the condyles of the femur ; under such circum- stances, the line of fracture is transverse, and the upper fragment may be drawn some distance upwards by the powerful muscles of the thigh. The patella is occasionally broken by direct violence, when the fracture may be comminuted or longitudinal. The diagnosis is easily made: in trans- 1 I will merely mention, without in any degree commending, the plan proposed by Dr. Hennequin, in an essay which received the Darbier 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. FRACTURES OF THE PATELLA. 279 verse fracture there is almost always some displacement, which is increased by flexing the knee;1 while in comminuted or longitudi- nal fractures, the nature of the case is ren- dered evident by the mobility* and crepitus, which, under such circumstances, are very distinct. Inability to walk or stand, w'hich is ofteu spoken of as a sign of fractured pa- tella, is, as remarked by Gouget, more appa- rent than real, the patient being able, though not willing, to walk, on account of the pain W*hich attends the effort. The prognosis is Fig. 152.—Fracture of patella ; frag- faVOrable; though bony Union is rarely Ob- ments separated by flexing the knee. tained, especially in the case of transverse fracture, the utility of the limb is not materially* impaired, and instances are on record in which patients, after recovery, have engaged in duties requiring great activity and strength of limb, although with a separation of several inches between the fragments of the patella. The treatment con- sists in placing the limb in a straight position, with the leg somewhat elevated, so as to relax the fibres of the quadriceps femoris muscle.2 The upper fragment of the patella, being drawn downwards, is held in place by means of a firm compress, which is secured by strips of adhesive plaster fastened to a broad posterior splint, provided for the purpose with notches or cross-pieces. The whole limb and splint are then surrounded with a roller, which, by figure-of-8 turns around the knee, gives additional security and firmness to the part. The limb should be raised, simply by pillow's 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 with all fractures of the lower extremity, to keep the foot strictly at right angles with the leg, so as to avoid the "pointed-toe" deformity which is otherwise apt to ensue. This simple mode of treatment, wiiich is essentially the same as that recommended by Ham- ilton, is quite as efficient as the more complicated plans devised by Lons- dale, Amesbury, Cooper, Burge, Callender, Beach, and others. Malgaigne's hooks, and their various modifications, introduced by Morton, Levis, J. M. White, Stimson, and others, while doubtless efficient, and probably less dangerous than is usually supposed, are at least unnecessary, and, from their formidable appearance, undesirable. A better mode of 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 twice succeeded in obtaining bony union. It is certainly a safer plan than that of Volkmann, who, by means of a curved needle, carries a strong silver wire around and beneath the patella, approximating the fragments by tightening the ring thus formed. Kocher operates in the same way, applying silk instead of wire, and Kbnig employs catgut. T. Curtis Smith employs anterior splints 1 T. Curtis Smith, of Ohio, has, however, recorded a case in which the only dis- 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. 2 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. Schede recommends, in these cases, that the joint should be tapped with antiseptic precau- tions. 2*0 SPECIAL FRACTURES. curved to fit the patella, and held together with elastic bands. Mayo- Robson i>asses pins transversely above and below the fragments, and ties the pins together with ligatures. Cameron, Lister, and others, reviv- ing an old plan, wire the fragments together (antiseptically ), and have thus obtained good results; but subsequent amputation has been re- quired in several cases, and at least twelve have terminated fatally. The annexed table, borrowed from Dr. Cutter, shows the result of 18(! eases. An additional fatal case (Dr. By rd's) raises the number of deaths to 12. Table showing Results of Wiring Fractures of the Patella. Cases. *3 3 3 •• of xi I £ a a 1 P.O E- II 8 cases treated without operation, 5<> recovered and only 12 died (17.65 per cent), while of 7 in which ampu- tation was performed, 5 recovered and 2 died (28.57 per cent.), and of 10 treated by- excision, only 4 recovered and 6 died (f>0 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. According to Turner's statistics, the func- tional results are better without than with suture of the fragments. Fractures of the Bones of the Leg.—Either the tibia or fibula, or both, may be broken, the cause of these injuries being usually direct, though occasionally indirect violence, and the line of fracture generally oblique, except in the upper part of the tibia, where it is commonly trans- verse. If only one bone be broken, there will not be much displacement, the other acting as a splint, except in fractures just above the ankle, when the foot inclines to the injured side. Fracture of both bones, in the middle or lower third, is often attended with considerable displacement, the line of fracture being oblique (from above downwards, forwards, and inwards), FRACTURES OF THE RONES OF THE LEG. 281 and the lower being drawn up behind the upper fragments by the power- ful muscles of the calf. The existence of this displacement, together with undue mobility and crepitus, renders the diagnosis easy ; and even when one bone only is broken, the nature of the case can be readily ascertained by careful examination. A "V-shaped" fracture, occurring at the junc- tion of the middle and lower thirds of the tibia, is described by Gosselin, Hodges and other writers. The line of fracture is sometimes spiral, when marked axial deformity may ensue. Fracture of the upper end of the fibula has been complicated with 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 acci- dent, there being, indeed, as far as I know, but five 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 ; others are recorded by Stinson, Heuston, and Manby, and the fifth occur- red in my own practice, in a boy eleven years old, who was caught between Fios. 153, 154.—Separation of upper epiphysis of tibia. (From a specimen in the museum of the Episcopal Hospital.) the bumpers of railway-cars ; the laceration of the soft parts w*as so great as to require amputation, and the nature of the accident was thus ascer- tained by dissection. (Figs. 153, 154.) Dr. Voss, of New York, has recorded a case of separation of the lower epiphysis in which, in spite of the occurrence of necrosis, recovery with a useful limb was ultimately obtained. Treatment.—For the treatment of the great majority of fractures of the leg, whether one or both bones be involved, I know of no apparatus which presents so many advantages as the old-fashioned fracture-box with mov- able sides (Fig. 155), containing a soft but firm pillow; the fracture having been reduced, the limb is gently laid in the box, the sole of the foot being ad- justed to the foot-board, with the heel well brought dow*n, and raised on a pad of cotton or tow placed beneath the tendo Achillis. The foot is then secured by a loop of bandage, and the sides of the box brought up so as to make firm and equable pressure upon the fractured limb Care must be taken to keep the P 282 SPECIAL FRACTURES. foot at a right angle with the leg, to prevent eversion of the knee by fre- quent adjustment,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 below those prominences, 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 with the simple fracture-box as with any of the complicated contrivances which the ingenuity of surgeons has suggested. In fact, the chief difficulty* with the fracture-box is that it is so simple that surgeons are apt to think that nothing is required beyond placing the limb in it, and there letting it stay for the requisite number of weeks; and it is, I believe to the neglect of the surgeon, rather than to any fault of the apparatus, that are to be attributed the bad results on which many modern writers, in objecting to the use of the fracture-box, lay such stress. If in cases of very oblique fracture it be desired to make extension, this can readily be done 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 the fracture-box. Certain cases of oblique fracture2 may be best treated in the flexed position, and a very good apparatus for this pur- pose is the anterior splint of the late Prof. N. K. Smith (Fig. 150). The comfort of the patient may sometimes 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. 15G), or the "anterior splint," may* be conveniently employed. Fio. 156.—Salter's cradle. After three or four weeks, when union is pretty well advanced, the limb may be advantageously surrounded with moulded and well-padded paste- board splints, being then replaced in the fracture-box; or the plaster-of- i A convenient, practical rule is to see at each visit that the ball of the great toe, the inner malleolus, and the inner condyle of the femur are all in the same vertical plane. 2 For the treatment of these oblique fractures, Malgaigne recommends an apparatus provided with a sharp screw to hold the fragments in place ; while Laugier, and morn recently Mr. Bloxam, recommend division of the tendo Achillis. I have no personal experience with either of these modes of treatment, which, however, I cannot but think unnecessarily severe. FRACTURES AE0UT THE ANKLE. 283 Paris bandage may be now 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 tw*o inches deep ; the fracture being reduced, the limb is laid in, the box, with a pad of cotton beneath the tendo Achillis and around either malleolus, and a layer of the same material around the limb just below the knee; the sides of the box are then brought up and secured, and more bran is dusted and packed around and over the leg till the box is filled, the fractured limb being thus firmly and evenly supported on all sides. The same precautions as to position are to be observed as in the management of a simple fracture, the daily dressing consisting in letting down one or both sides of the box, and, without disturbing the limb, re- moving the solid bran with a spatula, and replacing it with fresh material. The great advantages of the bran dressing are its simplicity and cleanli-' ness, the bran readily absorbing all discharges as they are formed, and affording a sure protection against flies; in recent cases, the uniform pres- sure of the bran has been, moreover, found very efficient in checking hemor- rhage. The bran dressing may be employed "in connection with the anti- septic method, the wound being first covered with protective and surrounded with antiseptic gauze, and the bran then packed around the limb in the way* already described. Fracture of the Head of the Tibia into the knee-joint is apt to be complicated with injury of the popliteal vessels (see page 241). For its treatment, a fracture-box, long enough to fix the joint, is employed, such as was recommended for fractures of the condyles of the femur. The injury is often followed by anchylosis. Fractures about the Ankle are, perhaps, more troublesome than any other fractures of the leg. The fibula alone may be broken, usually giving way about three inches above the joint, or the tip of the inner mal- leolus may be torn off as well (Pott's fracture); or either malleolus may be longitudinally splintered into the ankle-joint (an accident commonly fol- lowed by anchylosis) ; or, finally, the inner mal- leolus alone 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 care- ful adjustment and the judicious use of com- presses. In the case of Pott's fracture, one com- press should be placed on the inner side, above F,°' 157-Wl™™* for frac" .1 . n t -■ . . ture of the leg. the inner malleolus, and another on the outer side, below the outer malleolus, so as to press the foot inwards. I have never had occasion to use Dupuytren's splint for fractured fibula, though I doubt not that when carefully applied it is an efficient apparatus. In the management of fractures of the leg, or in fact of any part of the lower extremity, the injured limb should be protected from the weight of the bedclothes by* means of a suitable framework of bamboo, wood, or wire, as shown in Fig. 157. In cases of fractured leg occurring in very young children, or in adults suffering from mania a potu, when no restraint can be borne, it is a good plan to surround the broken limb with a soft pillow, which is held in place by means of firm bandages ; the part can then be tossed about without risk of further injury*. 284 SPECIAL FRACTURES. Fractures of the Bones of the Foot.—The only tarsal bones, the fractures of which require special notice, are the calcaneum and the astragalus. The Calcaneum may be broken by direct violence, or by muscular action ; the line of fracture mav assume any direction, and, when the injury results from direct violence, the fracture may* be com minuted or impacted. If the tuberosity* of the bone only be separated, the fragment may be drawn upwards for a considerable distance by the action of the gastrocnemius muscle, whereas, if the fracture be through the body of the bone, there can be little or no displacement, the fragments being held in place by the lateral ligaments. The treatment, if there be no displacement, consists merely in placing the limb in a fracture-box or on a pillow, and combating inflammation by evaporating lotions, etc., applying subsequently splints or a gypsum bandage. When the posterior fragment is drawn upwards, the foot should be kept in an extended position, so as to relax the gastrocne- mius, by means of a well-padded anterior splint, or the apparatus already recommended for rupture of the tendo Achillis (page 221). The Astragalus is almost invariably broken by the patient falling from a height, alighting on his feet. Simple fracture of this bone is rarely attended with displacement; in fact there are, as far as I know, but two cases of the kind on record, one reported by* Dr. Norris, and one by myself. In the former, the displacement was downwards and forwards; in the latter, downwards, outwards, and backwards. The treatment consists in reduction (if practicable), the limb being then placed in a fracture-box, and subsequently dressed with pasteboard splints or a starched bandage. If reduction were impracticable, in a case of simple fracture, I should be dis- posed to temporize, reserving excision (which is usually reconimended under such circumstances) as a secondary operation, to be employed should sloughing or necrosis ensue ; in Dr. Norris's case, the displaced fragment w*as excised by Barton, but amputation was subsequently required, and the patient ultimately died, a year and a half after the occurrence of the accident. Even in fractures unattended with displacement, necrosis may follow, when secondary 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 was broken, with the happiest results. In a Compound Fracture of the astragalus, if reduction were impracti- cable, I should advise complete excision, wiiich Rognetta (whose paper on this subject is classical) considers preferable to excision of the displaced fragment only. When, however, such an injury is attended with much comminution, or is complicated with fracture of the malleoli or other tarsal bones, amputaion will often be required as a primary operation. Fractures of the Metatarsal Bones or Toes are usually pro- duced by direct violence, and if attended with much laceration, commonly require amputation. In cases of simple fracture, it will be suffieient, after effecting reduction, to apply a plantar splint, and to place the limb in a fracture-box, the dressing being changed, after a time, for pasteboard splints or a plaster-of-Paris bandage. CAUSES OF DISLOCATION. 285 CHAPTER XIII. DISLOCATIONS. A dislocation or luxation is a displacement, as regards their relative position, of the bones which enter into the formation of a joint. Disloca- tions are variously classified: thus they are said to be traumatic, patho- logical or spontaneous, and congenital. Traumatic dislocations are such as result from the sudden application of force ; pathological or spontaneous luxations are such as occur from an alteration in a joint as the result of disease (as in the dislocation of the femur in hip-disease), or simply from a paralyzed condition of the muscles around the joint, without any evidence of disease of the articulation itself; w*hile congenital dislocations are, as the name implies, such as exist at the moment of birth (though often not recognized until the child attempts to walk), being usually* due to original malformation of the parts concerned. When the term dislocation or luxa- tion 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 the sacroiliac symphysis. 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 luxation (also called a subluxation), the articulating surfaces remain in contact, through a portion of their extent. The term simple, compound, and complicated, bear the same relative meanings as when applied to frac- tures. 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 complica- tions of a luxation may be mentioned fracture of either of the articulating surfaces of the injured joint, and rupture of the main artery of the limb, as of the popliteal in backward dislocation of the knee. A recent dislocation is one in which time has not been afforded for the production of inflamma- tory changes in the articulating surfaces and surrounding tissues, or at least not to such a degree as seriously to impede reduction ; an old disloca- tion being, of course, one in which sufficient time has elapsed to permit such changes to occur. A primitive luxation is one in which the displaced bone remains in the position into which it was first thrown by the luxat- ing force. A consecutive dislocation is one in w*hich the displaced bone has secondarily changed its position, either under a continuance of the in- fluence of the luxating force, or as the result of subsequent muscular con- traction, or of the surgeon's manipulations in attempts to effect reduction. Causes of Dislocation —Age and Sex are Predisposing Causes of dislocation, 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 with in those in active adult life, and much more fre- quently in men than in women. More important predisposing causes are the anatomical relations of the joint, and the condition of the neighboring 286 DISLOCATIONS. muscles and ligaments; thus the ball-and-socket joints are more liable to luxation than the ginglvmoid, while persons of vigorous muscular frame are less exposed to these injuries than those whose tissues are relaxed and feeble. The following table, compiled from Malgaigne's statistics, shows the relative frequency with which various parts are dislocated:— Cases. Cases. Canes Jaw 7 Elbow . . 45 Femur . . 40 Vertebrae . 4 Radius . 7 Patella . . 2 Pelvis . . 1 Wrist . . 16 Knee . 9 Clavicle . 42 Thumb . . 20 Ankle . . 31 Humerus . 370 Fingers . . 7 Metatarsus . 2 Atrophy and paralysis of a limb predispose it to dislocation, as do like- wise stretching and relaxation of ligaments from articular effusion, or from previous dislocation, ulceration, etc. The Exciting Causes of dislocation are external violence, direct or in- direct, and muscular action. The latter is the more usual agent in the production of pathological dislocations, when it acts slowly and gradually ; traumatic luxations may also, however, be traceable to the effect of mus- cular action, especially when the joint has been previously weakened by any of the causes above mentioned ; thus cases are recorded by Cooper, Haynes, Bigelow, and others, in which patients possessed the power of pro- ducing dislocation by* a voluntary effort, and I have myself seen such a case in the person of an epileptic woman, who was in the habit of disloca- ting her hip in the public streets, as a means of exciting sympathy. Symptoms and Diagnosis of Dislocation.—The usual signs of dislocation are: (1) a change in the shape of the joint and in the 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 which can be consid- ered essential, for in partial luxations (as of the elbow) there may be neither lengthening nor shortening, and if the articular ligaments be exten- sively 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 distinguished by observing the immobility (when that is present), the absence of crepitus, and the fact that the displacement when removed by reduction does not return. True crepitus does not exist in a case of pure dislocation ; there is, however, a rasping or crackling sound, due to effusion or inflammatory changes in the articular structures, or sim- ply to dryness of the joint from rupture of the capsular ligament and es- cape of the synovial fluid ; this sound may be developed in the course of a few hours, and may readily be mistaken for the crepitus of a fracture in which the process of repair has already* begun. Again, while displacement does not always occur in cases of fracture, it may recur in a case of dislo- cation, if there be much laceration of the ligamentous tissues, or if the ar- ticular surfaces themselves have undergone structural changes from inflam- matory 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 surgeons are occasionally liable to err in the diagnosis between luxation and articular fracture. Dislocation, like fracture, is commonly accompanied by pain, swelling, and ecchymosis; wide-spread extravasation may occur from rupture of vessels, and paralysis (temporary* or permanent), or neuralgia, from com- pression or laceration of neighboring nerves. PROGNOSIS AND TREATMENT OF DISLOCATIONS. 287 Articular Changes Produced by Dislocation__The immediate effects of the dislocation consist of a rupture more or less extensive of the capsular ligament, with or without laceration of the other ligaments of the joint, and of neighboring tendons, muscles, vessels, and nerves ; in cases of dislocation from muscular action, however, the capsular ligament may be merely stretched, without rupture. If the luxation be promptly reduced, the lacerated structures are gradually restored to their normal condition^ though the joint is often left permanently weakened, and paralysis or neu- ralgia 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 flat- tened, while a new socket is commonly formed around the head of the dislocated bone, which changes its shape, and becomes gradually accom- modated to its new position; if, however, the head of the bone rests upon muscle, instead of a new socket being formed, the soft tissues undergo con- densation, forming a cup-shaped cavity of fibrous structure, which becomes attached by* its margins to the displaced bone, and is lubricated by a syno- via-like fluid. In the hinge-joints similar changes occur, the osseous pro- minences being rounded off, and the displaced bones gradually accommo- dating themselves more or less perfectly to their new* positions. These changes, which occur with comparative rapidity in childhood, take place very slowly in adult life, often occupying several years in their completion. At the same time, the surrounding muscles and tendons become shortened and atrophied, and abnormal adhesions often form between the displaced bones and neighboring nervous and vascular trunks—a circumstance which 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 which has been the seat of luxation will not be completely restored for months or even years, or occasionally during the whole lifetime of the patient. An unreduced dislocation of course causes permanent disability, and yet it is surprising to what an extent the displaced parts accommodate themselves to their neAv positions, the utility of a limb after dislocation being often much greater than would be thought probable in view of its evident deformity ; so that it is some- times a question, in cases of old dislocation, w*hether reduction would 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 without undue inflamma- tion, and to encourage the restoration of the functions of the part. Reduction.—This should be effected, in every case, at the earliest pos- sible moment. While I have advised that in certain cases of suspected fracture, minute examination should be delayed until after the subsidence of swelling, the case meanwhile being treated as one of fracture, in a case of suspected dislocation no such temporizing course would be 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 impos- S| \a Hence'.-f tne nature of the case be not perfectly clear, the surgeon should not hesitate to employ anaesthesia as an aid to diagnosis, more par- UlU i'l\aS the use of the an«sthetic will greatly facilitate reduction, should the existence of a dislocation be determined. The principal obstacles to reduction, in any case of luxation, are mus- cular resistance and the anatomical relations of the joint. There are three 288 DISLOCATIONS. distinct elements to be considered in estimating the influence of the muscles in hindering reduction ; these are (1) the passive force which the muscles possess in common with the other soft structures of the body, and which is brought out by the stretching of their tissues across the displaced bony prominences; (2) the active force, whereby the patient voluntarily though unconsciously resists the surgeon's efforts at reduction; and ():$) a state of reflex tonic contraction into which the muscles are thrown as the result of the traumatic irritation, produced by the injury itself; this, which is the most important form in which muscular resistance is manifested, is more and more fully developed as the luxation remains longer unreduced. It often happens that if a patient is seen immediately upon the occurrence of a dislocation, the muscular relaxation, due to the general state of shock w*hich accompanies the accident, is so great, that the displacement can lie reduced with the greatest facility*, and, indeed, is often so reduced by the bystanders or by the patient himself. The knowledge of this fact led sur- geons, 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 bleeding. 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 contrac- tion of the muscles may be overcome, to a certain extent, by the use of opium, especially by the hypodermic method, or, as was done by Physick, by inducing intoxication ; but a more efficient and trustworthy plan than any of these, and the only one which is habitually resorted to at the pre- sent day, is the administration of ether or chloroform, so as to produce anaesthesia and complete muscular relaxation. Anaesthetics are indeed in- valuable in the treatment of dislocations, occurring in vigorous adults ; but in cases met with in children, or in adults of feeble and relaxed muscular frame, reduction should be attempted, and may often be conveniently effected, without anaesthesia. Muscular resistance having been overcome, all that the surgeon has to contend with, in a case of recent dislocation, is the hindrance to reduction presented by the anatomical structure of the joint, the shape and altered relations of the articular surfaces themselves, and the conditions of the cap- sular 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. Ham- ilton well observes, in a very large majority of instances force and perse- verance will finally succeed, by whomsoever they may be employed, but they succeed at the expense of great suffering, and perhaps permanent injury to the patient. It is the mark of the skilful surgeon not to employ blind force, but to adapt his manipulations to the exigencies of the case, gently eluding the resistance to his efforts, and making the ligaments, muscles, and bones themselves act as efficient mechanical powers under his intelligent guidance. In the immense majority* of cases, at least of recent dislocation, reduc- tion can be effected without the use of greater force than can be applied simply through the hands of the surgeon and his assistants. The pro- cesses by which reduction is effected, are three in number, viz., manipula- tion, extension and counter-extension, and direct pressure. 1. Manipulation.—This term is used in a technical sense to describe cer- tain movements by which the surgeon aims to effect reduction by utilizing the structural elements of the joint itself. COMPOUND DISLOCATION. 289 2. Extension and Counter-extension.—Here the proximal articular sur- face is fixed by the knee or heel of the operator, by the hands of an assist- ant, or by means of a folded sheet, padded belt, etc., while the extending force is applied directly by the surgeon's hands, through the medium of bandages or towels secured with the clove-hitch knot (Fig. 158), or by still more pow- erful means, such as the compound pulley* (Fig. 180), Fahne- stock's and Gilbert's rope windlass (Fig. 178), Bloxam's tourniquet (Fig. 179), or Jarvis's adjuster. Continuous Elastic Extension, by means of India-rubber bands, has Fl0'1'^8'-.CIove been utilized by Dr. H. Gr. Davis, of New York, in the treatment of old dislocations, and by this 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 with 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 elbow, or around the wrist. I have already indicated my preference for simple and gentle means of effecting reduction in cases of dislocation, and may add that, in my own practice, I have never had occasion to resort, in recent cases, to anything beyond manipulation, with manual extension and pressure; and though I should be 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 inju- ries 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 application of evaporating lotions or other topical remedies. Opium may be used to relieve pain, and the general condition of the patient should be attended to, laxatives, diaphoretics, etc., being administered, if necessary. To encourage the restoration of function, passive motion should be em- ployed as soon as the inflammatory symptoms have subsided, usually in the course of the second or third week. Loss of tone in the muscles should be combated by the use of friction, electricity, and the cold douche, and by the cautious administration of strychnia. Compound Dislocation is'always a very grave accident; if the wound be small and clean cut, with but little concomitant injury, 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 especially if there be a fracture of either or both articular extremities, excision or amputation should be performed, according to the particular joint affected, and the extent of lesion present. As far as any general rule can be given in such cases, it may be said that the surgeon's first thought should be of excision, except in the case of the knee, where amputation is preferable. 19 200 DISLOCATIONS. Complicated Luxations.—The complication of dislocation with fracture has already been considered in Chapter XI A graver compli- cation is rupture of the main artery of the limb. This has occurred in connection with dislocations of the shoulder and of the knee; in the former situation, ligation of the subclavian artery (after reduction), as success- fully practised in cases recorded by R. Adams,Warren, Letievant, Cras, and Rushton Parker, would be indicated, and in the latter (as a general rule), amputation. The consequence of non-interference would be the forma- tion of a diffused traumatic aneurism, which would prove fatal either by- hemorrhage, or by the supervention of gangrene. Extensive extravasa- tion from the rupture of the smaller vessels may, however, 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 likewise with more risk, than the reduction of recent dislocations. The increased difficulty is due to the permanent contraction and structural changes which occur in the muscles, to the abnormal adhe- sions which form between the displaced bone and the parts with which it is in contact, and to the changes which have already been described as taking place in the articular surfaces themselves. The increased dangers which attend efforts at reduction in these cases are dependent on the same morbid changes: among the accidents which have occurred under these circumstances may* be enumerated laceration of the skin and subcutaneous tissues, rupture of muscles in the neighborhood of the dislocated joint, deep- seated inflammation and suppuration around the joint, rupture of arteries, veins, or nerves, fracture of the displaced bone or of neighboring bones, and finally avulsion of the entire limb, as happened in a remarkable case reported by Guerin. Hence, while greater force is required in the treat- ment of these cases than in that of recent luxations, the employment of such force is always attended with considerable risk. Even manipulation without extension is not free from danger, for the displaced bone may, in its new position, have acquired adhesions to the main artery* or vein, rup- ture of which, in the action of reduction, would probably cause serious, if not fatal, hemorrhage. It is impossible to fix any definite period beyond which reduction should not be attempted in cases of old dislocation. Dr. Nathan Smith reduced a luxation of the shoulder nearly a year after the accident, and luxations of the hip have been reduced byr 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 mani- pulations, if practised with caution and gentleness, may be of service in increasing the mobility* of the limb, and thus adding to its usefulness in i\> abnormal position. Hence, in the case of dislocation, even of several months' standing, provided that the effort were warranted by the general condition of the patient, I should recommend an attempt at reduction, undertaken, of course, with the extremest caution and delicacy. The patient should be thoroughly relaxed by anaesthesia, and gentle manipula- tion and moderate extension then employed, so as to stretch or slowly sever any morbid adhesions, and allow the displaced bone to be gradually brought into its proper position ; or the elastic extension recommended by Dr. Davis might be resorted to, and would certainly be worthy of a trial in the event of other means failing. PATHOLOGICAL AND CONGENITAL DISLOCATIONS. 201 Subcutaneous Division of Muscles, Tendons, and Ligaments, was pro- posed by Dieffenbach as a preparatory* measure in the treatment of old dis- locations, and by this plan that surgeon succeeded in effecting reduction in a case of luxation of the humerus of two years' standing. In the hands of others, however, the operation has not been generally successful, while it has occasionally given rise to extensive suppuration and sloughing. Sub- cutaneous osteotomy has been successfully employed by Dr. Mears, of this city, in a case of irreducible dislocation of the shoulder. Yolkmann and MacCormac have successfully excised the head of the femur, in long-stand- ing cases of hip-dislocation. Treatment of Accidents occurring during Attempts at Reduction of Old Dislocations.—If a fracture occur in the effort to reduce an old disloca- tion, the attempt should be at once discontinued, and the broken bone placed in such a position as to favor union. The rupture of an important muscle, such as the pectoralis major, would likewise oblige the surgeon to desist from further efforts at reduction. Rupture of the main artery, with for- mation of a traumatic aneurism, is a very grave accident when occurring under these circumstances ; it has been chiefly met with in the case of the axillary artery, in connection with dislocation of the humerus. There are four courses open to the surgeon in dealing with such a case, viz., to try the effect of pressure, to amputate at the shoulder, to ligate the subclavian, or to resort to the "old operation," laying open the sac, and tying the vessel above and below the point of rupture. The latter course has, accord- ing to Stimson, been adopted in 7 cases (2 of them, however, having been cases of recent luxation), but in every instance with a fatal result. Liga- tion of the subclavian has been practised, in all, in 15 cases; 10 times for recent dislocation, with 5 recoveries and 4 deaths (the result in one case being unknown), and 5 times for old dislocation, with only one recovery and 4 deaths. In a case of supposed dislocation, which afterwards proved to have been a fracture, Blackman tied the axillary artery in its upper por- tion, but the patient died on the eleventh day* from hemorrhage; and a case in the Newcastle-upon-Tyne Infirmary likewise proved fatal from hemorrhage after an unsuccessful attempt to secure the ruptured vessel. Ampu- tation at the shoulder-joint succeeded in the hands of Jungken, but proved fatal in cases recorded by Bell, Bellamy, and Le Dentu, the latter having been a case of recent luxation. Rupture of the axillary vein terminated fatally* in a case recorded by Froriep, but in a similar case in the practice of my colleague, Prof. Agnew, recovery ensued without the necessity of a resort to operative interference. Expectant measures have, according to Stimson, proved successful altogether in six cases of shoulder-dislocation with vascular injury, but, on the other hand, 14 cases thus treated have ended fatally.1 The inference from these figures would seem to be that, if the symptoms were urgent, ligation of the subclavian should be performed in a case of recent dislocation, and in one of old luxation the same opera- tion or disarticulation. Avulsion of the limb, as occurred in Guerin's case, would, of course, require immediate amputation. Embolism, followed by gangrene of the forearm, is a rare complication, of which I have seen one instance. The patient recovered after amputation above the elbow. Spontaneous, Pathological, and Congenital Dislocations—In the treatment of these cases there is usually not as much difficulty in effecting, as in maintaining reduction. Guerin, Brodhurst, Barwell, and others, have successfully employed subcutaneous tenotomy and myotomy, followed by 1 The 14th case occurred in the practice of Mr. Holmes. The patient refused to permit any operation. 292 DISLOCATIONS. Fin. 159 —Congenital dislocation of both hip». (Holmes.) continued extension, in the treatment of congenital luxations, and the same treatment might be adopted in cases of pathological dislocations, provided that no active joint disease were present at the time of oper- ation. Esmarch succeeded by extension alone, and Buckminster Brown, in a very aggravated ease, by extension, pressure, and fixation, combined. Pose, Royher, Heusner, and Margary have successfully treated cases of congenital hip-luxation by excision, as have llawdon and Adams those of the patho- logical variety. In cases dependent on muscular paralysis, the difficulty would be in maintaining reduction, and here external support (in the form of carved or moulded splints, elastic bandages, or some of the ingenious devices which are used in the treat- ment of deformities), nii»ht be usefully employed. Con- genital dislocation of both hips is well show*n in Fig. 159. Special Dislocations. Dislocation of the Lower Jaw is a rare accident, occurring chiefly in earlv adult age, and rather oftener in women than in men. It is usually double or bilateral, though occasionally one side only is displaced. The most common cause of dislocated jaw is muscular action, though it may also result from a blow on the chin while the mouth is open, or from other forms of violence, such as the forcible introduction of a foreign body into the mouth, or the extraction of teeth. When the mouth is opened, the maxillary condyles ride forwards upon the articular eminences of the tem- poral bones, and a very slight degree of force is then necessary to make them slip still further forw*ards into the zygomatic fossae, thus producing dislocation. The contraction of the external pterygoid muscles, and perhaps of some fibres of the niasseters, is thus quite sufficient to produce luxation when the mouth is widely opened, the tonic contraction of the same mus- cles, combined with the position of the coronoid processes (which catcti against the malar bones), being the principal obstacles to reduction. J. W. Hamilton, of Ohio, describes a spontaneous, backward dislocation oi the lower jaw. DISLOCATION OF THE LOWER JAW. 203 160.—Double dislocation of the inferior maxilla. Symptoms.—The symptoms of a recent dislocation of the jaw are suffi- ciently obvious. There is prominence of the chin, the mouth being widely open, and the jaw almost immovable ; there is likewise a marked depression over the seat of the articulation, with a slight fulness anteriorly*. In unilateral dislocation the jaw* usually inclines to the opposite side—a sy*mptom which serves for the diagnosis between luxa- tion and fracture, but which, according to Hey and R. Smith, is not always pre- sent. There is generally, but not always, pain ; the patient speaks and swallows with difficulty ; and there is a constant flow of saliva from the mouth. Prognosis.—Even if the dislocated jaw be unreduced, the patient gradually acquires considerable use of the part, and is ultimately* able toclose the mouth, chew*, swallow, and talk—much less in- convenience being felt from the displace- ment than would at first be supposed. Reduction in a recent case is easily* ac- complished, and has even been effected (by Donovan) more than three months after the reception of the injury. Some- times the ligaments are left permanently* weakened, motion of the part being painful, and the joint being liable to a reproduction of the dislocation Fig. 161, from an electrotype kindly* sent me by Dr. W. R. Whitehead, of Denver, Colorado, shows the appearance in a case of dislocated lower jaw reduced by* him more than two months after the injury*. Treatment.—Reduction is effected by* disen- gaging the coronoid processes from the malar bones, and the condyles from the zygomatic fossae, by pressing the chin upwards, while a ful- crum 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 towel) as a fulcrum, pressing the angles of the j&w downwards, while he elevates the chin with his fingers ; or pieces of cork or wood may- be used as a fulcrum, in which case they should be provided with strings to facilitate their with- drawal. Nelaton recommends simply* pushing the coronoid processes backwards with the thumbs, applied either from within the mouth, or from without. In any case of diffi- culty*, one side might be reduced at a time, taking care, while manipulating the second, not to reproduce the luxation of the first. Anaesthesia is not usually required in these cases, though there would be no particular objec- tion to its employment if it were thought desirable. After reduction, the part should be supported for at least a week or ten days, by means of a four-tailed sling or other suitable bandage. FlG. 161.—Unreduced disloca- tion of the lower jaw. (From a patient under care of Dr. W*. R. Whitehead.) 294 DISLOCATIONS. Subluxation of the Jaw.—Under this name, Sir Astlev Cooper has de- scribed a peculiar condition, met with chiefly in those of relaxed and feeble muscular frame, which is supposed to depend on the condyles slipping in front of the inter-articular cartilages, and thus rendering the jaw tempo- rarily immovable. Annandale believes that the lesion is really a displace- ment, of the inter-articular cartilage itself. Whatever be the true nature of this affection, it is undoubtedly accompanied by relaxation of the artic- ular ligaments, which allow the condyles to slip about during the act of chewing, thus often producing a clacking sound, which is sometimes audi- ble at a distance. The subluxation, if such it be, may be bilateral or uni- lateral only ; it is sometimes produced by the act of opening the mouth widely*, as in gaping or laughing, but, in other cases, occurs without any apparent exciting cause; it may usually be reduced by the patient himself, by pressing the jaw sideways, or by lifting the chin slightly upwards. Sometimes this condition appears to depend on spasm of the muscles of mastication, when it may be made to disappear by friction over the affected part. Tonics should be given, if the general condition of the pa- tient appears to indicate their use, and the recurrence of the displacement may be prevented by wearing a slinjr, held in place by elastic bands. An- nandale advises that an incision should be made, and that the cartilage should be replaced and held in position by the introduction of a suture. Hyoid Bone.—Cases of dislocation of this bone have been recorded by Dr. Ripley, of South Carolina, and by Dr. Gibb, of London : the treat ment consists in throwing back the head, depressing the lower jaw, and pushing the luxated bone into position. Ribs, Sternum, and Pelvis.—Dislocations of the Ribs are described as occurring either at their vertebral articulations, or at the junction of their costal cartilages. The symptoms would be much the same as those of fracture in the same localities, except that, of course, crepitus would he wanting. The treatment would be the same as for fractures. Dislocations, or rather diastases of the Sternum and Pelvis, were referred to in connec- tion with fractures of those parts. Salleron lias reported three cases of dislocation of the ilium at the sacroiliac joint, without fracture, in each of which reduction was readily accomplished, and was followed by complete recovery. Gallez has met with diastasis of the pubic symphysis as the result of muscular action. Clavicle.—The clavicle is more frequently dislocated at the acromial than at the sternal end, the former injury occurring, according to Hamil- ton, about four times as often as the latter. Dislocation of the Sternal end of the Clavicle usually results from indirect violence, and is almost always in a forward direction. Disloca- tion backwards, however, occasionally occurs, and sometimes gives rise to troublesome dyspnoea or dysphagia, from pressure on the trachea or oesophagus, or to cerebral congestion, from pressure on the cervical veins. Dyspnoea and dysphagia may also occur in instances of upward dislocation, of which rare injury R. W. Smith has been able to collect but eight cases, including one observed by him- self, to which, however, may be added four others since recorded by Bryant and Shaw. The diagnosis in these eases is usually easy, + **~~Ai ■••<--**?; the subcutaneous position of the clavicle no. 162-Digiocation of Btemai end of rendering the deformity very apparent. clavicle, forward*. (Bry.nt.) Reduction can commonly be effected with- DISLOCATIONS OF THE SHOULDER. 295 Fio 163—Dislocation of the clavicle on the acromion. (Bryant.) out much difficulty, by placing the knee against the spine, and drawing the shoulders outwards and backwards, but the displacement is exceedingly apt to be reproduced. The apparatus most generally* applicable, consists in a compress over the projecting end of the clavicle (in cases of forward or upward displacement), held in 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 backward disloca- tion, the compress should be omitted, the shoulders being simply drawn backwards by a figure-of-8 bandage, or some similar contrivance. Though the deformity in these cases (especially when the displacement is forwards or upwards) is seldom entirely overcome, yet the utility of the limb does not appear to be materially diminished by the accident. In one or two cases of backward dislocation, the pressure- effects have been so serious as to induce the surgeons in attendance to resort to excision of the displaced portions of bone. The Outer End of the Clavicle is usually dislocated in an upward direction, resting upon the margin of the acromion process; the acci- dent results from indirect violence, and the nature of the case is usually* apparent, though, if there be much swelling, it may be mistaken for a downward dislocation of the humerus. Occasionally the acromial end of the clavicle is displaced downwards, by direct violence, such as the kick of a horse; and dislocation under the cor- acoid process has been described, though the cases on record are somewhat apocryphal. An instance of backward dislocation is recorded by Nicaise. Dislocation of the acromial end of the clavicle may be commonly reduced without much trouble, though, as in the case of luxation of the sternal end, reduction can with difficulty be maintained. 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 entirely removed, the mo- tions of the limb are less interfered with than might be anticipated. Dr. Montgomery, of Rochester, has reported a case successfully- 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 ob- served by Richerand, Gerdy, Morel-Lavalle, Haynes, Lund, North, Col, and Kaufmann. Scapula—Under the name of dislocation of the scapula, systematic writers describe a projection of the inferior angle of this bone, due either to its escape from beneath the edge of the latissimus dorsi muscle, or to great relaxation of the fibres of that muscle or of the serratus magnus ; the symptoms consist in the deformity, which is obvious, with some pain and weakness of the corresponding upper extremity. The treatment would consist in the application of external support, With the administra- tion 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 296 DISLOCATIONS. Fin. 164—Dislocation of the humerus downwards, into the axilla; subglenoid. (Pirrie.) of the humerus, though it is occasionally caused by indirect force, such as a fall on the hand or elbow, the arm being abducted at the 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 cap- sular ligament is widely torn, the long head of the biceps often rup- tured or detached, and the supra- and infra- spinatus, subscapulars, eoraco-brachialis and deltoid muscles much stretched and sometimes lacerated, while the axil- lary* vessels and nerves are compressed. The symptoms, in a recent case, are usually obvious : there is, beneath the acro- mion process, a marked depression, which can commonly be seen as well as felt, the arm is lengthened by nearly an inch, and the head of the humerus can be felt in the axilla, especially wiien the elbow is lifted away from the body. The arm is kept somewhat abducted, and pain is developed by pres- sing the elbow to the side ; the hand cannot be placed on the opposite shoulder when the elbow is in contact with the chest. The diagnosis in a recent case is thus usually very easy, but, when swelling and inflamma- tion have occurred, it becomes more difficult, if not occasionally impossi- ble, to be again simplified upon the subsidence of the inflammatory con- dition. Hence, although by a careful and systematic examination, the true nature of the injury may* almost always be eventually determined, the suieeon should hesitate before criticising another practitioner for a mistake which may* have been unavoidable under different circumstances. Prof. Dugas, of Georgia, has proposed as a test of the existence 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 existence of dislocation established, no other injury of the shoulder being capable of causing this disability*. The progiutsis should be somewhat guarded: although reduction is usually effected without difficulty, yet the arm not unfre- quently remains permanently weakened, partially anchviosed, 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 longhead DISLOCATIONS OF THE SHOULDER. 297 of the biceps muscle. The laceration and stretching of the capsular liga- ment leave the joint predisposed to a recurrence of the dislocation. In a rare variety of this injury, of which cases have been recorded by Middeldorpf, Busch, Nikolaysen, Alberti, and Linde"n, the arm is elevated ("luxatio humeri erecta"), and the forearm is pronated and stretched over the head. Dislocation Forwards.—Of this form of dislocation there are two varie- ties, the Subcoracoid (Fig. 165) and the Subclavicular : the latter may* be considered as an aggravated condition of the former, which was, indeed, described by* Sir Astley Cooper as a partial luxation. As the names imply*, the head of the hu- merus, in these inju- ries, rests beneath the coracoid process, or beneath the mid- dle of the clavicle. These luxations, which more often re- sult from indirect than from direct vio- lence, are accompa- nied by a great deal of muscular and liga- mentous laceration, and are attended with even more pain than the dislocation into the axilla. The symptoms are much the same as those of the dow*nw*ard luxa- tion, except that the axis of the arm is even more altered, and that the head of the bone can be felt in a different position. The subcoracoid is more often met with than the subclavicular dislocation, and is said by Mr. Flower and others to be the most common form of luxation of the shoulder-joint. Reduction appears to be morediffcult in cases of forward 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 symptoms from the dislocations already described, in that the elbow is brought forw*ards. 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 deformity is the prominence of the coracoid process of the scapula, which seems to project forward, and over which the skin is tightly stretched. Keduction has usually been effected without much difficulty in these cases, but in one instance, mentioned by Cooper, it was impossible to maintain the reduction, on account of rupture of the subscapularis muscle. 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 Fio. 165.—Subcoracoid luxation of the humerus. (Pirrie.) 298 DISLOCATIONS. six weeks after the occurrence of the dislocation. I succeeded in effectim? reduction 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 was firmly fixed by an assistant. Partial Dislocation.—Under this name has been described an injury, which appears to consist in the 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 ordi- nary downward or forward dislocation. Le Gros (Mark has reported a case of partial backward dislocation which resulted from injury, and in which reduction was readily effected. Treatment of Dislocations of the Shoulder.—The subglenoid and the subcoracoid dislocations may be reduced by the same means, while the subspinous and subclavian varieties require slight modifications in the direction in which the force is applied. Thus, in applying extension in the luxation beneath the clavicle, the head of the bone should be first drawn downwards, outwards, and subsequently backwards, so as to clear the cora- coid process; while in the subspinous dislocation, extension should be made downwards, outwards, and subsequently forwards. A great manv different plans have been devised for the reduction of dislocations of the shoulder, but they may all be classified in four divisions, as aiming to effect their object: 1, by extension and counter-extension alone; 2, by leverage alone; .'>, by a combination of these methods ; and, 4, by* manipulation, in its technical tense (see page 288). 1. Extension may be made (1) more or less downwards, as in Hippo- crates's and Cooper's method (Fig. 106), in which counter-extension is Fio. 16-;.—si,. Astley Cooper's method of applying extension with the heel in the axilla. made by the heel in the axilla;2 as in Skey's method in which the heel is replaced by an iron knob; as in Hamilton's plan, in which the scapula in fixed by the ball of the foot, placed against the acromion process ; or as in i This inward displacement of tlie biceps tendon, which Soden, J. Wni. White, and others have considered traumatic, is believed by Canton to be due to the existence of chronic rheumatic arthritis, wiiich may or may not have been the result of injury. I have myself been in the habit of considering it as a lesion of periarthritis. 2 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. DISLOCATIONS OF THE SHOULDER. 299 Abril's method (a revival of the Hippocratic ladder) in which the patient is suspended by the axilla over a crutch-head; (2) it may be made out- wards, as recommended by Malgaigne; or (3) it may be made upwards, as directed by White, of Manchester, Mothe, and others, the scapula being Fio. 167.—Reduction of dislocated shoulder by White's and Mothe's method. then fixed by the foot or hand placed above the acromion process. The latter, though painful, is probably the most efficient of any of the methods which professedly act by extension and counter-extension alone. 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 which I am in the habit of employ- ing, in these cases, is essentially that which was described by Dupuytren as a modification of Mothe's method, and which, according to Bromfeild, was in common use in his day; it consists in placing the patient, thor- oughly etherized, if necessary, in a supine position, and then, having drawn the arm directly* upwards, bringing it down fully extended in a broad sweep over an assistant's fist, placed in the axilla to act as a fulcrum —the scapula being at the same time steadied from above by the assistant's other hand. By this plan I have succeeded in reducing dislocations of the shoulder which had defied prolonged efforts made in other ways, and, in- deed, have as yet never failed in effecting reduction in a recent case. The same principle, that of extension combined with leverage, is involved in the methods recommended by Sir William Fergusson and by Prof. N. R. Smith, of Maryland, in which, however, the force is applied through the medium of extending lacs or bands. The peculiarity of Prof. Smith's method is that counter-extension is made from the opposite wrist, so as to insure the fixation of the scapula, by provoking the contraction of the trapezii muscles. Another mode of applying extension and leverage is that of Kelly, of Dublin, who folds the patient's arm around hisown pelvis, and, holding it there, by a sudden turn of his body draws the luxated bone into place. 4. Manipulation.—The reduction of dislocations of the humerus by manipulation alone has been practised by various surgeons, among w*hom 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 300 DISLOCATIONS. of the profession, in this country at least, is, I believe, due to Prof. II. II. Smith, of this city, whose method consists in first converting the luxation (if it be either forwards or backwards) into the ordinary downward or subglenoid variety, and then proceeding as follows: " Kiev ate the elbow and arm as high as possible, and flex the forearm at right angles with the arm, thus relaxing the supra-spinatus muscle. Then using the forearm as a lever, rotate the head of the humerus 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 subscapulars muscles, keeping the forearm for a few seconds in its position with the palm of the hand looking upward ; then bring the elbow promptly but steadily down'to the side, carrying the elbow* towards the body, and keeping the forearm so that the palm of the hand yet looks to the surgeon. Then quickly but gently rotate the head of the humerus upward and outward by carrying the palm of the hand downw*ard 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 in- juring 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 illustrated by Kocher, and by 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 a sling, for a week or ten days, so as to allow time for repair of the lacerated ligaments Dislocations of the Elbow.—Both bones of the forearm may be dislocated at the elbow-joint, or either separately. The Head of the Radius alone may be displaced forwards, outwards, or backwards, the forward dislocation 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 ordinarily be felt in its abnormal position, and the diagnosis can thus, unless there be much swel- ling, be readily made The forearm is kept in a semi-flexed position, and either pronated, or midway between pronation and supination ; any motion of the part is attended with great pain. Reduction is to be effected by making extension and counter-extension 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 main- tain reduction in these cases, and reduction itself is occasionally impossible; fortunately, the usefulness of the limb does not appear to be materially im- paired 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 behind the condyles of the humerus, while the head of the radius can be felt in its proper position. The elbow in such a case will be flexed at a right amie, and the forearm twisted in- wards and pronated. Reduction may be effected by Sir Astley Cooper's method of flexing the elbow over the knee; by extension and counter- extension, combined with direct pressure upon the olecranon ; or (as recently recommended by Dr. Waterman, of Boston) by* extending the forearm on 1 Packard's Minor Surgery, p. 204. DISLOCATIONS OF THE ELBOW. 301 the arm bey*ond 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 disloca- tion backwards, which is the most com- mon, is usually caused by indirect vio- lence, though occasionally by a direct blow, or by muscular action. Not only are the bones displaced backwards, but they are drawn upwards by the power- ful action of the triceps muscle. The diagnosis, if swelling have not occurred, can usually be made without difficulty; the arm is held in a slightly flexed position (rarely at a right angle), and the slightest attempt at motion causes great pain ; the olecranon and head of the radius can be felt projecting back- wards, while the condyies of the humerus form a hard and broad prom- inence on the front of the arm. The relative position of the olecranon and condyles is markedly altered, this being an important diagnostic mark between dislocation and fracture. Malgaigne, Littre, and Bennett, however, describe an incomplete form of luxation, in which the position of the olecranon is not materially changed. Reduction in a recent case is usually easy, though Fi3. 168—Dislocation of head of radius forwards . external appearance of limh. (Lis- ton ) Fiu. 169.—Dislocation of hoth bones of the forearm backwards. (Liston.) instances are on record in which failure has attended the efforts of the most skilful surgeons ; the prognosis is decidedly unfavorable as regards 802 DISLOCATIONS. old dislocations, though reduction has been effected by Hamilton, Miner, and others, at as late a period as seven months after the reception of the injury. The usual method of treatment is that recommended by Sir Astley Cooper, which consists in forcibly* but slowly bending the arm over the knee, which is placed on the inner side of the elbow, so as to press on the radius and ulna, separating them from the humerus, and thus freeing the coronoid process from its abnormal position (Fig. 170). Mr. J. E. Kelly, of Dublin, sits on a table, and fixing the patient's arm under one thigh, draws the forearm up- wards, and simultaneously presses on the olecranon with his other thigh. Another plan is to forcibly extend the arm so as to relax the triceps, making counter-ex- tension against tlie 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 without the aid of anaesthesia; prolonged efforts at reduction are, however, so painful, that in any case of difficulty an anaesthetic should be employed. Sayre has reported two cases of old dislocation of the elbow in which reduction was greatly facilitated by subcutaneous division of the triceps tendon. Hamilton recommends, as a test for reduc- tion, to flex the elbow to a right angle ; if this can be done without much pain, it proves that reduction is complete. McGraw advises that in old backward 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 which occurrences, he believes, would improve the con- dition of the joint. Stimson recommends arthrotomy in old dislocations, and, if this fails, excision of the joint. Lateral dislocation of the radius and ulna at the elbow is rarely com- plete, but in the majority* of cases is partial, and in an outw*ard 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 unmis- takable, although I have reduced an inward luxation of two weeks' stand- ing which was at first attended with 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 dis- placed bones, and counter-pressure on the lower end of the humerus. Lateral dislocation is sometimes found coexisting with the ordinary back- ward 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. Osteoplastic resection, or temporary separation of the ole- cranon, is recommended by Yblker as a means of exposing the joint in cases of irreducible luxation. Fio. 170.—.Reduction with the knee in the bend of the elbow. DISLOCATIONS OF THE HANDS. 303 Luxation forwards of both bones of the forearm, without fracture of the olecranon, is a very rare accident, there being not more than six or seven well-authenticated cases on record. The injury appears usually to have resulted from direct violence, and the most striking symptom is elon- gation of the forearm, which 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 w*as 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 dislocated from the radius, either forwards, backwards, or inwards. These accidents, 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 backward direction to violent pro- nation. The inward is the rarest form of luxation, Tillmans's figures giving but 9 cases of this, as compared with 16 of the forward, and 18 of the backward variety, with 5 in which the direction of the displacement was not specified. Reduction is easily effected bv fixing the radius, and simply pushing the ulna back into place", the limb being then placed between anterior and posterior splints. In connection with fractures of the lower end of the radius, backward dislocation of the ulna is not uncommon. The ligaments sometimes remain permanently stretched after the accident, so as to allow a certain amount of mobility of the ulna, and I have known such a condition to be mistaken for ununited fracture of this bone. The Carpus may be dislocated upon the bones of the forearm, either backwards or forwards These injuries are, however, rarely met with— Tillmans has collected but 24 cases—and in every case that has been sub- mitted to the test of dissection, the luxation has, according to Hamilton, been found complicated with fracture. The usual cause of either form of dislocation is a fall on the palm, though in a case of backw*ard displacement recorded by Hamilton, the injury resulted from a fall on the back of the hand, the w*rist being strongly- flexed. The diagnosis is made by observ- ing 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 subsequently* no tendency to reproduction of the dis- placement. Individual Bones of the Carpus are occasionally luxated in a backward direction, those bones which have been found thus displaced being the os magnum, semilunare, and pisiform, to which some writers add the cunei- form and unciform. Dr. Nolan Stewart records a backward dislocation of the scaphoid. The treatment would consist in effecting reduction by extension and pressure, supporting the part afterwards with splints and compresses. Chisholm reports a case of forward luxation of the semilu- nare, in which excision of the displaced bone was required. Dr. Nancrede has met with a fonvard 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 backwards, and the metacarpal of the thumb either backwards or forwards. Dr. P. K. Taylor records a case of backward dislocation of the fourth meta- carpal. Reduction is effected by extension and pressure, the hand being afterwards secured to a straight splint with compresses. 304 DISLOCATIONS. The Fingers may be dislocated at the metacarpophalangeal, or, more rarely, at the inter-phalangeal joints. The proximal phalanx of the thumb is not unfrequentlv dislocated backwards, reduction being sometimes very- difficult, owing, probably*, to the head of the metacarpal bone being caught Fin. 171—Unreduced dislocation of thumb. (From a patient in the University Hospital.) either between the lateral ligaments or between the heads of the flexor brevis muscle, or, according to Farabeuf, to the interposition of the external sesamoid bone. In the treatment of these luxations, extension may be made with the ordinary clove-hitch, or with Dr. Levis's ingenious appa- Fiq. 172.—Levis's instrument applied to the first finger. ratus, or with the "Indian puzzle," as recommended by Prof. Hamilton and others. A better plan, perhaps, is that practised by Prof. Crosby, which consists, according to Gross, " in pushing the phalanx back until it stands perpendicularly on the metacarpal bone, when, by strong pressure against its base, from behind forwards, it is readily carried by flexion into its natural position." In extreme cases subcutaneous division of the resist- ing 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. An inward lateral dislocation of the ungual phalanx of the thumb has been observed by Mr. Pratt, an Irish surgeon. Dislocations of the second phalanx of the thumb, or of the second or third phalanges of the fingers, may be reduced by simple extension and pressure, made with the surgeon's hands, or, if more force be required, with the apparatus of Dr. Levis. Dislocations of the Hip.—The subject of dislocation of the hip has been most ably investigated by Prof. Bigelow, of Boston, of whose ex- cellent monograph on the subject I shall not hesitate to make free use in the following pages. To understand the pathology of these dislocations, and the mechanism of their reduction, it is necessary to turn for a few min- utes to consider the anatomy of the joint, and especially of that portion of the capsule which is known as the ilio-femoral ligament, or ligament of DISLOCATIONS OF THE HIP. 3Q5 Bertin, and for w*hich Bigelow 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 Fig. 173.—The Y ligament; the inner fasciculus is Fig. 174.—Backward dislocation of hip ; exter- known as the ilio-femoral ligament, or ligament of nal appearance. Bertin. (Biuelow.) and but little less than two inches and a half wide at 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 lower part of the same line, and about half an inch in front of the small trochanter." Both of these divergent branches re- main unruptured in the ordinary dislocations of the hip, and their attach- ments must be borne in mind in attempting reduction of the various forms of displacement. The head of the femur may* be dislocated in almost any direction ; but there are three forms of luxation which occur so much oftener than the others as to be usually classed as regular dislocations, the other varieties being called irregular or anomalous. The regular dislocations are—1, backwards: 2, downwards: and 3, upwards. 1. The Dislocation Backwards, or Ilio-sciatic Luxation, presents two principal varieties, viz., upwards andbackwards, or on the dorsum ilii, and backwards only, the dislocation into the ischiatic notch of Sir Astley Cooper, or, which is a better name, dorsal below the tendon (of the obtu- rator interims), according to Prof. Bigelow. These two forms of luxa- tion, taken together, probably* embrace more than three-fourths of the 306 DISLOCATIONS. whole number of cases. Prof. Hamilton having found that of 104 cases, 55 were on the dorsum ilii, and 28 into the isehiatic notch. These injuries usually result from indirect violence: thus, the dislocation on the dorsum may be caused by any force wiiich produces great abduction, or abduction with inversion, the head of the bone being driven at the same time up- wards and backwards. A fall on the outside of the knee, or on the foot, while the limb is abducted,1 or a severe blow on the pelvis, while the body- is bent forwards, may each in turn be a cause of this dislocation. The etiology* of the isehiatic 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 when the limbs are flexed to a right angle than when 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 lower third in the dorsal dislocation, and just above the knee in the isehiatic 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 measure- ment, the patient being etherized so as to obviate spasmodic muscular resistance. If the limb can be readily everted, the case is not one of luxation. From ordinary non-impacted fracture, a dislocation can be distinguished by the fact that in the former there are mobility, crepitus, and eversion ; in the latter, immobility, no crepitus, and inversion. From the rare cases of impacted fracture with inversion, the diagnosis is more difficult, but may be made by observing that in such cases the trochanter is flattened, and the head of the bone still rotates in the socket, while in dislocation the tro- chanter 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, consists 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. " Bryant's line" is described on page 273. Reduction of Backward Dislocations.—The capsular ligament is usually widely lacerated in these injuries, except at its anterior part, where it is reinforced by what has already been described as the Y ligament. The ligamentum teres, also, is usually, though not necessarily, torn in these dislocations. The attachments of the Y ligament are such that extension 1 Fahbri, 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 consecu- tive displacements; this is, however, denied by F. S. Eve, of St. Bartholomew's Hospital. 2 According to Bigelow, in the isehiatic variety (dorsal below the tendon), the axis of th^ 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 hone 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. 307 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 acknowledged difficulty which attends reduction of the isehiatic variety of this luxation is due (as shown by Bigelow), not to the head of the bone being lodged in the sciatic notch, but to its being fixed behind and below the tendon of the obturator internus muscle, which separates it from the acetabulum, and which renders reduc- tion 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 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 simply 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 288), which, though practised empirically in these cases for a great many years previously, was first reduced to a sy*stem by Nathan Smith, of New* Haven, and Keid, of Rochester, and has been particularly illustrated, of late years, by Prof. Bigelow, and by the late Prof. Gunn, of Chicago. In the form of dislocation now* under consideration, the man- Fio. 175.—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. (Bioblow.) ipulation necessary for reduction consists (1) in flexing the leg upon the thigh (to gain leverage), and the thigh upon the pelvis (to relax the Y ligament, and, in the case of an isehiatic luxation, to disengage the head of the femur from the obturator tendon) ; (2) in abducting and at the same time rotating outwards the thigh in a broad sweep across the abdomen; 308 DISLOCATIONS. and (3) in finally- bringing down the limb into its natural position. The process, in fact, embraces the three motions of flexion, outward circumduc- tion, and outward rotation. The mechanism of this mode of reduction is that, by the abduction and rotation, the outer branch of the Y ligament is made to wind around the neck of the femur, thus constituting a sliding fulcrum by means of which the head of the bone is lifted into the aceta- bulum. 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 jiosterior part of the capsule will be unnecessarily torn, and the head of tlie 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 140J. The first mistake (that of undue flexion) is readily remedied by repeating the manoeuvre with the limb somewhat more extended; to remedy the second error, it is necessary, w*hile making abduction, to lift the limb, when the head of the.bone will usually slip readily into its socket. 2. Dislocation of the Head of the Femur Downwards, or dowmwards and forwards into the Thyroid Foramen, is produced by the application of force while the thigh is in a position of abduction, or by a blow on the back of the pelvis while the body is bent and the legs widely apart. The Fig. 176.—External appearance Fio. 177.—Reduction of downward dislocation, by rotatiou and of downward dislocation. inward circumduction. (Bigelow.) 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 fora- men. The symptoms of this dislocation are very apparent: there is coni- 1 This accident, according to the late Dr. Erskine Mason, of New York, occurs 0Diy when there has been rupture of the obturator internus muscle. DISLOCATIONS OF THE HIP. 309 monly an elongation of from half an inch to two inches, though, according to Rivihgton, 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 depressed, and, in a thin person, the head of the bone may be felt in its abnormal situation. Reduction is effected by a process exactly the reverse of that recom- mended for the backward dislocations; the leg and thigh being flexed as before, the limb is brought up in a position of abduction, then adducted and rotated inwards1 in a broad sweep across the abdomen (Fig. 177), the inner branch of the Y ligament being in this case the sliding fulcrum by which the bone is lifted into its socket. Care must be taken, in this manoeuvre, to avoid excessive flexion and excessive adduction, which would throw the head of the bone past the acetabulum, on to the dorsum ilii. The manipulation may be sometimes assisted by drawing the upper part of the thigh outwards with a towel. Fig. 178.—Application of the rope windlass, for backward dislocation. 3. Dislocation Upwards, or upwards and forwards on the Pubis, usually results from indirect violence, such as falling on the foot while the leg is stretched backwards, or stepping into a hole while w*alking, the foot being arrested while the body goes forward; it may also result from a blow or fall on the pelvis. In this luxation, the head of the femur rests on or above the 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), with great depression of the trochanter, and promi- nence of the head of the bone, w-hich may be felt over the body of the pubis, and outside of the femoral vessels. The diagnosis from fracture is made by observing the absence of crepitus, the immobility, the impossi- bility, or at least great difficulty, of inverting the limb, and the presence of the head of the bone in its new* position. Reduction may be accomplished, according to Prof. Bigelow, "by* much the same method as in the thyroid dislocation, except that in the pubic luxation the flexed limb should be carried across the sound thigh at a higher point. First, semi-flex the thigh, to relax the Y ligament, at the same Dr. Markoe, in one case, succeeded in reducing a thyroid luxation by outward rotation (using, therefore, the outer branch of tlie Y ligament as a fulcrum), inward rotarjtm 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. 310 DISLOCATIONS. time drawing the head of the bone dow*n from the pubis. Then semi-abduct and rotate inward, to disengage the bone completely. Lastly, while rotat- ing inward and still drawing on the thigh, carry the knee inward and downward to its place by the side of its fellow. As in the thyroid luxa- tion, this manoeuvre guides the head of the bone to its socket by a rotation which winds up and shortens the ligament, enabling the operator, by 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 dislocation in which reduction was successfully accomplished after twenty-six days. I can testify, from my own experience, to the facility with which recent dislocations may be reduced by the methods above described, and believe, with Prof. Bigelow*, that the period is not far distant " when longitudinal extension by pulleys to reduce a recent hip-luxation will be unheard of.''1 As, therefore, I cannot recommend the use of pulley's in these cases, I for- bear to describe their application. Illustrations are, however, given to show the positions in which the pulleys may be applied, and the directions in which extension is to be made, in the various forms of hip luxation, according to the teachings of Sir Astley Cooper and other standard authorities (Figs. 178, 179, 180). Beside the three regular forms of dislocation which have been above described, there are vari- ous anomalous forms, as (1) directly upwards (usually con- secutive upon the pubic disloca- tion), (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, in- wards and forwards into the perineum. These various forms of downward dislocation may he either primitive, or consecutive upon the ordinary thyroid va- riety. In these irregular forms of dislocation, there is usually great laceration of the capsular ligament, with, in some cases, rupture of the external branch, or even both branches of the Y Fio. 179.—Bloxam's dislocation tourniquet, applied for downward dislocation. (Erichsen.) ligament. Reduction may usually be effected by simply flexing the thigh, and then lifting and pushing the displaced bone in the direction of its 1 Mr. Kelly, of Dublin, reduces forward dislocations of the hip by a process analo- gous to that which he employs for dislocations of the humerus, viz., folding the pa- tient's limb around his own pelvis, and then making a sudden turn, so as, by extension and leverage combined, to draw the luxated bone into place. DISLOCATIONS OF THE HIP. 311 socket; or the luxation may be converted into one of the " regular" varie- ties, when manipulation can be applied according to the methods already described. Dislocations of both hips have been observed by Gibson W Cooper, Boisnot, and Crawford. ' In cases of old dislocation of the hip, greater force may be sometimes required than can be applied by the surgeon's unaided hands, and under Fig. 180.—Mode of reducing upward dislocation with pulleys. such circumstances the apparatus recommended by Prof. Bigelow for effect- ing angular extension may be usefully employed, 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 reduc- tion, owing to the struc- tural changes which occur in the acetabulum and in the head of the femur. To meet this difficulty, Prof. Bigelow suggests that the limb should be fixed in the position in which reduction was effected, until the socket has become again excavated by absorption ; the same plan should .be adopted in cases of recent luxation, in which there is any tendency to reproduc- tion of the deformity after reduction. Volkmann and MacCormac report cases of old dislocation of the hip successfully treated by ex- cision. The complication of dis- location of the hip with 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. Fig. 181.—Angular extension, in reduction of old dislocation of the hip. (Bigelow.) 312 DISLOCATIONS. After reduction of a hip dislocation, it is usually sufficient to tie the knees together with a few turns of a bandage, keeping the patient in bed for a week or ten days. An unreduced dislocation, especially of the isehi- atic variety, allows, after a time, much more use of the limb than would at first be supposed possible. Anaesthesia is almost always required for the reduction of hip-disloca- tions in adults, though in cases of children, or of very feeble persons, it may* often be dispensed with. Dislocations of the Patella.—The patella may be dislocated out- wards, inwards, or upwards, or it may be rotated upon its own axis, con- stituting the vertical luxation of Malgaigne. These accidents may result from muscular action, or from direct violence. The Outward dislocation is the most common, and may be either partial or complete; it may be re- cognized by the undue prominence of the inner condyle, and by the patella being felt in its new position ; the limb is usually slightly flexed. lied ac- tion 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 own shoulder. If this mameuvre fail, reduction may be accomplished by alternately flexing and extending the knee, w'hile lateral pressure is simultaneously made upon the patella. Dislocation Inwards is very seldom met with ; its symptoms and treatment are (mutatis mutandis) the same as those of the outward variety. Dislocation of the Patella on its Axis is produced by the same causes as lateral dislocation, of which, indeed, it may be looked upon as an aggra- vated 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 im- possible. Reduction may commonly be effected, as in cases of lateral dis- location, by direct pressure, aided by alternate flexion and extension. A case is recorded by W. F. Marsh Jackson, in which, after the failure of other methods, reduction was readily* effected by simply pushing up the displaced bone. It has been proposed to divide the ligamentum patella- and tendon of the quadriceps extensor muscle, with a view of facilitating reduc- tion in these cases, but the operation does not appear to have been pro- ductive of any marked benefit, while in one case it caused fatal suppura- tion. Dislocation Upwards can only result from rupture of the ligamentum patellae; the treatment would be the same as for fracture of the patella itself. Dislocations of the Knee.—The Head of the Tibia may be dislo- cated to either side, forwards, backwards, or in an intermediate direction, as backwards and outwards, etc. These accidents may result from direct or from indirect violence, such as twisting the thigh upon the leg by step- ping into a hole while walking. The lateral dislocations are always in- complete, while the antero-posterior luxations may* be either complete or partial. The symptoms of these injuries are very obvious ; the complete luxations are usually accompanied with shortening. Reduction may be effected by forced flexion of the knee, with direct pressure, aided by rock- ing movements, to which, if there be shortening, extension and counter- extension may be usefully added. The antero-posterior luxations, if com- plete, are apt to be attended with serious injury to the popliteal vessels and nerves, a complication which may require amputation. After reduction, the limb should be placed at rest in a long fracture-box, or on a suitable DISLOCATIONS OF THE ANKLE. 313 splint, until the subsidence of all inflammation of the joint, the part beino- afterwards protected from sudden motion by the use of an elastic knee-cap or firm bandage. Compound Dislocation of the Knee is usually a case for amputation. Dislocation of the Semilunar Cartilages, or Internal Derangement of the Knee-joint (Subluxation of the Knee), consists, according to Erichsen in the semilunar cartilages slipping either forwards or backwards from be- neath 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 mem- brane ; most authorities, however, teach that in this accident the cartilages themselves become wedged between the articulating surfaces, in such a way as to impede the motions of the joint, and give rise to the sickening pain which characterizes the injury. According to J. F. Knott, w-ho has suffered from this affection in his own person, the margin of the femoral condyle is jerked over the semilunar cartilage, which remains attached to the tibia. The accident is usually caused by twisting the knee, or by tripping over a stone or other obstacle in walking, though it has occurred from simply turning in bed. The symptoms are inability to walk, or even to extend the limb, intense pain, and rapid swelling of the joint.' Reduc- tion is efl'ected by alternately- flexing and extending the knee, combinin-r these movements with slight twisting and rocking of the joint. As the process is painful, ether may appropriately be used in these cases. After reduction, the patient should wear an elastic knee-cap, to prevent recur- rence of the displacement. Annandale, Owen, Cotterill, and H. W. Ailingham have effected cures in several cases by opening the joint and pulling the displaced cartilage into its proper place with forceps and then securing it with sutures. Brodhurst, Croft, and Annandale have also treated displacements of the semilunar cartilages bv excision, the patients recovering with the functions of the joint unimpaired. Dislocation of the Head of the Fibula is a very unusual accident, except as a complication of more serious injuries of the knee. The displacement may be either forwards or backwards, and the subcutaneous position of the bone renders the diagnosis easy. Reduction may be efl'ected by extension and direct pressure, or by pressure while the leg" is fixed 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 bv Sir Astley Cooper, Malgaigne, and Hamilton, as dislocations of the lower end <>f the tibia; I think, however, that it is better to speak of them, with Beyer and others, as dislocations of the foot upon the bones of the leg. Ihe displacement occurs between the upper articulating surface of the astragalus and those of the tibia and fibula, and the foot may be dislocated forwards, backwards, to either side, or, as in a case mentioned by Druitt, directly upwards between the bones of the leg. The lateral luxations are usually attended with fracture of one or both malleoli, the outward dislo- cation being sometimes additionally complicated by fracture of the outer edge of the tibia into the joint, a circumstance which, as pointed out by Hamilton, may render reduction impossible. The backward dislocation is usually accompanied with fracture of the fibula, and sometimes of the tibia as well. The forward dislocation is very rare, usually attended with frac- ture, and, according to R. W. Smith, always incomplete. These injuries may result from either direct or indirect violence, the particular form of the displacement depending upon the position of the foot at the moment at w*hich the accident occurs. The antero-posterior luxations can be easily recognized by the characteristic deformity, the foot being lengthened in the 314 DISLOCATIONS. forward, and shortened in the backward, dislocation. True lateral luxa- tion is a less frequent accident than is generally supposed, the majority of the eases which are called dislocation, being really instances merely of rotation of the astragalus, without actual separation 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 with direct pressure, and flexion and rotation of the ankle in various directions, according to the nature of the displacement ; section of the tendo Achillis may occasionally be required. After reduction, the limb should be fomented with lead-water and laudanum and placed in a fracture-box with suitable compresses, or on a splint of binders' board, until recovery is complete. Compound Dislocation of the Ankle is a very serious accident, and often requires amputation, particularly when complicated with fracture, though in suitable cases an attempt should be made to save the limb by excision of the joint. I once succeeded in effecting a cure without opera- tion, 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), for- wards and outwards, 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 mo- ment at which the accident occurs. In the forward dislocations, the leg is shortened, the astragalus projects in front of one or the other malleolus, and the foot is somewhat extended and twisted to the opposite side. In the backward luxation, which occurs least often, the foot is in a state of extreme flexion, and the heel is elongated while the instep is shortened. Reduction should be attempted by making firm traction (the leg being flexed upon the thigh), and rotating and twisting the foot in the opposite direction to that in which it is found, while firm pressure is made upon the projecting astragalus. Subcutaneous division of the tendo Achillis has been found a useful adjuvant in cases of forward displacement, and in a case of great difficulty Desault's plan of dividing the attachments of the astragalus itself might be tried, as has been successfully done by Fitz- gerald, 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 dislocation of the astragalus is usually irreducible, the patient notwithstanding recovering with a very* useful foot. In a case of compound dislocation, it would be proper (unless reduction were readily* accomplished) to excise the astraga- lus 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 calcaneum upon the astragalus and cuboid, or upon the astragalus alone; of the scaphoid and cuboid upon the calcis and astragalus; or of the cuboid, scaphoid, or cuneiform bones, separately or together. Reduction in these cases may usually be accomplished by pressure and traction in different directions, according to the nature of the particular displacement. Forward extension (that is, at a right angle to the leg) 1- advised by H. Lee and Pick in the subastragaloid variety. Even if EFFECTS OF BURNS AND SCALDS. 315 reduction 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. 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 corre- sponding effect of the application of a hot liquid, and it is often said that these two forms of injury may be distinguished by the fact that a burn singes the cutaneous hairs, w*hich are, on the other hand, uninjured by a scald. It is evident, however, that though this distinction answers well enough for the burns and scalds met with inevery-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 in- juries 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 tem- perature of the body* which inflicts the injury, and the length of time dur- ing which its application is continued. Thus, a momentary contact with flame will produce a less degree of disorganization than prolonged contact with a substance the temperature of which may be much lower. Dupuy- tren divided burns into six classes or degrees, according to the extent of injury- inflicted; and this classification, w*hich 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 fol- lowed by the formation of numerous vesicles and bulla?. In the third class the whole depth of the skin is involved, and is thrown off in the form of thin superficial sloughs. In the fourth class the destructive effect reaches the subcutaneous areolar tissue, the sloughs are firmer and deeper, and, on separating, leave granulating ulcers. In the fifth class the deeper-seated structures, muscles, tendons, etc., are affected; while in the sixth class of burns, all the constituents of the part, including the bones, are involved in destruction. The various changes which take place in a part that is burnt, are those that have already been fully described in the chapter on Inflammation, and the processes of granulation, cicatrization, etc., by which repair is accomplished in these cases, are the same as in solutions of con- tinuity 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 consti- tutional symptoms may be divided into three stages, viz., that of depres- sion, that of reaction, and that of exhaustion. The stage of depression is 316 EFFECTS OF HEAT AND COLD. 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 with other causes, such as intense pain, or suppression of the physiological action of the skin. Thus, often patients received into the Pennsylvania Hospital from a fire at the Continental Theatre, in September, 18(51, six died within twenty-four hours, some without any reaction, and others having reacted very imper- fectly. The second stage is marked by the occurrence of inflammatory fever, accompanied often by violent traumatic delirium; the duration of this stage is usually from the second to the tenth or twelfth day, and dur- ing this period death may occur from internal congestion, or from inflam- mation of the brain, air-passages, kidneys, or alimentary- canal ; the locality of the burn influences the seat of these secondary complications, a burn of the chest being followed by bronchitis or pneumonia, while one of the abdomen is more apt to cause inflammation of the bowels or peritoneum. A peculiar and very grave complication of this stage, which has been par- ticularly 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 defi- cient action of the skin, but, according to Feltz and Wertheini, is, in com- mon 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, without regard to the particular cause of the injury; death may occur from simple exhaustion, from secondary visceral degenera- tion (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 disintegration of the red blood-corpuscles, with secondary* parenchymatous inflammation of the kidneys, and ursemic poisoning. Symptoms.—The Local Symptoms of burns are those of inflammation of the tissue affected, without regard to the cause. The intensity of the inflammatory* process varies in different cases, and in different parts of the body in the same case, so that we generally find the first four, and some- times 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 chilli- ness, the temperature of the surface is depressed, the features are pinched, and the whole body is in a state of partial collapse. With t he development of the second stage, thirst becomes the most distressing symptom; there is an insatiable craving for liquids, w*hich are rejected by vomiting as soon as they are swallowed. The patient is now very restless and feverish, and tosses off the bed-clothes, 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 neces- sary 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 TREATMENT OF BURNS. 317 of the cutaneous surface be affected, no matter how slightly, the case will probably- terminate fatally. Even if one-third, or one-fourth, of the sur- face 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 seri- ous than one of similar extent upon the extremities. The depth of a burn is of less prognostic importance than its extent, at least as regards life, which may often be saved (when the lesion is in one of the extremities) by a timely amputation. There is a popular idea that patients who are burnt often die from inhal- ing 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), when 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, however (and this corresponds with my own experience), most deaths from burn occur during the first forty-eight hours; of 194 fatal cases which were received into St. George's Hospital in sixteen years, 98 terminated during the first two days, 55 more during the first fortnight, and only 41 at a later period. Treatment.—The Constitutional Treatment of burns is of the greatest importance. The first thing to be done is to promote reaction. The patient should be placed in bed and covered with blankets, while foot-warmers, or hot bricks or bottles, are employed to maintain an elevated temperature. 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 permitting the patient to suck small lumps of ice, or by the moderate use of carbonic-acid water; but the patient should not be allowed to deluge his stomach with liquids, as the consequent vomiting and attend- ing depression would 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 always be watched for during the early stages of a burn, especially with female patients, who, from a feeling of modesty*, frequently conceal their sufferings in this respect. When a patient has thoroughly reacted, the treatment consists chiefly in the administration of food and stimulus. Two or three pounds of beef, in the shape of beef-tea, with six or eight fluid ounces of brandy, and a quart or two of milk, is no unreasonable daily allowance for a bad case of burn. The only drug habitually- required is opium; twenty minims of laudanum, or half a grain of sulphate of morphia, every* six hours, is often not too much to relieve pain and promote 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 exhaustion of the patient; if by the latter, the operation should not be too 318 EFFECTS OF HEAT AND COLD. long postponed, on account of the risk, already referred to, of the occur- rence of visceral degeneration, probably of the so-called amyloid or albu- minoid variety. With regard to Local Applications to burns, I do not believe that it makes a great deal of difference what article is used, jirovided that the surface is thoroughly excluded from the air, and that the process of dress- ing is neatly* and properly attended to. The application which I my self prefer in cases of recent burn, is the old-fashioned carron oil, made by- stirring linseed oil and lime-w*ater into a thick paste, which is then spread upon old linen or muslin, and covered with oiled silk. It is customary to speak of this as a filthy dressing, but I cannot see that it is any less clean than other applications, while it is certainly, according to my experience, extremely soothing and agreeable to the patient. Other dressings may, however, be used, if the surgeon prefer, and excellent results are doubtless obtained with raw* cotton, flour, white paint, lard, glycerine, iodoform, chlorate of potassium, or any other of the host of substances which have been recommended. More important than the particular article used is the mode of using it. Only a small portion of the surface should be uncovered at once, and the burn, if extensive, should thus be dressed, as it were, in detachments. Vesications, if there lie any, should be punctured with the point of a sharp knife, the contained serum being allowed to drain away of itself, so as to preserve the cuticle as a covering for the parts beneath. The dressings should be covered with oiled silk or waxed paper, to prevent evaporation, and should be held in place with roller bandages, the injured parts being supported in an easy position, with soft pillows covered with oiled silk, or with pads of cotton wadding. The dressings should be entirely renewed, as a rule, once in two days; while unnecessary disturbance of the patient is to be deprecated, the discharge is usually so profuse and offensive, that to delay* a change of the dressings longer than this does more harm than good. When the sloughs have separated, the remaining ulcers may be daily painted with a weak solution of silver-nitrate (gr. iv-f§j), and dressed with lime-water, dilute alcohol, or zinc or resin cerate, as in the case of any* other granulating surface. While the dressing is to be con- ducted with all gentleness, it must be neat and thorough; especial care should be taken to wipe clean the newly-formed skin around the healing ulcer, which may be advantageously stimulated from time to time by light touches with lunar caustic or blue stone. During the healing process, care must be taken to guard against undue contraction of the cicatrix, by the use of 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 opera- tive 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 possible to prevent deformity- by the use of splints and careful bandaging, or by* means of elastic rings and bands, so applied as to coun- teract 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 amputation. In the neighborhood of the joints, as of the elbow-, it may* be sufficient to divide the cicatrix by a free incision carried into healthy* tissue on both sides of, and beneath, the scar; the after-treatment consists in making extension by means of screw- OPERATIONS FOR CONTRACTED CICATRICES. 319 Fia. 182.—Contraction of arm following a burn. (From a patient in the Episcopal Hospital.) apparatus, or, which I think better, the ordinary weight-extension, applied to the limb below the scar, with lateral support" by means of side-splints or a fracture-box, the wound being allowed to heal while the limb is in an extended position. The re- sult of such an operation is shown in Figs. 182 and 183, from pho- tographs of a patient under my care some years since in the Epis- copal 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 con- traction, when their integrity- will be endangered by the process of extension. Simple division of the cicatrix is not sufficient in the case of burns about the face and neck, and here various plastic operations have been practised by Mutter, Buck, and others, to rem- edy the deformity, which is both annoying and painful. No gene- ral rules can be given for the man- agement of these cases, which must be left to the ingenuity and skill of the surgeon in each par- ticular instance. It may be said, however, that when the extent of the injury permits it, flaps of sound tissue should be brought, by twisting or by sliding, to cover the space left free by division and dis- section of the cicatrix. In cases, on the other hand, in which this cannot be done, an attempt may be made to utilize the cicatricial tissue itself, as has been ingeniously and successfully done by Butcher, of Dublin. Mr. Butcher's operation, which has for its object the restoration of the elasti- city of the cicatricial flap, consists in scoring subcutaneously the hardened tissue, with numerous incisions made with a long, narrow-bladed knife. The surgeon is thus enabled to unfold, as it were, the matted cica- trix, and render it available for autoplastic pur- poses. When the deformity is limited to drag- ging down and eversion of the lower lip, Teale's modification of Buchanan's cheiloplastic opera- tion will be found very useful; this consists in dissecting up flaps from the side of the lower lip (Fig. 184, a), and then joining these flaps together, and to the freshened edge of the cen- tral portion (b), which affords a firm basis for their support; the triangular spaces (c) which are left, are allowed to heal by granulation. James, of Exeter, has supplemented the use of the knife, in these cases, by the employment of a screw-collar, wiiich gradually pushes Fig. 183.—Result of plastic operation for contrac- tion of arm following burn. (From the same patient as Fig. 182.) Fig. 184.—Teale's operation; the flaps in place. (Erichsen.) 320 EFFECTS OF HEAT AND COLD. the chin away from the sternum. In the case of the upper lip, Teale makes a crucial incision, of wiiich the point of intersection is immediately below the septum of the nose. The incision involves the whole thickness of the part, and the operation is completed by dovetailing together the resulting lateral triangles, so as to increase the depth of the lip at the ex- pense 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 particu- larly* recommended by its author for the cicatrices resulting from glandular suppurations or from bone-disease. 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 circum- stances, 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 with a narrow* saw in front of the cicatrix, so that mastication may be accom- plished by means of the natural articulation on one side, and the artificial false joint on the other. Esmarch meets the same indication by excising a wedge-shaped portion of bone, three-quarters of an inch wide at its upper part, and an inch below ; but in a case thus operated on by the late Dr. Gur- don Buck (for cicatricial contraction resulting from cancrum oris), though an inch and a half of bone w*as removed, the parts became re-approximated, and the operation seems to have been only partially successful: a better plan is, according to Durham, to separate the jaw with a screw-lever, and then endeavor to restore the functions of the part by practising passive motion. The statistics of Rizzoli's and Esmarch's operations have been investigated by Schulten, who finds that 26 cases of the former gave 13 permanent recoveries and 3 deaths, while 40 cases of the latter gave 15 permanent recoveries 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 potassa*. Occasionally* a true cancerous formation appears to be developed in an old cicatrix, rendering excision (if practicable) still more imperative. Effects of Cold. The effects of cold are both constitutional and local. The 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, will terminate in coma and death. Hunger, great fatigue, or any circum- stance which impairs the general tone of the system, may increase the sus- ceptibility to the effects of cold, and hence the liability- of soldiers in a winter campaign to suffer from this cause. The mechanism of death from cobl has been investigated by Lebastard, who finds that it may occur from several distinct conditions, viz., (1) in cases of sudden and progressive chilling, from cerebral anaemia ; (2) in those of slow and continuous chill- ing, 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 FROST-BITE. 321 congelation, usually from congestion, but sometimes from ansemia, 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, accord- ing to Larrey, observed in many of the survivors of the retreat from Mos- cow*. The treatment of a person apparently dead from cold, consists in placing him in a room of low temperature, and in practising systematic but gentle friction w-ith snow, or with flannel wrung out of tincture of camphor or dilute alcohol, together with a resort to artificial respiration. These means should be continued until reaction is well established, when the body may be wrapped in blankets, stimulating draughts administered, and the temperature of the room gradually raised. Efforts at resuscitation in such cases should not be prematurely discontinued, as patients have occasionally been saved, even when apparently dead for several hours. Tedenat refers to a case in wiiich a patient recovered after being buried in snow for 24 hours, and others in which persons were taken out alive after being simi- larly buried for four and eight days respectively. Nicolaysen reports a case in which recovery- followed, 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 Chapter XXVII.) Peripheral 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 penis, hands, and face. The part affected is more or less deeply congested and swollen, and the seat of intense itching and burning. Vesication sometimes occurs, and may leave ulceration of an intractable character. A patient who has once had chilblains is very apt to suffer from a recurrence of the affection, upon even slight changes of weather. The treatment consists in plunging the part into cold water or rubbing it with snow, following this application by the use of local stimulants, such as the nitrate of silver, tincture of iodine, or soap liniment. Fergus speaks very favorably of the employment of sulphurous acid. The remedy which I am in the habit of employing is the nitrate of silver in weak solution (gr. iv-v to f|j), frequently painted upon the part, which is then wrapped in raw cotton. The nitrate of silver seems to obtund the local sensibility, and certaintly relieves the burning and itching which in these cases are so distressing. Lapatin applies equal parts of dilute nitric acid and peppermint water. The ulcerations which sometimes attend chil- blain require stimulating applications, such as resin cerate, or dilute citrine ointment. T. Smith has called attention to the periodicity with which the paroxysms of itching in 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 anticipated, if the patient's convenience so dictate, by immersing the part for a few minutes in a mustard bath. Frost-bite results either from exposure to an intense degree of cold, or from prolonged exposure to a less degree. The parts most often affected are the nose, lips, ears, fingers, and toes, though occasionally the effect is more extensively diffused, whole limbs becoming frost-bitten. Fremmert, of St. Petersburg, found from an analysis of 494 cases, that in 333 the 322 EFFECTS OF HEAT AND COLD. lower extremities alone were 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 f>, other parts of the body without the extremities. " 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 suscep- tible age appeared to be from 30 to 35. Of the whole 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 were performed upon 134 individuals, 15 of whom submitted to major amputations upon one or more limbs. The first effect of cold is the production of a dusky- redness, with some tingling and pain ; but further exposure causes a tal- lowy whiteness of the affected part, which is also shrunken, insensible, and motionless, presenting much the appearance of gangrene from arterial oc- clusion. Mortification may* be induced directly by the intensity of the cold depriving the tissues of vitality, though more usually death of the part follows from the violent inflammation which results from undue reaction. Thus, Larrey found numerous cases of frost-bite caused by a sudden thaw, when the previous severe cold had given the affected persons no inconve- nience. The treatment of frost-bite consists in moderating the intensity of the reaction, and thus endeavoring to prevent the occurrence of mortifi- cation. 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 in the meanwhile kept in a cold room. Bergmann recom- mends that the injured part should be suspended 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 lie continued, as long as the gangrene manifests 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 remove the gangrenous mass by cutting through the dead tissue below the line of separation, waiting to improve the shape of the stump by a regular amputation at a subsequent period, when the patient's general condition has been improved by appropriate constitutional treatment. WOUNDS OF THE SCALP. 323 CHAPTER XV. INJURIES OF THE HEAD. Injuries of the Scalp. Contusions of the Scalp are chiefly* of interest in a diagnostic point of view, the sensation which they communicate to the fingers of the sur- geon being often deceptive, and leading to the supposition that the case is one of fractured skull. There is in both affections a rim of indurated tissue with a central soft depression, but, in a contusion, firm pressure will usually detect the bone at the bottom of the cavity*. The most skilful surgeons may, however, be deceived by these cases, and incisions have been made with a view of elevating depressed bone, the operation showing that no fracture existed. Large collections of blood, either coagulated or fluid, may result from contusions of the scalp, remaining apparently* without change for a considerable period. As a rule, no incision should be made in these cases, but the surgeon should encourage absorption by the use of evaporating lotions, or of moderate pressure. If, however, suppuration occur, the pus must be evacuated by a free incision. Cephalhematoma, or Caput Succedaneum, is a bloody tumor of the scalp in new-born children, resulting from pressure during birth. The blood is usually effused between the scalp and pericranium, though more rarely beneath the latter. The treatment is the same as for similar extravasations resulting from other causes. Wounds of the Scalp.—Scalp-wounds do not differ materially from similar injuries in other parts of the body*, as regards their pathology* and treatment. The tissues of the scalp are extremely vascular,1 hence the hemorrhage in .these cases is often profuse; on the other hand, the vascu- larity of the scalp is of advantage, in enabling the parts to preserve their vitality after injuries which, in other tissues, weuld be certainly followed by extensive sloughing. In all ordinary* wounds of the scalp, whether in- cised or lacerated, the detached flaps should be carefully replaced (the parts being cleanly shaved), and held in position with strips of isinglass plaster, or, wiiich is better, with the gauze and collodion dressing, or one of its modifications (see page 153). A firm and broad compress should then be placed over the seat of injury, and secured by a suitable bandage ; bleeding is thus readily checked, and the flaps are held in such a position as to favor union. I do not advise the use of either sutures or ligatures, in ordinary cases of scalp-wound, simply because I do not believe them to be necessary. They are, indeed, thought by many surgeons to act as exciting causes of erysipelas, when applied to the scalp ; but there is no proof, as far as I am aware, that they exert any such influence. They- are, however, usually unnecessary, and therefore, of course, undesirable. If a wound of the scalp be accompanied with so much contusion and laceration that sloughing appears unavoidable, it will be proper simply to support the flaps with adhesive strips, and apply to the wound some warm and soothing application, such as moist antiseptic gauze, olive oil, or di- luted alcohol. 1 W. J. Tyson has recorded a remarkable case of traumatic aneurism of the scalp. (Trans. Clin. Society, vol. xiii.) 324 INJURIES OF THE HEAD. As in every case of scalp-w*ound there is at least a possibility of some concomitant injury to the brain, a patient with such an injury should be carefully watched during the entire course of treatment; the diet should be regulated (all irritating or indigestible substances being avoided, while at the same time easily assimilable nutriment is provided in sufficient quanti- ties), and attention should be given to the condition of the various secre- tions and excretions of the body. Erysipelas and Diffuse Inflammation of the Subcutaneous Areolar Tissue are usually said to be especially apt to follow upon wounds of the scalp. Such has not been my own experience, though I can readily under- stand 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 compli- cations arising, w-ould be to remove all pressure or sources of tension, by reopening the lips of the wound, 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, follow*s in cases of scalp-wound in which the bone is denuded of pericra- nium. Such a ease should be treated upon ordinary principles, the seques- trum being removed as soon as it has become loose. The accompanying cuts (Figs. 185, 186) illustrate the severest case of scalp-wound which I have ever seen followed by recovery. The patient was a girl of fifteen, an operative in a cotton-mill, who was caught by her hair between rollers which were revolving in opposite directions, her scalp Fias. 185, 1S6.—severe scalp wound. (From a patient in the Episcopal Hospital.) being thus, as it were, squeezed off from her head and forming a large horse- shoe-shaped flap. The linear extent of the wound was fourteen inches, the distance between its two extremities being but four inches. This large flap was thrown backwards, like the lid of a box, the skull bein deaths and 101 recoveries ; 451 cases of removal of splinters or ele- vation of fragments, without trephining, gave 176 deaths and 275 recoveries ; while 3447 cases treated by expec- tancy gave 2159 deaths and only 1288 recoveries. (Otis.) As, however, 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 would be manifestly unfair to found upon these statistics any argument as to the value of the operation of trephining Fiu. 193—Conical trephine. INJURIES OF THE SPINAL CORD. 343 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). Total. Recovered. Died. Mortality per cent. Secondary ..... Late...... . Period unknown .... 114 158 59 592 51 94 39 266 63 64 20 326 55.26 39.24 33.90 55.07 Aggregates .... 923 450 473 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, already referred to, of trephining for epilepsy. In these cases the only traumatism, to borrow* a Gallicism, is that due to the operation itself, and here we find that the mortality is about 20 per cent. Walsham puts the figures still lower, giving the mortality of " late trephining" as only 10.6 per cent. But even with these comparatively small death-rates, it behooves the surgeon to be very cautious not unnecessarily to employ an operation which of itself kills one out of every five or ten patients, more especially as, upon consideration of the pathology and natural history of brain inju- ries, the probability of benefit from the operation is seen to be limited to an exceedingly small number of cases. CHAPTER XVI INJURIES 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 vertebral column and its important contents to be in- volved in lesions of the back, that injuries of this region acquire the interest which they possess in the eyes of the surgeon. In entering upon the im- portant subject of spinal injuries, I shall consider, first, the traumatic lesions of the spinal cord itself, reserving for a later page what I have to say with regard to sprains, fractures, and dislocations of the vertebral column. 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 dis- organization. Unlike concussion of the brain, however, it is very seldom that the spinal injury is so severe as to prove immediately, or even rapidly, 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. ^ee remarks on Concussion of the Brain, in Chap. XV. 344 INJURIES OF THE BACK. fatal (except when accompanied by fracture or dislocation), death as a result of spinal concussion usually* occurring after a considerable interval, and being preceded by inflammation of the spinal meninges or of the cord itself, or by progressive softening without inflammatory 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 as readily exposed to injury as the brain, which fits comparatively closely to its bony investment. I do not believe it pos- sible for death to occur from concussion of the spinal cord, without lesions demonstrable by post-mortem inspection. Though several eases have been recorded by- Boyer, Frank, and others, in which such an event has been supposed to occur, it is probable that, with the more accurate means of examination which are now* possessed, positive lesions could have been dis- covered. Death may, of course, occur from shock, which is an occasional complication of spinal injuries ; or from concomitant lesions of other organs —lesions which may readily* escape detection, if attention be directed chiefly to the condition of the spine.1 The post-mortem appearances, in fatal eases of spinal concussion, may be classed as (1) extravasation of blood—which may occur in the substance of the cord itself, between the cord and its membranes, or between the latter and the vertebral column ; (2) laceration of the membranes, or of the cord; (3) inflammatory changes—meningitis or myelitis—with or without compression of the cord from the so-called products of inflammation, lymph, pus, etc.; and (4) degeneration of the structure of the cord, without any evidences of pre-existing inflammation. Hemorrhage into the Vertebral Canal is a not unfrequent occur- rence 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 absorbed, and the compressed cord becoming gradually- accus- tomed to its presence ; in other cases it may remain in a fluid condition, or may possibly be clotted and subsequently re-liquefied. In some cases it would appear that slow extravasation may continue for a considerable period, fatal paralysis not coming on for some time after the injury (in Mr. Heaviside's case nearly a year), and death thus resulting, as pointed out by Aston Key, from the cumulative effect of spinal compression. I do not know* of any sign by which the surgeon can positively determine the exact seat of extravasation in cases of spinal hemorrhage ; in the majority of instances the effused blood is found outside of the membranes, or between the latter and the cord; and it is probably in one of these positions that extravasation usually* occurs, when the symptoms are slow and progressive in their development, and when the power 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 symptoms in the remarkable case recorded by Hughes, of Dublin, in which an injury of the cervical spine caused instant but temporary loss of both motion and sensation, in the lower extremities, followed by gradually developed but long-persistent motor paralysis, in the upper extremities. Instant loss of both motion and sensation, if temporary, may be supposed to be due to a slight hemorrhage into the substance of the cord itself; while gradually developed paralysis, especially affecting the motor power, may be reasonably attributed to hemorrhage upon the surface of the cord, or even outside of the membranes. 1 See, in connection with this subject, an interesting paper, by Dr. W. Moxon, on thrombosis of the renal vessels through injury to the lumbar spine. (Guy't Uotp. Reports, 3d s., vol. xiv., pp. 99-111). SYMPTOMS OF SPINAL INJURIES. 345 The upper limit of paralysis will, of course, indicate clearly the height at which the extravsation has occurred. Laceration or Rupture may occur in the spinal membranes (par- ticularly the pia mater, allowing a hernia of the medulla), or in the fibres of the spinal cord itself. These lesions are, however, more frequently- produced by violent twistings or bendings, or by fractures or dislocations of the spinal column, than by any injury to which the term concussion can be properly applied. Inflammation of the Spinal Membranes (Meningitis), and of the Cord (Myelitis), are very frequent secondary* occurrences in cases of spinal injury. In spinal meningitis there is great congestion, and often effusion of serum, or formation of lymph or pus. Myelitis may affect the whole thickness of the cord, or principally the gray matter ; though, if consecutive to meningitis, the white portion may alone be involved. Inflammation of the cord-substance is commonly attended with softening, which may end in total disappearance of the nervous structures at the part affected—nothing but connective tissue remaining; more rarely induration occurs, the nervous substance being increased in bulk, and of a dull whitish color. The occurrence of inflammation, in cases of spinal injury, is attended with great pain, distressing sensations, as of a cord tied around the waist or limbs, tetanic spasms, general convulsions, etc. Progressive Disorganization of the Cord may occur as the re- sult of injury to the spine, without the manifestation of any evidence of inflammation, either during life or upon post-mortem inspection. Paraly- sis, both motor and sensory, sometimes accompanied with muscular rigi- dity, gradually creeps upwards, until death ensues from interference with the respiratory function. The autopsy shows diffused w*hite softening of the spinal cord, without evidence of either meningitis or myelitis. In other instances, as in a case of Bastian's, the cord, to the unaided eye, appears perfectly healthy, though marked changes are subsequently discov- ered by careful microscopic inspection. Wounds of the Spinal Cord.—The spinal cord may be wounded by sharp-pointed or cutting instruments, by pistol-balls, etc., without any, or with very slight injury to the vertebral canal. The symptoms of such a lesion are those which we shall presently consider as common to all spinal injuries, though there may be some modifications, owing to the greater limitation of the injury to certain parts of the cord than in cases of spinal concussion, or of vertebral fracture or dislocation ; thus, while in the latter classes of cases paralysis is usually bilateral, and involves both motion and sensation, in cases of wound of the cord we not unfrequently find paraly- sis 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 following account of the symptomatology of injuries of the spine is to be understood as applying to all forms of injury in which the cord is involved, whether the vertebral column itself has or has not escaped; as we shall see hereafter, the differ- ential diagnosis of the various forms of spinal injury is often impracticable, and always difficult, a fact w*hich 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 wiiich I employed in my mono- graph on Injuries of the Spine, published in 1867, and w*hich 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, 346 INJURIES OF THE BACK. symptom in cases of spinal injury, is paralysis of the voluntary muscles below 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 below this point, and the cauda equina appearing to be comparatively free from risk of in- jury. In lesions below the eleventh dorsal vertebra, the paralysis is usu- ally 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 the parts which derive their nervous supply from the portion of the cord above the seat of injury, and the exact point of lesion can be thus determined in most cases; the apparent exceptions reported by Staf- ford, Brodie, and others, are probably explicable by the fact that a second lesion, such as contusion or extravasation, existed at the; higher point, as the result of indirect violence to which the older writers would have given the name of counterstroke. The extent of the spinal lesion in a down- ward direction, may be determined by means of the electrical test, proposed bv 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 electri- city, while those of the leg, though equally- paralyzed, continued to contract in response to the electric stimulus. The autopsy showed that the part of the cord wrhich supplied nerves to the femoral muscles was disorganized, while that whence arose the nerves going to the leg was quite healthy. Thus the fact that each segment of the cord constitutes a separate nerve centre, affords a means of accurately determining the extent of that portion which has been injured. Motor paralysis is usually symmetrical; when unilateral (as in a case of fractured spine observed by Liston), it indicates that one side only of the cord is involved, as in the instances of wound of the cord already referred to. Motor paralysis after spinal injuries may be due to various causes, as to division of the cord-fibres, to compression (either from extravasation, or from the products of inflammation), or to progres- sive disorganization, of the nervous structures. If the paralysis be im- mediate, 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 progressive disorganization of the cord—a condition which, almost always, ultimately proves fatal. A few cases are referred to by Yelpeau, in which 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 explana- tions—either, as believed by* Brodie, that they were 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 were 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 case-. The value of this symptom for diagnostic purposes is, however, diminished by the fact that the cord is often found compressed, after death, without spasms having been observed during life. The occurrence of convulsions at a later period (as already mentioned), may denote the onset of spinal meningitis: while again, in cases which recover, muscular twitchings not unfrequently accompany the return of motor power. SYMPTOMS OF SPINAL INJURIES. 347 Loss of Sensation usually accompanies and is coextensive with motor paralysis, in injuries of the spine. So complete was the loss of feeling in a case recorded by Purple, that the patient submitted to amputation of both thighs, without the use of an anesthetic, and without manifesting any emotion during the operation. Occasionally sensory precedes motor paralysis, while, on the other hand, in favorable cases, the power of feeling is not unfrequently regained while that of motion is still very imperfect. Hyperesthesia is occasionally observed in connection with motor paraly- sis. South saw a case of fracture of the cervical spine in which there was loss of motion with hyperaesthesia on the right side, and anaesthesia on the left. On the other hand, in a case reported by Gama, intense hyperaes- thesia followed a bayonet wound of the posterior columns of the spinal cord, there being absolutely no paralysis ; a circumstance which, as pointed out by Brown-Sequard, would indicate that the anterior portion of the cord had escaped injury. A zone of hyperaesthesia sometimes marks the upper limit of sensory paralysis, due probably to irritation of the spinal nerves, before their exit from the vertebral column. 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, con- striction, etc., may be referred to parts, the nervous connection of which with the sensorium is entirely destroyed. Dyspnoea.—This is a marked and distressing symptom of injuries of the cervical and upper dorsal regions of the spine. It is often said that, in lesions of the cervical cord, respiration is performed by the diaphragm alone; this is not strictly correct, for, as pointed out byShaw, in many cases the diaphragm is helped by the serratus magnus muscle (supplied by the external thoracic nerve), w*bich, when the shoulders are fixed, tends to lift and expand the chest. If the spinal cord be destroyed above the origin of the phrenic nerve, death is instantaneous. The occurrence of dyspnoea in dorsal injuries depends upon two causes: first, the abdominal muscles being paralyzed, the act of expiration is necessarily incomplete ; and, sec- ondly, paralysis of these muscles allows the bowels to become distended with gas, thus thrusting the diaphragm upwards, and mechanically im- peding its motion. The occurrence of dyspnoea at a late period of spinal injuries is attributable to progressive 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, without any hepatic lesion having been discovered after death. Involuntary Fecal Discharges are met with in those cases in which the injury has involved the lowest portion of the cord—that which presides over the sphincter muscle of the rectum ; when 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, which is coin- cident with, though not necessarily dependent upon, the spinal lesion. Retention of Urine is present in most cases of spinal injury, being fol- lowed after a time by Overflow, and subsequently by true Incontinence. A few cases are recorded by Morgagni and others, in which incontinence was present from the outset. Suppression of Urine is a more serious, but fortunately a rarer, symp- tom than retention. Several remarkable instances of this occurrence have been recorded by Brodie, Dorsey, Comstock, and others. Hematuria, from coincident contusion or partial laceration of the kid- 348 INJURIES OF THE BACK. nevs, is not unfrequentlv met with in cases of sprain of the lumbar spine. This symptom is not usually* one of serious import, though Mr. Shaw reports a case in which the bleeding was so profuse as to render the patient anaemic. There is, according to Le Gros Clark, no reason to believe; that organic disease of the kidney ever ensues in these cases. Glycosuria has been met with in connection with injury of the cervical spine; the circumstance is interesting, in view of the experiments which have been made as to the artificial production of diabetes. 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 mine, from being clear and acid, becomes tur- bid, ammoniacal, and loaded with mucus, and at a later period with phos- phate of lime. This condition may continue indefinitely, or may disappear, or acidity and alkalinity- of the urine may alternate, without any very- obvious reason. In some rare cases, according to Brodie, the urine first secreted after a spinal injury, though acid, and free from mucus, has a peculiarly- offensive and disgusting odor. In other cases it is highly acid, having an opaque yellow appearance, and depositing a yellow amorphous sediment, which, in one instance, stained the mucous membrane of the bladder, though the latter presented no marks of inflammation. Cystitis is an almost constant sequence of severe spinal lesions; it is probably due, chiefly to the mechanical injury to the bladder from over- distention and the frequent use of the catheter, but is no doubt, further aggravated by the altered character of the urine. This alteration, how- ever, is itself usually- secondary, depending on the inflamed state of the lining membrane of the bladder, though, in some cases, according to Hilton, the urine is alkaline as it comes from the kidneys. The cystitis of spinal injuries is, according to Brovvn-Sequard and Lidell. of neuropathic origin, and thus analogous to the cutaneous inflammation which ends in bed-sores. Priajtism.—This curious symptom is occasionally met with in connec- tion with lesions of all portions of the spinal cord, except the lowest, it is totally unconnected with any voluptuous sensation, and is only found in cases accompanied by motor paralysis. In some cases, particularly when the injury is in the cervical region, priapism may occur spontane- ously*, 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 sponta- eously—at a later period, owing to central irritation, generally from slight extravasation into the substance of the cord; while in still other cases it occurs merely as a reflex phenomenon, and may be excited by touching the scrotum, or by passing the catheter. The existence of priapism is usu- ally evidence of severe and permanent injury to the spinal cord, though that this symptom may occur in connection with simple concussion is shown by a case recorded by Le Gros Clark, in which sensation returned on the ninth day, though the power of motion was not restored for sev- eral months. Flushed Face, usually accompanied by Lachrymation, and by Con- tracted or merely Myotic Pupils, is, I believe, only met with in cases of injury* involving the cervical portion of the cord. It appears to be due to a partial paralysis of the sympathetic nerve, which derives its ccrvico- 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 particu- larly investigated by Chossatand Brodie. The temperature of the para- SYMPTOMS OF SPINAL INJURIES. 349 lyzed parts frequently rises much above the normal standard, this symptom being probably most frequent in lesions of the upper portion of the cord, though a temperature of 100° has been noted by Hutchinson in a case of fracture of the lumbar spine. In a case of injury of the cervical region ob- served by Brodie, the thermometer placed between the thighs rose to 111° Fahr., and this elevated temperature persisted even after the patient's death.1 This symptom, to which Hutchinson gives the name of Paralytic Pyrexia, is probably* due, like the flushing of the face, to a paralyzed con- dition 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 prognosis. 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 diminution of temperature, the patient often experiences a distressing sensation of coldness. Nutritive Changes in Paralyzed Parts.—In patients who survive the first risks of spinal injury, the paralyzed extremities usually, but not always, become flabby and atrophied; the skin assumes a sallow hue, and often desquamates in flakes; the joints are often contracted and stiff. Partly from the lessened vitality* of the tissues, but more particularly from the patient's insensitiveness to pain and inability to change his position, gangrene and sloughing are apt to occur in parts that are exposed to pres- sure; large bed-sores are thus formed over the sacrum, hips, knees, or any part that touches the bed, and may slowly exhaust the patient's strength, or, more rarely, may* give rise to pyaemia, and thus quickly induce a fatal result. Bed-sores are most frequently met with in cases of injury of the lower portion of the cord, simply, I believe, because in these cases life is more often prolonged than when the upper part of the spine is involved. According to Brown-Sequard, Charcot, and Lidell, certain of the so-called bed-sores met with after spinal injuries result directly from irritation of the spinal cord, and not from pressure. These Dr, Lidell proposes to call neuropathic eschars, which seems to me a better name that that of decu- bitus acutus, adopted by Samuel and Charcot. Tetanus, contrary to what might a priori be expected, is rarely met with 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. Tetanus followed a punctured wound of the cord in a case observed by Tadlock, of Tennessee. Cerebral Complications.— Concussion of the Brain may complicate in- juries of any portion of the spinal cord, resulting either from direct violence simultaneously- inflicted on the head, or from counterstroke. Delirium, Coma, and Insomnia, have each been occasionally noted in cases of spinal injury; the latter symptoms, however, I believe, only in instances in which 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 1253 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 thermometer, 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- viQS-naie' in the Adelaide Hospital, Dublin, the temperature is said to have risen to 133.60 Fahr., without evil result to the patient. 2 Temperatures of 820 Fahr., 81.7f>o Fahr., and 80.GO Fahr., were observed in fatal cases reported by Van der Kolk, Wagstaffe, and Nieden. Kosiirew has recorded a m«« Case of cranial injury, in which the temperature ranged from 79.7 Fahr. to s4.20 Fahr. 350 INJURIES OF THE BACK. the cervical region has been involved. Crrebral 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 Krichseu and other English surgeons, a peculiar morbid condition characterized by verv 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 companies, on account of alleged injuries received in colli- sions. The symptoms appear to be rather those of general nervous pros- tration and debility*, than the definite spinal symptoms which have been discussed in the preceding pages, and they are often accompanied by remark- able perversions of the special senses, double vision, photophobia, tinnitus aurium, loss of tactile sensibility, etc. Hyperaemia of the optic disk has been observed by AV. Bruce Clark, and serious intra-ocular changes have also been noticed by Dr. Allbutt and Mr. Wharton Jones. Many of the symptoms resemble those of ordinary progressive locomotor 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 ver- tebrae that are affected vary necessarily in different cases; but the exalted sensibility always includes two, and usually three, at each of these points. It is in consequence of the pain that is occasioned by any movement of the trunk in the way of flexion or rotation, that the spine loses its natural suppleness, and that the vertebral column moves as a whole, as if cut out of one solid piece, instead of with its usual flexibility." Other writers of eminence are disposed to doubt the necessary connection of these symptoms with any* particular morbid condition of the spine, looking upon "these cases of so-called railway spinal concussion as, generally, instances of ner- vous shock, rather than of special injury to the spinal cord."1 There is, as far as I know, but one case in which the post-mortem appearances after death from "railw*ay concussion" have been recorded, and that is Mr. Core's case, which has been successively published by Dr. J. Lockhart Clarke, Mr. Erichsen, Mr. Le Gros Clark, Mr. Shaw, and Mr. H. W. Page. The con- dition of the cord in this case closely* resembled, as pointed out by Le (fro.- Clark, that which, according to Dr. Radcliffe, is found in ordinary case-of locomotor ataxia, so that there is at least room for suspecting, with Mr. Shaw and Mr. Page, that the spinal injury was a mere coincidence— particularly as Mr. Gore, the attending surgeon, did not see the patient until a year after the injury. "On the whole, it may be affirmed," says Mr. Shaw, "that what is most wanted for the better understanding of those cases commonly known under the title of 'concussion of the spine' is a greatly enlarged number of post-mortem examination's. Hitherto onr 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." It is right, however, to add that autopsies showing marked microscopic lesions of the cord, the result of injuries similar to but other than those from railway collisions, have been recorded by Sir AV. Gull and Dr. Bastian. In view of the great obscurity which is thus seen to surround this subject, I think that the surgeon will 1 Le Gros Clark, Lectures on the Principles of Surgical Diagnosis, etc., p. 152. INJURIES OF THE VERTEBRAL COLUMN. 351 do wisely to exercise great caution in declaring that a patient is sufferino- from "concussion of the spine from indirect causes," whether the result of railway, or of other injury; at the same time, there can be no doubt that grave morbid changes in the spinal cord do result from comparatively slight blows upon the back, and, of course, in a railway collision, it is very possible that an injury might be received, which would induce such changes. This fact has long been recognized in a general manner, but is clearly proved by a case which Dr. H. Charlton Bastian has published in the fif- tieth volume of the Medico-Chirurgical Transactions, and which has been already referred to (see page 345). Injuries of the Vertebral Column. Sprains—AArhen we consider the number of joints in the vertebral column (nearly eighty), it is not surprising that twists and sprains in this part are occasionally met with, but rather that they are not more frequent than experience shows them to be. The part of the spine most exposed to sprains is the lumbar region, next the cervical, and lastly the dorsal, which is rarely affected. Apart from the risk of concomitant lesion of the cord or nerves, these injuries, though painful, are not often attended with danger. They may* be caused by various forms of accident, as by falls or sudden twists, and are not unfrequently met with as the result of railway collisions. The symptoms, 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 ligamentous and other affected tissues gradually return to a healthy condition, but, under other circumstances, if great stretching and laceration have occurred, permanent weakening of the part may ensue, re- quiring the constant employment of artificial means of support. An occa- sional but more dangerous consequence is the extension of inflammation to the structures within the vertebral canal, fatal meningitis or myelitis thus sometimes supervening upon what at first was a simple sprain. In other instances, particularly in the case of the occipito-atloid and atlo-axoid articulations, the accident becomes the exciting cause for the development of chronic disease (white-swelling) of the joint, an affection which in this situation may prove suddenly fatal, through the occurrence of secondary dislocation. The treatment of vertebral sprains, unaccompanied bv nerve- lesion, is essentially that of sprains in other parts of the body. Rest, me- chanical support, soothing applications at first, and at a later period stimu- lating embrocations, with friction, and perhaps the cold douche, will usually be found sufficient to effect a cure. It is often desirable to 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 treat- ment of the cord complications, when present, is the same as in other forms of spinal injury, and will be considered when we have disposed of the re- maining 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 w*hether a given injury ot the spine be a fracture or a dislocation, until a post-mortem examination reveals the exact nature of the lesion. The possibility of luxation occur- ring in the vertebral column has been denied by many surgeons, and Sir Astley Cooper, with his large experience, declared that he had never met with a case of this nature ; other writers, however, have considered them comparatively frequent, and Mr. Brvant says that of seventeen autopsies 352 INJURIES OF THE BACK. made at Guy's Hospital in cases of spinal injury, during six years, no loss than six showed the lesion to have been pure dislocation. I have noi myself met with any instance of absolutely uncomplicated spinal disloca- tion, but the elaborate tables which I have published in the monograph already referred to, show that 124 of 3!>4 recorded cases of spinal injury were believed by the surgeons who reported them to have been of this nature. I cannot help suspecting, however, that in many, if not most, of these cases there was some slight bone-lesion which escaped attention, so that perhaps the term diastasis would, in many instances, be more strictly applicable than dislocation. The large majority of reported cases of verte- bral 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 verv various: in most of the instances met with in civil practice, the alleged causes have been falls or blows, acting sometimes by direct, but probably more often by indirect violence. In the cervical region, these injuries have resulted from falls upon the head or the buttocks, from plunging headlong into shallow water, from falls in turning somersaults, from the head being twisted in executions by hanging, etc. It is popularly believed that hang- ing 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 sus- pension wrenched to one side (as, according to Louis, was formerly done by the Lyons hangman, who sat on the shoulders of his victims, and twisted their necks until he heard a crack), dislocation does not commonly occur. Fractures and luxations of the vertebrae are, as might be expected, more frequent among men than women, in the proportion of nearly seven to one. No age is entirely exempt from these injuries, though most eases occur among those in early adult life. Maschka has recorded a case of dislocated axis, in a child killed by its mother, when it was only eight days old, while Arnott saw a fracture of the same bone, produced by falling down stairs, in a man aged seventy-four. Symjitoms.—The rational symptoms of vertebral fracture and disloca- tion are due to the accompanying lesions of the spinal cord, and are those which have already been described as common to all forms of spinal injury. The physical signs, or those which are peculiar to the mechanical disturb- ance of the vertebral column, are deformity, increased or diminished mobility, and crepitus. Local pain and tenderness on pressure, though often present in these cases, are in no wise distinctive, for they are fre- quently 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, which may involve the vertebral arches, or merely the spinous processes themselves. Fracture of the body of a vertebra, by allowing the approximation of the vertebrae above and below, usually causes angular deformity marked by undue prominence of the spinous process of the affected vertebra, or of that next above. Rotatory deformity, or twisting of the spinal column upon its long axis, may be considered indicative of luxation, which may or may not he accompanied by fracture; it is seldom recognized, I believe, during life, except in the cervical region. Bilateral dislocation, an injury almost exclusively confined to the neck, would be marked by angular deformity, and, if in a backward direction, probably could not in most cases be distin- guished 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 luxa- INJURIES OF THE VERTEBRAL COLUMN. 353 tion 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 oc- cur, which yet might not be revealed ex- cept by careful post-mortem dissection. (2) Undue Mobility 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 can be relied upon to distinguish the in- jury, 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 move- ment, 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 not indicate in what part of the vertebra the lesion existed. Statistics show, however, that crepitus has been observed in about tw*o per cent, only of recorded cases. Diagnosis.—From what has been said, already observed, the differential diagnosis'of spinal injuries is always dif- ficult, and often impossible. This is, however, fortunately a matter*of no practical moment, for, as we shall presently see, the treatment is essentially the same, whatever may be in any case the exact nature of the injury. Prognosis.—The prognosis of fracture or luxation of the vertebrae, while always grave, is not by any means as gloomy as is ordinarily represented. Sir Astley Cooper, and more lately Prof. Brown-Sequard, have surmised that the proportion of recoveries in these cases is less than one per cent., while Mr. Erichsen goes so far as to declare that " fractures of the spine, through the bodies of the vertebrae, with displacement, are inevitably fatal." The opinion of these authors is not, however, borne out by the results of statistical investigation, which show* that the mortality of terminated cases met with in civil practice varies from IS per cent, in injuries of the cervi- cal region to so low a figure as 61 per cent, in those of the lumbar spine, the corresponding proportions of recoveries being 18 per cent, in the former, and 27 per cent, in the latter region. The chances of a fatal issue in these cases vary inversely with the distance of the point of injury from the Lesions above the third cervical vertebra usually prove immedi- Fig. 194.—Bilateral forward dislocation of the fifth cervical vertebra. (Atres.) it will be perceived that, as brain. ately, 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 Philips, the elder Cline, Willard Parker, IV. Bayard, Stephen Smith, C. S. May, and several other surgeons. The prognosis in cases of gunshot injury of the vertebrae is, also, less unfavorable 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 23 J > 354 INJURIES OF THE BACK. having been treated during our late war, only 349 terminated in death, while 27H 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 Kokitansky, rarely met with after fracture of the vertebrae, though instances of its oc- currence have been recorded by CIo- quet, Aston Key, and others. The accompanying cuts (Figs. 195, lilt;, 197), from photographs given me by Dr. Richard A. Cleemann, of this city, illustrate very beautifully the occur- rence of osseous union after spinal fracture. The specimen, which was derived from the body of a patient whom I saw in consultation with Dr. Cleemann, is one of very great interest, showing, in addition to a tract ure of the lumbar vertebrae, unilateral dislocation, which is a. rare lesion in this region of the spine. The case illustrates the dif- ficulty 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 Fio. 195.—Bony union of fractured vertebrae. Figs. 196, 197.—Fracture of vertebral body, and unilateral dislocation of a lumbar vertebra. fracture of a vertebral body, but giving no reason to suspect the existence of luxation. TREATMENT OF SPINAL INJURIES. 355 With regard to the general condition of patients after recovery from injuries of the vertebral column, the prognosis will, of course, depend chiefly upon the nature and extent of the lesion to the spina] 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 in- jury will 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 which life was yet prolonged for periods varying from a few days to twenty-two years ; and the only instance of these in which paralysis was not constant from the time of the injury, was Mr. Shaw's case, in w*hich 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 pro- duced a return of paraplegia before death. The only case with w*hich I am acquainted, in which complete recovery is supposed to have followed complete division of the cord, is one reported by Dr. Eli Hurd, of New York, in which, however, the diagnosis was not confirmed by post-mortem inspection. When the injury to the cord is less severe, the prognosis is, of course, more favorable. The proportion of recoveries, with restoration to a useful and comparatively* active life, is, for injuries of the dorsal and lumbar regions, about 23 per cent, of terminated cases, but in injuries of the cer- vical 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 spinal cord. Treatment as regards Vertebral Column__If in any case there be evident vertebral displacement, or marked deformity, with paralysis, so that the surgeon has reason to believe that he has to deal with a spinal luxation, whether complicated or not with fracture, he should at once pro- ceed to attempt reduction by means of extension and counter-extension, aided by cautious manipulation, rotation, and pressure. I am aw*are that this advice will be looked upon by many as injudicious; but statistical in- vestigation shows that while there is but one case recorded (Petit-Radel's), in which efforts at reduction were the cause of death, there are many per- fectly authentic instances, in which such efforts have been followed by the most gratifying success ; and we should no more be deterred from attempt- ing reduction, by the fatal result in one case of vertebral luxation, than we are from attempting to reduce dislocations of the shoulder or hip, by the fact that death has occasionally followed such attempts in the hands of the most skilful surgeons. The mortality after spinal dislocation has been about four times as great when reduction has not been attempted, as when 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 permanent extension from both legs, or, in an upward direction, from the shoulders, by means of the ordinary weight-apparatus ; the surgeon should, however, in such a case take great care, lest, from the pressure of the adhesive plaster or bandages, excoriation or sloughing should occur, and seriously complicate the patient's condition; and, as a matter of fact, deformity is not usually apparent until nature's effort to effect repair by approximating the neighboring vertebral bodies,.causes projection of the 356 INJURIES OF THE BACK. spinous process of that which has been injured. I have not had occasion to employ splints in cases of fractured spine, but have adopted, with advantage, Hodgen's suggestion to give support by means of a plaster-of- Paris jacket, a mode of treatment which has also been employed by Kbnig, of Gottingen, and by Coskery, of Baltimore. Treatment as regards Spinal Cord—Tn every case of spinal in- jury, the patient should be placed in bed, and kept at complete rest, both physical and physiological: a water-bed, if it can be obtained, or down pillows, will be found of great use in preventing the formation of bed-sores. If the vertebral column itself be not affected, the prone position, as advised by Erichsen, will probably* be found the best, as facilitating the application of local remedies to the spine. In cases of fracture, however, the supine position is preferable, and the patient should not be incautiously turned upon his side, lest sudden displacement should occur, which might prove fatal. The patient should be kept scrupulously clean, and parts exposed to pressure should be frequently bathed with astringent or slightly stimu- lating washes. The bowels should be emptied from time to time by the use of enemata. It is usually recommended to draw off the urine at stated intervals, by means of a flexible catheter, and such has always been my own practice. It has, however, been recommended by Mr. Hutchinson, to dispense with the catheter, except in the rare cases of spinal injury in which retention is painful, allowing the bladder to become distended, and then trusting to the mechanical overflow to prevent injurious con- sequences. Fatal ulceration of the bladder has undoubtedly been occa- sionally traced to the use of the catheter, which in any case must aggravate the cystitis produced by distention 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 with a flexible instrument, used without the stilletle. 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 with advantage ; at a later period, various forms of coun- ter-irritation may be employed, with a view to a derivative action on the spinal cord and membranes. Constitutional Treatment.—The general treatment during the early stages, should be such only as is indicated by the constitutional condi- tion of the patient. Opium may be given at any period, to relieve pain or nervous irritation. Dr. McDonnell highly recommends the administra- tion of belladonna as a sedative to the spinal cord, and advises that it should be combined with opium, whenever the latter remedy is prescribed in these cases. On the onset of inflammatory symptoms, small doses of calomel, or of the corrosive chloride of mercury, may be employed, or the iodide or bromide of potassium. Ergot has proved useful, in the hands of Prof. Hammond, in cases of myelitis following spinal injury. After the subsidence of inflammation, strychnia has often proved of the greatest benefit; at the same time, electricity, systematically applied to the para- lyzed parts, with friction, and cold or warm douches to the spine, may often be serviceable. Tonics, especially iron, quinia, and cod-liver oil, which may be required at an early period, are peculiarly indicated in the later stages of spinal injuries. The diet throughout should be nutritious RESECTION IN INJURIES OF THE SPINE. 357 but unirritating, with or without stimulus according to the circumstances of each individual case. Trephining or Resection in Injuries of the Spine___This opera- tion has been suggested and described by surgical writers 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 subject, 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 whole number of cases now on record amounting to over sixty. 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 compres- sion 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 dis- organized as to preclude any benefit from operative interference; moreover, compression, w*hen it does exist, is almost always due to the pressure exercised by the body of the vertebra, so that all that resection could possibly do would be, as Dr. McDonnell has phrased it, to take away* the ••counter-pressure." The operation is by no means an easy one,2 and is in itself attended with no small danger to the patient; beside the inevitable risks w*hich must follow* the conversion of the injury into a compound fracture, the exposure of the delicate structures within the vertebral canal, and the permanent loss of firmness and strength in the spinal column, consequent on the removal of one or more of the vertebral arches, the operation entails immediate peril upon the patient, death having occurred in one case (AVillett'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 recovery. The only* cases in wiiich I can think it at all justifiable are the rare instances in which the injury, inflicted by direct violence, is manifestly limited to the vertebral laminae. The following table embraces a record of 61 cases, being all of which I have been able to obtain information, in which the operation of spinal re- section for fracture3 has been hitherto performed:— 1 Louis's operation, in 1762, often referred to as an instance of spinal resection, consisted merely in the removal of detached fragments in a case of gunshot injury ; a perfectly legitimate and conservative procedure, 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 Resection of the spine for disease has been performed by various surgeons, includ- ing Heine, Roux, Holscher, Dupuytren, Macewen, Maydl, Wright, Abbe, 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. Jones, of Manchester, records a successful case of trephining for "traumatic paraplegia." Dr. Dandridge is said to have operated in several cases, but in no instance with complete success. These cases are not included in my Table. 358 INJURIES OF THE BACK. Cases of Resection of the Spine No. Result. Operator's name. Refereuce. 1 Died. Cline, Sr. Chelius's Surgery; ed. by South, vol. i. p. 590. 2 " Wick ham, Lancet, 1827. 3 ii Oldknow, Hutchison, in Am. Med. Times, 1861. 4 11 Tyrrell, Malgaigne, Fractures et Luxations, t. i. p. 42.'». 5 " Id. Ibid. 6 (I Barton, Malgaigne (Packard's translation), p :!4:?. 7 11 Boyer, Heyfelder, Traite des Resections (trad, par Boeckel), p. 244. s (( D. L. Rogers, Am. Journ. of Med. Sciences, o. s., vol. xvi, 9 11 Attenburrow, Chelius and Heyfelder, op. cit. 10 II Laugier, Malgaigne, op. cit. 11 l( Holscher, Brown-Sequard, Central Nervous System, p. 256. 12 Relieved. A. Gr. Smith, N. A. Med. and Surg. Journ., vol. viii. p. 94. 13 Died. Mayer, Heyfelder, op. cit. 14 ii South, Notes to Chelius, vol. i. p. 591, etc. 15 K Blackman, Hutchison, loo. cit. 16 Edwards, Blair, Goldsmith, Stephen Smith, Brit, and For. Med. Review, 1838. 17 Ballingall, apud Hutchison, loc. cit. Gross's Surgery, 2d edit., vol. i. Hutchison, loc. cit. 18 19 Died. 20 u Hutchison, Ibid. 21 u G. M. Jones, Brown-Sequard, op. cit., p. 255. 22 ii H. A. Potter, Hurd, N. Y. Journ. of Med., 1845. 23 u Id. Am. Journ. of Med. Sciences, n. s., vol. xlv. 24 Not improved. Id. Ibid. 25 Died. R. McDonnell, Ibid., vol. 1. 26 Relieved. Sam'l Gordon, Med.-Chir. Trans., vol. xlix. p. 21. 27 Died. Tillaux, Brit, and For. Med.-Chir. Review, 1866. 28 k Willett, St. Barth. Hosp. Rep., vol. ii. p. 242. 20 H. J. Tyrrell, Dub. Quart. Journ. of Med. Sci., Aug. 1866. 30 Died. Maunder, Med. Times and Gazette, Feb. 23, l8i'.7. 31 Not improved; Eve, Am. Journ. of Med. Sciences, n. s , vol. lvi. 32 Died. Cheever, Boston City Hosp. Reports, 1870, p. 577. 33 " Id. Ibid., p. 580. 34 ' St. Bartholomew's Hosp. Reports, vol. vi. Med. Times and Gazette, Aug. 7, 1869. 35 Nunneley, 36 u Id. Ibid. 37 " Id. Ibid. 38 Relieved. Id. Ibid. 39 Died. Willard, Am. Journ. of Med. Sciences, n. s. vol. lxiii. 40 Relieved Stemen, Fort Wayne Journ. of Med. Sci., April, 1883. 41 Not improved. Id. Ibid. 42 Died. Id. Ibid., October, 1883. 43 Not improved. Lucke, Revue des Sciences Medicales, Avril, 1880. 44 Died. Pinkerton, Med. News, Jan. 3, 1885, p. 16. 45 ii Halsted, Ibid. 46 Recovered. Macewen, Glasgow Med. Journ., March, 1886, p. 210. 47 Died. Keetley, Brit. Med. Journ., Aug. 25, 1888, p. 421. 48 Recovered. Lauenstein, Centralbl. f. Chirurgie, No. 51, 1886. 49 Not improved. Albert, Ibid. 50 Died. Lucke, Ibid. 51 u Morris, Annals of Surgery, June, 1886. 52 Relieved. Mears, Med. News, Dec. 22, 1888. 53 Died. ' Mynter, Med. Record, Sept. 15, 1888, p. 305. 54 Abbe, Communicated by Dr. Keen. Med. Record, May 1,1886, p. 512. 55 Died. Jaeobi, 56 u [Cupples], Report on Surg, to Texas State Med. Asso., 1886. 57 Recovered. P6an, Brit. Med. Journ., March 23, 1889. 58 Died. Lampiasi, Ibid., May 4, 1889. 59 Not improved. H. Allingham, Ibid., April 13, 1889. 60 Died. Id. Ibid. 61 Relieved. Dawbarn. New York Med. Journ., June 29, 1889. WOUNDS OF THE FACE. 359 In 56 of the above 61 cases the result is known: 41 patients died, 6 were relieved, 6 received no benefit from the operation, and only 3 re- covered. The most successful cases which the advocates of spinal resection have yet been able to produce, are those of Gordon, Nunneley, Stemen, Pean, Lauenstein, and Macewen; in the first, more than a year after the operation, the patient was "unable to stand or walk;" in the second, the patient, during the two and a half years which he survived, was, though strong in the arms, "weak and partially paralyzed in the legs;" while in the third, though living seven years after the operation, the patient had "not been able to walk or move his limbs." In both Pean's and Mac- ewen's cases, the only ones beside Lauenstein's in which the operation can be said to have been followed by recovery, the fractures were limited to the laminae, resulting from direct violence, and, therefore, resembling Louis's well-known case, which has already been referred to. Considering, therefore, the not unfrequent favorable issue of these cases under expectant treatment, and in view of the fact that the mortality after the operation has been over 73 per cent, of terminated cases, and that only three in- stances of complete recovery after its employment have yet been recorded, less than five per cent.; surely we are justified in declaring that trephining of the spine, if ever resorted to, should be reserved for very exceptional cases. I would respectfully invite the reader, who is interested in the further investigation of this subject, to consult the elaborate statistical tables em- braced 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 laminae, on either side of the spinous process of the injured vertebra, with strong cutting forceps bent at an angle—an instrument w*hich would prove more serviceable, in this position, than either a trephine or a Hey's saw; a single arch having been removed, any additional portions of bone may be readily taken away with the ordinary gouge-forceps. Dr. McDonnell recommends very highly the internal administration of belladonna, or atropia, during the after- treatment of these cases, in order to prevent the development of inflamma- tion 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 treatment from that of similar injuries in other parts. The tissues of the face are so vascular, that primary union is usually attainable, at least in the case of incised wounds. As it is desirable to avoid any disfigurement, in a part which is constantly exposed to observation, I think it best to dispense with sutures, in the" treatment of superficial wounds of the face, approximating the parts as accurately as possible by means of the gauze and collodion dressing. In certain localities, however, as in the eyelids or eyebrows, nose, ears, and lips, the employment of sutures is usually indis- pensable : in penetrating wounds of the cheeks, also, stitches, embracing almost the entire thickness of the parts, should be applied. Harelip pins, 360 INJURIES OF THE FACE AND NECK. which may always be used with advantage in wounds of the lips, may In- 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 mav occur. The deformity which 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 which mechanical extension has failed to procure relief (see p. 319). Orbit and Eyeball.—Injuries of the Orbit may prove fatal through implication of the brain, either primarily, or, at a later period, by the ex- tension 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. Pep- per, a knife was thrust through the sphenoidal fissure, wounding a large meningeal vein, and causing death from intra-cranial hemorrhage. In other instances, again, wounds of the orbit have been followed by the for- mation of arterio-venous aneurisms, as in a case of Nelaton's, in which the point of an umbrella wounded the cavernous sinus and internal carotid artery of the opposite side—'death ultimately resulting from the bursting of the aneurismal tumor. Deep-seated Suppuration (Orbital Abscess) may occur as the result of orbital injury*, the abscess pointing in either eyelid, or proving fatal by extending backwards to the brain. It may be so chronic as to give rise to the symptoms of a solid tumor, and may be mistaken for chronic in- flammation or morbid growth in the lachrymal gland, while, as especially pointed out by Coupland, thrombosis of the cavernous sinus produces local symptoms difficult to distinguish from those of cellulitis of the orbit. A free incision is indicated as soon as the occurrence of suppuration is recog- nized (>ee Chap. XXXV.) Wounds of the orbit may cause blindness, without directly involving the eyeballs, either by injury to the optic nerv es, 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 followed a gunshot wound of both orbits, the patient surviving the injury for four years and a half, and eventually dying from other causes. Emphysema, or the presence of air in the cellular tissue of the orbit, appears as part of a general emphysema, or follows rupture of the lachrymal sic, or fracture of the frontal sinus or ethmoidal cells. There is usually slight exophthalmos, and palpation with the finger produces crepitation. Foreign Bodies lodging on the eye may be embedded in the cornea, or may be concealed between the ball and either eyelid. From the cornea, the offending particle may be removed without much difficulty, simply by picking or gently prying it off" with an ordinary cataract needle, or with a spud (Fig. 198), after the instillation of cocaine; if, in doing this, the cornea be superficially abraded, it is well, before dismissing the patient, to apply a drop of castor oil, w*hich will effectually protect the surface until the slight breach of continuity has been repaired. The corneal wound sometimes becomes inflamed, and from this cause iritis may result; hence it is advisable, if the iris be discolored, to instil a drop of atropia after re- moval of the foreign body. Grandcle'nient has described, under the name of 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. INJURIES OF THE ORBIT AND EYEBALL. 361 traumatic keratalgia, a condition in which pain, probably the result of a neuritis, may continue for years in a cornea which has been subjected to Fio. 198.—Schell's spud for removal of foreign bodies from the cornea. slight injury. A foreign body on the cornea can usually be readily de- tected by carefully examining the part in a bright light; in any case of doubt, however, oblique illumination should be employed (Fig. 199), a second convex lens being used, if necessary, as a magnifier. The con- Fig. 199.—Oblique illumination. (Welj.b.) Fig. 200.—Eversion of upper lid for detection of foreign bodies. (Erichsen.) junctival fold of the lower eyelid may be explored by simply drawing down the lid, and directing the patient to look upwards ; to explore the fold of the upper lid it is necessary to evert the eyelid, w*hich may be done either with the forefinger and thumb (Fig. 200), or with a probe, or the end of a pencil or quill, laid transversely across the lid. This little operation, which is more difficult than it appears, is done by firmly* but lightly seizing the edge of the lid between the thumb and forefinger (the patient looking downwards, and the lid being drawn well down and slightly away from the ball), and then by a quick movement turning up the edge of the lid over the point of the finger, which is simultaneously depressed. If the probe be employed, the central eyelashes, or the edge of the lid, must be taken between the thumb and finger of one hand, while the probe is manipulated with the other. The eyelid being everted, its edge is pressed against the edge of the orbit, when almost the whole conjunctival fold comes into view. The foreign body may then be removed with delicate forceps, the smooth end of a probe, or a moistened camel's-hair brush ; it is sometimes possible to feel the foreign body with the tip of the finger, when, from its 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 with a camel's-hair brush ; and, in one instance, after I had failed to detect the foreign body by everting the lid, I succeeded by placing the patient in a bright light, with his head thrown very far backwards, when by simply drawing the lid away from the ball, I was enabled to see almost up to the sulcus. Contusion and Concussion of the Eyeball may cause temporary blind- ness by inducing a condition of the retina analogous to concussion of the brain. In traumatic oedema of the retina (commotio retinae), vision is 7 362 INJURIES OF THE FACE AND NECK. often only slightly affected, and the ophthalmoscope reveals either no change, or else an area of white cloudiness in the neighborhood of the optic nerve and macula. A blow* upon the eye is sometimes followed by con- siderable amblyopia, with contraction of the field of vision, without abnor- mal ophthalmoscopic appearance. This traumatic amestbesia of the retina may persist for a long time, often at last terminating in perfect cure, bnt sometimes leaving the patient with very defective sight. Ifruise of the eyeball may be followed, in addition to the localized (edema of the choroid and retina, by a transient myopia or astigmatism, as in a ease reported by Dr. Edward Jackson, of this city. The ordinary " black eye" of pugilists consists in an extravasation of blood beneath the conjunctiva, and into tin- loose areolar tissue of the eyelids. In this situation absorption is often very slow, the subconjunctival stain sometimes persisting for several weeks ; the best application is cold water, or a mild alcoholic lotion. Contusion of the eyeball is sometimes accompanied by rupture of the cornea or sclerotic; ruptures by blows with blunt bodies, according to Xuel, are usually situated in front of the ciliary- body, at the sclero-corneal junction. These ruptures may permit the escape of the humors of the eye, and cause permanent loss of vision ; in other cases they may be internal, extravasation occurring and filling the anterior chamber of the eye with blood (hyphaema), the iris being sometimes torn from its ciliary attach- ment (coredialysis), the lens loosened by rupture of the suspensory liga- ment (thus removing the support of the iris and causing the so-called "tremulous iris"), the lens dislocated from its position (as shown in Fig. 201, '-'* Fio. 201.—Dislocation of crystalline lens into anterior chamber. (From a patient under the care of Dr. De Schweinitz ) taken from a drawing kindly given me by Dr. De Schweinitz), or the choroid ruptured. Occasionally* the conjunctiva is untorn, but more often it is lacerated, when the wound is spoken of as "compound." The treat- ment consists in the frequent instillation of a solution of atropia, gr. ij-iv to f^j, and in the administration of calomel and opium, while the patient is kept in bed, in a darkened room, and upon milk diet. After the absorp- tion of the effused blood, which is usually soon effected, vision may he restored, though it is often rendered imperfect by bands of lymph cms-ini.' 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 ease, extraction should INJURIES OF THE ORBIT AND EYEBALL. 363 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. For the removal of a lens dislocated into the vitreous humor, the late Dr. C. R. Agnew devised an operation in which a double needle, or "bident," was thrust into this humor far enough back to avoid wound- ing the iris or touching the lens, when, by depressing the handle of the instrument, this was caught and brought forward through the pupil into the anterior chamber, whence it could be removed in the ordinary way. This operation has been specially* employed by Drs. Pomeroy, Webster, and Andrews, and Agnew*'s instrument has been ingeniously modified by the last-named surgeon. If the dislocation be beneath the conjunctiva, the lens should be removed through a small incision made in this mem- brane, directly over the tumor. A rare form of luxation of the lens is that beneath Tenon's capsule, an instance of which has been recorded by 0. F. Wadswerth, of Boston. If suppurative disorganization of an eyeball occur, excision may be necessary to prevent the other eye from becoming sympathetically involved. If the rupture of the sclera be "compound," that is, if the overlying conjunctiva be lacerated, immediate excision is generally the best treatment; should, however, an attempt be made to save the eye, Nuel recommends suture of the conjunctiva in such a manner that it may be drawn into a roll and thus close the scleral wound. Dislocation of the Eyeball from between the lids, wrhich are contracted behind it, is a rare form of injury of which a few cases are on record. In order to facilitate reduction, Van Dooremaal divided the external commis- sure with blunt-pointed scissors, closing the weund with sutures after the eyeball had been replaced in its proper position. Wounds of the Eyelids require no special form of treatment. Careful apposition by means of sutures or small hare-lip pins will secure primary union. If the wounding body have penetrated through the lid, it may pass deeply into the orbit, or may tear off the attachment of a rectus tendon, an occurrence which would be followed by double vision. An attempt may be made to suture the torn ends of the tendon, but the operation will often be unsuccessful. Ptosis sometimes follows blows upon the eyelids, and may be accompanied by temporary dilatation of the pupil and paresis of accommodation. Burns of the Eye by splashes of molten metal, or by acids or alkalies, especially freshly slaked lime, are likely to be followed by severe inflam- mation of the cornea, with suppuration and the formation of hypopyon. A common result is the adhesion of the lids to the ball, and the formation of symblepharon. Chemical neutralization of the caustic substance, if an acid or alkali, should be instituted in the early stages of the injury*, and cold compresses, with atropia and castor oil, should be applied ; or the atropia may be conveniently incorporated w*ith vaseline. If suppurative keratitis ensues, the treatment should be the same as for sloughing ulcers. (Sec Chapter XXXY.) Injuries to the Eye. from Lightning-Stroke.—A few instances of injury to the visual apparatus from lightning are upon record. The lesions have variously consisted in paralysis of the power of accommodation, cataract, hemorrhages into the retina and rupture of the choroid, detachment of the retina, and optic atrophy*. Buller, of Montreal, has described a case in which the injury resulted in damage to the external eye muscles, the crys- talline lens, choroid, and optic nerve. It must be remembered, as Buller points out, that such lesions may arise from the mechanical violence done to the patient, rather than from the chemical or thermal action of the current. 364 INJURIES OF THE FACE AND NECK. Non-penetrating Wounds of the Eyeball are not usually of a serious nature. The treatment consists in the removal of foreign bodies, followed bv the application of a drop or two of castor oil, with the use of cold com- presses if the injury be attended with much pain. Penetrating Wou/uls are attended with much greater risk, the chief dangers being from prolapse of the iris, escape of vitreous humor, and, at a later period, from inflamma- tion. If the iris protrude, an effort should be made to replace it by means of a fine probe; if this be impossible, the projecting portion should be snipped off with curved scissors, and, if a staphyloma be subsequently formed, an iridectomy should be done opposite the most transparent part of the cornea ; this operation is, according to Soelberg Wells, much prefer- able to the old mode of treatment, by the repeated application of nitrate of silver. An effort may be made to obtain a flat, or, if possible, a non-ad- herent cicatrix, by snipping off the prolapsed iris, freeing the edges of the wound, and covering the opening in the cornea with a flap of bulbar con- junctiva, which is pushed into the opening with a blunt probe; a firm bandage is then applied, and should not be removed for two or three days. Incised wounds of the sclerotic, if not very large, may be brought together with one or two fine sutures, any protruding portion of iris or vitreous humor being first cut away. In cases of extensive wound, with escape of a large portion of the contents of the eye, excision should, as a rule, he immediately performed, especially in patients of the poorer class, to whom the time required for treatment is a matter of importance. Wounds which lie within a zone nearly a quarter of an inch wide, sur- rounding the cornea, and which Nettleship has termed " the dangerous region," if no hope of useful sight remains, or even small wounds which have penetrated this region and set up a severe iritis, call for immediate excision of the globe. If an attempt be made to save the ball, cold compres- ses 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 trau- matic cataract), or to perform excision, if vision be lost and suppurative disorganization 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 while preserving useful vision. Dr. McKeown, of Belfast, has recorded several cases in which fragments of steel were removed by the aid of a pointed magnet introduced through the wound, and recommends the u>c of a large magnet, moved about externally to the eye, as a means of diag- nosis. Magnets have also been successfully employed in cases recorded by Mcllardy, Hirschberg, Snell, Appleyard, Galezowski, Oppenheimer, Owen, Reid, Jeffries, Kollock, Minor, and Knap}). Convenient instru- ments for the purpose have been devised by Hirschberg, Snell, and Oru- ening, of New York. Nose___Foreign bodies, such as beads, peas, bits of sponge, etc., are often introduced by children into the nostrils, where they occasionally he- come firmly fixed, and, if allowed to remain, cause a troublesome form of ozaena. 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 Thudiehuni* 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. Displacements of the nasal septum have already been referred to on page 252. Wounds of the nose require careful stitching. EAR, CHEEK, AND MOUTH. 365 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 with tepid water, the pinna being drawn upwards, or in the case of very young infants, downwards, so as to straighten the auditory canal. Gross's instrument, which is of steel, spoon-shaped at one end, and pro- vided at the other with a delicate tooth, placed at a right angle, is doubtless very efficient and safe in skilful hands, but the general prac- titioner will, I think, do wisely to be satisfied with simple syringing, which is, indeed, according to Roosa and Gruber, 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 beneath the ear. When there is much inflam- mation, Gruber advises that attempts at removal should be postponed until the subsidence of acute symptoms, when the auditory passage may be dilated with sponge tents, and shrinking of the foreign body promoted by the use of astringent solutions. Guersant prefers to ordinary syringing irrigation, which may be conveniently effected w*ith a Thudichum's douche, or by means of the double hand-ball syringe used for the administration of enemata. Should syringing fail, 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 JEgineta, consists in the introduction of a delicate pencil, tipped with glue or plaster of Paris, which is allowed to remain in contact with the foreign body* until adhesion takes place, w'hen both may be withdrawn together. Wounds of the ear require sutures. Ruptures of the membrana tympani, which may follow "boxing the ears," are referred to in Chapter XXXYI. Cheek.— Wounds of the cheek occasionally result in the formation of troublesome fistulse. 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 result. 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 Yan Buren, Langenbeck, J. R. Wood, and E. Mason ; by the ingenious operation of the late PrOf. Horner, which consists in cutting out the dis- eased 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; or by Ricbelot's plan, which accomplishes the same purpose by the use of an elastic ligature. J. Allen reports two 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. Molliere advises injecting fatty substances, in order to destroy the substance of the gland and thus induce cicatrization. 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 366 INJURIES OF THE FACE AND NECK. harelip. Wounds of the Tongue do not require sutures, unless a consider- able 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 staphylorraphy. Foreign bodies, such as pistol-balls, teeth, or pieces of tobacco-pipe, may be lodged deeply* in the tongue or pharynx, giving rise in the latter situation to suppuration, and sometimes to fatal secondary hemorrhage. INJI'UIES OF THE NKCK. Wounds.—These injuries, w'hich are usually of the character of Incised Wounds, are most commonly inflicted in attempts to commit suicide. It is occasionally* a matter of some importance, in a medico-legal point of view, to be able to determine whether a given wound of the neck has been self- inflicted, or received at the hands of another; it is, of course, impossible to arrive at absolute certainty upon this point, but it may be said, in general terms, that suicidal wounds commonly begin on the left side of the neck (the person being right-handed), and pass transversely or obliquely down- wards across the part, the extent of the wound on the right, being usually less than that of the left, side. They rarely penetrate so deeply as to divide the great vessels ; hence the prima facie probability w-ith regard to a very deep wound, "penetrating as by a stab perpendicularly towards the spine," and perhaps involving the vertebra?, would be that it was not self-inflicted (Taylor). Wounds of the neck may be divided into—1. Non-Penetrating Wounds, which do not involve the air-passage or oesophagus; and 2, Pene- trating Wounds, which 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 pro- fuse; if the carotid artery or internal jugular vein be wounded, death may be almost instantaneous, and even bleeding from comparatively small ves- sels may prove fatal in the depressed state, both physical and mental, which is usually present inpatients who have attempted suicide. Another danger is from the entrance of air into the large veins in this region, which may cause sudden death, or, as in a case recorded by Le Gros Clark, may prove fatal at a later period, by the air becoming gradually mixed with the blood, and thus interfering with the heart's action. The pneumogastric or phrenic nerve may also be wounded in these cases, and either event would of itself almost certainly cause the death of the patient. The treatment of 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, whether artery or vein, should be secured by liga- tures above and below the opening in its coats, or to either extremity if it be completely* divided. In cases of arterial bleeding, in which the precise source of hemorrhage cannot be detected, the surgeon should not hesitate, 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 with 20 recoveries, and, according to Cripps, in 51 instances with 2o recoveries (to which may be added a successful case in my own hands), the total number of cases in which the carotid has been tied for hemor- rhage being, according to the first-named author, 228, with 94 recoveries Whenever it is practicable, however, an effort should be made to substi- tute ligation of the external carotid, which Cripps has shown to be a much safer operation. Approximation of the lips of the wound is best effected by numerous points of the. interrupted suture, small tubes or catgut threads INJURIES OF THE NECK. 367 being brought out at the angles of the wound, so as to secure drain- age. 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, which 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 unfrequently 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 fre- quency of these wounds in different situations, may be seen from the fol- lowing table of 232 cases, collected by Mr. Durham :— Situation of wound. Number of cases. Above the hyoid bone . . . . . . . . .17 Through the thyro-hyoid membrane......80 Through the thyroid cartilage ....... 42 Through the crico-thyroid membrane or cricoid cartilage . . 36 Into the trachea ••........ 57 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, apncea, emphysema, dysphagia, and, at a later period, bronchitis and pneumonia. Difficulty of Breathing, ending, perhaps, in complete Suffocation or Apncea, in wounds of the throat, may depend upon several causes. It may result directly from the accumulation of blood, either liquid or clotted, in the air-passages ; from displacement of divided parts, as from a portion of the tongue, the epiglottis, or a fragment of cartilage, falling backwards and obstructing the rima glottidis; or, if the rings of the trachea be widely separated, from the external soft parts being sucked inwards, and producing valvular occlusion of the air-tube. Again, 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 occasionally a source of great danger. Either from a wound of the oesophagus—or, without 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 extension of inflammation from the seat of injury. Among the occasional remote consequences of penetrating wounds of the throat, may be mentioned alteration or loss of voice, and the 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-pene- trating wound, the surgeon may apply a few sutures to either extremity of the incision, leaving, however, the central portion, as a general rule, 368 INJURIES OF THE FACE AND NECK. to heal bv granulation ; an exception should be made in those cases in which the air-tube is completely cut across, when, to prevent wide separa- tion, it may be necessary to apply a stitch on either side, so as to hold the parts in apposition. The sutures, which in such a case should be of catgut or fine silk, may be passed through the superincumbent connective tissue, or even superficially through the cartilages themselves; if silk is used, one end is cut off, and the other brought through the external wound. In other cases, from the persistence of venous oozing, or from the occurrence of dvspncea 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, artificial respiration resorted to. Tracheal or laryngeal stricture may, at a later period, require the performance of tracheotomy, followed by systematic dilatation, as em- ployed by Schrbtter ; or even by external division, as in a case recorded by Tren- delenburg; or by excision of portions of no. 202-Tracheai stricture. (Cohen.) the tracheal rings, or cricoid cartilage, as practised by II. Lee, of London, and by myself, in a case under my* care at the University Hospital; in other cases the stricture may be divided from within, as done by Cohen in the case from which the annexed illustration is taken. (Fig. 202.) Intubation is recommended in cases of laryngeal stricture by O'Dwyer and Dillon Brown. Aerial fistula may (provided that the larynx be unobstructed) be closed by a plastic operation. Injuries of the Larynx and Trachea. A blow upon the larynx may prove fatal through shock, or by inducing spasm of the glottis ; when the injury is less severe, temporary 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 mortality, according to Durham's statistics, being over 80 per cent.1 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 per- son over forty-five years of age. The usual causes, apart from gunshot wounds, are, according to the same writer, " falls against hard and pro- jecting substances, blows, kicks, and pressure." The symptoms are local pain and tenderness ; swelling of the neck, with an alteration of its form, consisting either of flattening or of undue prominence ; mobility of the cartilages, and occasionally crepitus. There are, besides, often dysprxea 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 ' Mr. Arbuthnot Lane, however, from an examination of numerous dissecting-H*0™ specimens, concludes that many cases present very slight symptoms, and e" recovery without their nature having been recognized. FRACTURE OF THE LARYNX. 369 Figs. 203, 204.—Fractures of the larynx. (After Roe.) mucous membrane. The annexed table gives a summary of II recorded cases, 52 collected by Henoque, IT added by Durham, and 8 by myself.1 Cartilages Fractdrbd. No. of cases. Deaths. Recoveries. TLyroid and os hyoides " and cricoid " cricoid, and os hyoides . " " and trachea Cricoid and trachea " trachea, and os hyoides . " Fractures of larynx" 35 12 4 10 2 3 3 1 7 23 11 2 10 2 2 3 1 3 12 1 2 i 4 Total...... 77 57 20 The treatment, in cases in which the displacement is slight, and in which there is no dyspnoea, may consist simply in supporting the parts with com- presses and strips of adhesive plaster. If, however, the respiration be embarrassed, and particularly* if there be bloody expectoration, no time should be lost in resorting to tracheotomy, which, under such circumstances, affords almost the only chance of saving the patient. Twelve of the 1 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. Recovery also fol- lowed in a case of cricoid fracture reported by Masucci. Another case (fatal) of frac- ture of both thyroid and cricoid is recorded by Wagner. One of fractured thyroid ended in recovery without operation in the hands of Bauer, and one after tracheotomy in those of Tillaux, while other (fatal) cases are recorded by Landgraf, Barendt, and Fussell. 24 370 INJURIES OF THE FACE AND NECK. twenty cases of recovery were saved by operation, while in at least four of the remainder, from the absence of haunoptysis and emphysema, there is reason to believe, as remarked by Hunt, that the fractures were in the median line, and did not involve the mucous membrane. After the opera- tion, an attempt may be made to restore the displaced parts to their proper position by manipulation. Panas and C'aterinopoulos recommend, instead of tracheotomy, a section of the thyroid cartilage, followed by the intro- duction of a large tube, so as to keep the fragments in position. Dr. E. Holden, of Newark, 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 tw*o cases by Stoerk, and a case of dislocated cricoid cartilage, reduced by extension and manipulation, is referred to in the Lancet for 188f>. Fracture or Rupture of the Trachea, without injury of the larynx, and wit bout external wound, is an extremely rare and usually fatal acci- dent. Cases are reported by Lonsdale, Berger, Beck, J. L. At lee, Jr., Robertson, Corley, Garrard, Bennett, Long, Drumniond, Wagner, and Norton—those seen by the four last-mentioned surgeons being the onlv instances of recovery.1 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 was under my care a few years since, at the Episcopal Hospital, in which an injury of the neck was followed 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 was maintained for several weeks by means of nutritive enemata, and the patient eventually recovered. Dr. Lang, a German surgeon, has re- ported a remarkable case of intussusception of the trachea, which proved fatal at the end of ten weeks. Burns and Scalds of the mouth, pharynx, and glottis are occasion- ally 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 mercurializaticn is considered by Bevan 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 twenty- four grains of calomel, and had six drachms of mercurial ointment rubbed into his groins and axillae. The cedematous mucous membrane of the fauces and epiglottis may be scarified with a long needle, or with a curved bistoury, wrapped almost to its point with a strip of sticking plaster, and, if suffocation appear imminent, tracheotomy must be performed as a last resort, though its results under these circumstances are far from satisfac- tory, 35 out of 51 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 he the same as in the case of scald of the glottis or larynx. Of three eases mentioned by Durham, in which tracheotomy was performed for such an injury, two died and one recovered. 1 Another fatal case is mentioned in the British Medical Journal for March 3, 1*"*' page 500. FOREIGN BODIES IN THE AIR-PASSAGES. 371 Foreign Bodies in the Air-Passages.—A great variety of sub- stances have been met with as foreign bodies in the air-passages, the most common being, according to Gross, grains of corn, beans, melon-seeds, pebbles, and cherry-stones. Several such objects, sometimes of a dissimilar character, have been occasionally met with in the same case. In four in- stances leeches have been extracted from the larynx, by Marcacci, Trolard, Massei, and Clementi. Foreign bodies usually enter the air-passages through the glottis, being drawn in, in the act of inspiration, or simply dropping in, as in the case of coins tossed in the air and caught in the mouth, or—as has probably happened in some cases, in which, suffocation having occurred during sleep or intoxication, the air-passages have been found to contain partially digested food—the foreign body may be regur- gitated from the stomach, and may then make its way through the glottis, the sensibility of which is obtunded by the patient's condition. In other instances foreign bodies have entered the air-passages through accidental wounds or ulcerations of the oesophagus, of the tissues of the neck, or of the w*alls of the chest. Finally, in one case referred to by Gross, a lym- phatic gland passed through an ulcer in one of the bronchi, and caused death by becoming impacted in the rima glottidis. Situation.—A foreign body may be arrested in any portion of the air- passages, or, more rarely, may be movable, changing its position from time to time. The parts in which extraneous substances are most apt to become impacted are the larynx and one of the bronchi, usually the right. Symptoms.—The primary symptoms, or those of Obstruction, are similar to those of inflammatory or spasmodic croup, only, if possible, more vio- lent. The patient feels a sense of impending death, and is, indeed, for the time, in most imminent danger. The face becomes livid, the eyes appa- rently 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. Auscultation will reveal various signs, ac- cording to the position of the foreign body ; if this be loose in any part of the tube, it may be heard moving up and down with a flapping sound, and occasionally striking the wall of the trachea; if fixed in the larynx, there will be a harsh, rough sound in respiration, coinciding with croupy cough and the other symptoms of obstruction ; if impacted in a bronchus, or one of its subdivisions, the respiratory murmur will usually be 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 which an impacted plum- stone, perforated through its middle, gave rise to a strange whistling sound. Diagnosis.—The diagnosis, though often very obscure, may in most instances be made by careful inquiry into the history of the case, and in- vestigation of its symptoms. From croup the diagnosis can be made, as pointed out by Gross, by observing that in that affection the dyspnoea is most marked in inspiration, while expiration is most affected in obstruc- tion from a foreign body. Aphonia is, according to the same author, the most trustworthy sign of impaction in the larynx, as distinguished from impaction in other portions of the air-tube. From pharyngeal, or oesopha- geal obstruction, the diagnosis is to be made by careful exploration with 372 INJURIES OF THE FACE AND NECK. the finger and probang. 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 suffocation (which may occur at any* moment), hemorrhage, inflammation, ulceration, abscess, or simple exhaustion. The annexed summary, taken from Air. Durham's essay, shows compendiously the results in 636 cases— these being, I believe, with the exception of Dr. Weist's, to be presently referred to, the most comprehensive statistics which have yet been pub- lished :—. 1. Cases in which no. operation was performed:— Resclt. Death without expulsion of foreign body Spontaneous expulsion of foreign body Expulsion after emetics (recorded as useless in 46 cases) Discharge at a late period through thoracic abscess Total of cases not operated on 2. Cases in which operative measures were adopted:— Operation. Laryngotomy, followed by expulsion .... " not followed by expulsion Tracheotomy ........ Laryngo-tracheotomy—laryngo-chondrotomy Direct extraction through the mouth .... Inversion of body and succussion .... Total of cases operated upon .... Total number of cases operated upon or not Total number of cases. 102 176 7 13 298 16 3 263 32 9 15 338 636 Recov- eries. 161 7 8 176 Deaths. 102 15 122 15 196 25 9 15 260 1 3 67 7 78 436 200 The mortality, according to these figures, is, in general terms, therefore, nearly 1 in 3 (31.4 per cent.), the death-rate after operation being less than 1 in 4 (23.0per cent.), but without operation more than 2 in 5 (40.9 per cent.). The period during which a foreign body may remain in the air-passages, and yet be spontaneously expelled, varies from a few hours up to many years; in 68 of 136 cases of spontaneous expulsion with recovery, collected by Mr. Durham, this period was between one and twelve months. Dr. J. R. Weist has published statistics of 1000 cases, chiefly collected by* private correspondence, wrhich show a somewhat different result, as follows:— Cases not submitted to operation .... " submitted to operation other than bronehotomy " " to bronehotomy .... Total. 599 6:5 338 Recov-ered. 1 Died. 460 02 245 139 1 93 Mortality per cent. 23.20 l.r.s 27.42 Aggregates . . . . . .loon 233 | 23.:iti If, for the sake of comparison with Mr. Durham's figures, the second and third classes (embracing all submitted to operation) are taken together, the number will be 401, with 94 deaths, or 23.44 per cent., a death-rate but fractionally greater than that given by the Engli>h writer. The dis- FOREIGN BODIES IN THE AIR-PASSAGES. 373 crepancv* then is only in regard to the cases treated by expectancy, and here if we combine the two sets of figures—as it is fair to do, since they are derived from different sources—we find a total of 897 cases treated without operation, with 261 deaths or 29.09 percent., nearly 6 percent. more than when an operation is resorted to. Treatment.—In a case in which the dyspnoea is not urgent, a careful laryngoscopic 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. Dr. Thorner, of Cincinnati, has succeeded in extracting a cockleburr from the larynx by passing a probe armed with a small sponge alongside and below the foreign body, and then suddenly drawing it upw*ards. Yoltolini 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 occasion- ally successful before tracheotomy, are under such circumstances both dangerous and painful, 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, laryn- gotomy, the latter operation being more quickly and more easily accom- plished. If the foreign body be now* found in the larynx, it should be dis- lodged 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 maybe immediately expelled through the tracheal weund—or more rarely through Fio. 205.—Application of the laryngoscope. (Erichsen.) the mouth—though in other cases it may not be ejected until several hours or days, or even a much longer period, after the operation. There is some difference of opinion, among surgeons, as to the propriety of endeavoring to extract foreign bodies through the tracheal wound by means of forceps. Mr. Durham's statistics show, I think, conclusively, that such attempts are not only justifiable, but eminently proper, 61 cases, in which removal was effected by forceps, having given 58 recoveries and but 3 deaths, none 374 INJURIES OF THE FACE AND NECK. of which appear to have been due to the use of the instrument. Among the best forceps for the purpose are those devised by Prof, (iross (Fig. Fig. 206.—Throat-mirror used in laryngoscopy. 207), the blades of which are five inches long, and which, being made of German silver, can be bent to suit any particular case, while they are so Fig. 207.—Gross's tracheal forceps. delicate as not materially to interfere with the passage of air during the necessary manipulations. Another excellent form of tracheal forceps is that devised by Dr. Cohen (Fig. 208). Fin. 208.—Cohen's tracheal forceps. After the exit of the foreign body, the wound may usually be closed at once ; but if there be much laryngeal irritation, a tube may be introduced for a few days, until this has subsided. Occasionally the foreign body causes not only intense congestion and bleeding from the trachea, but the formation of fibrinous casts similar to those found in croup. Fig. 209 shows such a cast removed by Dr. Wharton, w*ith a shawl-pin (Fig. 210), Fia. 209—Fibrinous cast from trachea (actual size). Fin. 210.—Brass shawl-pin removed seven boor» after tracheotomy. from a patient of mine at the Children's Hospital, seven hours after I had opened the trachea—search for the foreign body at the time of the opera- tion having been precluded by the profuse hemorrhage by which it «'«•-< followed. Subhyoidean pharyngotomy (see Chapter XXXYIII.) may in some ARTIFICIAL RESPIRATION. 375 eases 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. Apncea, or, as it is more commonly called, Asphyxia,1 may arise from various causes, such as drowning, inhalation of chloroform or of poi- sonous gases, spasm or oedema of the larynx, or the presence of false mem- brane, of a morbid growth, or of a foreign body in any portion of the air- passages. The surgical operations employed in the treatment of apncea, are, artificial respiration, intubation, and the various procedures which are included under the general term of bronehotomy. Intubation and bronehotomy are applicable to cases in which the air-passages themselves are in any way obstructed; artificial respiration to cases in which the air-passages are free, or in which apncea continues after the performance of bronehotomy. Artificial Respiration___This may be effected in several ways:— 1. Mouth to Mouth. Inflation, though objectionable as furnishing air which has already been expired, is occasionally the only method which can be employed in an emergency, and may be resorted to, in any case, while more efficient means are being procured. 2. Inflation with Bellows, provided with a suitable mouth- or nose-piece, may be efficiently used, provided that care be taken to secure expiration by manual compression, and that the instrument be worked gently, and not more than ten or twelve times in the minute. 3. Inflation with Oxygen Gas might be tried in extreme cases, or when other means had failed; the gas might conveniently be administered from a bladder, fitted with a mouth-piece. 4. Artificial respiration may readily be practised by alternately Com- pressing the Chest and Abdomen with the Hands, to imitate expiration, and then allowing the natural resiliency of the thoracic walls to produce ex- pansion, and thus imitate inspiration. This method is very easily applied, and is particularly suitable in cases of apparent death from chloroform. 5. Silvester's Method, which is that adopted by the Royal Humane Society of England, consists in placing the patient in a supine 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 together above his head, which is kept low*, and practising artificial respi- ration by compressing the lower part of the chest, and letting go with a jerk so as to allow the parts to expand by their natural resiliency*. 1 Apnoea (a. privative and mm, Epic wvom, Doric tnaa. or wvoia) is etymologically the more correct term, signifying " absence of breathing ;" asphyxia (a. privative and a-4 recoveries, or 27 per cent., and Dr. Waxham 210 cases with 69 recoveries, or *> per cent. TRACHEOTOMY. 379 is confirmed by my own experience, and of late years I have abandoned the use of anaesthetics in this operation. The patient being in the position already described, the surgeon standing at his left side, or, which 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 to the length of the neck. The subcutaneous fat and areolar tissue are similarly 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 with 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 below the thyroid isthmus, the last being, in the large majority of cases, 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 pre- sents itself having been gently withdrawn, the tube is introduced, and, when the respiration has become tranquil, the surgeon may, if it be thought proper, temporarily* remove it, and proceed to cut away an ellip- tical portion of the front wall of the trachea; this step, though not, I Fio. 212.—Tracheotomy. (Liston.) tracheal dilator. the tube at once, but to keep the opening patulous for a time by means of the dilator invented by Mr. Golding-Bird (Fig. 213). The above description presupposes that the surgeon has time to make a careful dissection of the superincumbent parts, before opening the wind- pipe—and, in the immense majority of instances, enough time is afforded for this purpose. I believe, however, with Mr. Durham, that cases are occasionally met with in which it is very important to hasten the steps of the operation; and, in such an emergency, would recommend a plan de- scribed by that author, and which he assures us that he has advantageously employed in 23 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 backwards until he feels the pulsation of both carotid arteries. By slightly approximating the finger and thumb, he feels that the trachea is firmly and securely held between them, and knows that the safety of the great vessels is insured, while the tissues xiver the windpipe are rendered tense. The finger and 380 INJURIES OF THE FACE AND NECK. thumb thus placed are not to be moved until the trachea is reached. Hv a succession of careful incisions, the surgeon now cuts boldly down on the windpipe, the finger and thumb on either side helping him to judge of the position of the median line (from which the knife must not deviate), and, by their pressure, causing the wound to gape, and the trachea to advance. The forefinger of the right hand is passed from time to time into the wound, to make sure that no important vessel is in the way, and when the trachea is reached the knife is introduced (guarded by the right fore- finger), or the windpipe may be seized with a tenaculum and opened as in the ordinary operation. The chief danger from tracheotomy is from hemorrhage; instances are on record in which the carotid, or even the innominate, artery1 has been wounded, while fatal bleeding has not unfrequently occurred from the division of large veins. Arterial hemorrhage should, of course, be checked before openfng the trachea, and bleeding veins should also be secured, pro- vided that death from suffocation be not likely to occur while this is being done. It must be remembered, however, that the venous congestion is due, in great measure, to the obstruction of the patient's breathing, and will be lessened as soon as free respiration is established; hence the sur- geon should not fear, if necessary, to open the windpipe even while venous bleeding continues, introducing the canula, as has been forcibly said, "even through a very pool of blood." In order to avoid the risk of hemorrhage, Verneuil, Bourdon, and Fowler, 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 performed. I cannot but doubt, however, whether this mode of treatment will ever supersede the ordinary operation with the simple scalpel. Laryngo-tracheotomy is, as its name implies, a combination of laryn- gotomy with tracheotomy above the thyroid isthmus. Its mode of |>er- formance requires no special description. After-treatment of Cases of Bronehotomy—In almost all cases, except those of foreign body in the air-passages, it is necessary to introduce a tracheal canula or tube, which must he w*orn until the power of breathing through the larynx is restored. The tube should he made of silver, with a curve of rather less than a quarter of a circle, double, so that the inner canula may be removed and cleansed, while the outer ietains its position, the two being secured 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 motion-of no 2H -Tracheal tube. the trachea, and the inner tube should project beyond the outer one for about a quarter oi an inch, at either extremity. 'The canula should be from two to three inches in length, and, as advised by Mr. Howse and Mr. Parker, as large i Secondary hemorrhage from the innominate artery, resulting from ulceration due to pressure of the canula, proved fatal in two cases reported to the Anatomical *w™> of Paris, and referred to in the British Medical Journal for April 2, lssl. Hemorrnaj, from the tracheal mucous membrane proved fatal in one of my own cases, by gin K rise to broncho-pneumonia. , , a 2 Amussat had previously employed the galvanic cautery, dividing the traci ^ from within outwards with a platinum wire previously introduced by ™ea"§' curved needle. Paquelin'* thermo-cautery has been recently employed in tram otomy by Poinsot, of Bordeaux. AFTER-TREATMENT OF CASES OF BRONCHOTOMY. 381 as can be conveniently introduced into the trachea. For use after laryng- otomy the canula may be a little flattened, the transverse being somewhat greater than the antero-posterior diameter of its section. Fig. 215.—Trousseau's two-bladed tracheal forceps. Fig. 21S.—Elsberg's three-bladed tracheal forceps. Fig 217.—Cohen's tracheal tube with fenestrated trocar. The canula above described, which embraces the improvements of both Obre and Roger, is, I think, preferable to either the ordinary double tube, or the bivalve canula of Fuller. Mr. Dur- ham has suggested a still further modi- fication, by which the length of the tube can be regulated, by means of a screw, to meet the emergencies of any particu- lar case. Mr. Parker employs a tube, the shape of w*hich 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 easily held apart with two-bladed or three- bladed dilating forceps (Figs. 215, 216), or, which is better, a blunt-pointed pilot trocar, as suggested by Dr. Gairdner, or a fenestrated tubular trocar, as employed by M. Pean and Dr. Cohen (Fig. 211), 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. Mprrant 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 m 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 diphtheria, lime-water or dilute carbolic acid may, from time to time, be vaporized through the tube with an atomizer. Cheyne advises that the trachea above the tube should be plugged with gauze dipped in a 1-2000 solution of bichloride of mercury, in order to prevent the membrane from spreading dowmvards. The plug should be renewed every two hours. Hypodermic injections of pilocarpine are recommended in these cases by Duliscourt and other French surgeons. The expectorated matters should be constantly wiped away, and accumula- tions of mucus or false membrane removed with a camel's-hair brush, feather, or "elbow-forceps" (Fig. 218), or, as suggested by Bush, of Bristol, *.ramoneur,\\be but smaller than that employed for the oesophagus (see Fig. 223). As soon as the canula can be safely dispensed with, it may be removed, 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 382 INJURIES OF THE FACE AND NECK. larynx has been restored. Great difficulty may* be experienced in getting rid of the canula in quite young children, in whom the wall of the trachea is so soft that it is sucked in when the child cries, and obstructs the Fig. 21S —Trousseau's elbow-forceps. breathing like a closed valve. In cases of stenosis from neoplasm it may be necessary to wear a tube permanently, when such an instrument as is shown in Fig 219, may be found convenient. This is furnished with a ball-valve which offers no obstacle to inspi- ration, but in expiration forces the air to pass through the larynx, thus enabling the patient to speak in an audible tone. If it be necessary to perform broneho- tomy in an emergency, and when a tracheal canula cannot be obtained, the surgeon may, as suggested by Bloch, of Copen- hagen, substitute a piece of drainage-tube, kept from slipping into the trachea by transfixing it with a "safety-pin" laid across the wound, or may have recourse to excising an elliptical portion of the tracheal wall, and keeping the edges of the wound apart with retractors made of bent wire (the hooks of ordinary large "hooks and eyes" will answer), secured by an elastic band passing behind the neck. (Fig. 220.) If apncea persist after a free opening has been made into the windpipe, the surgeon must at once resort to one or other of the methods of practising artificial respiration already described. Dr. Beverly Robinson, of New York, has devised an ingenious "insufflator," by means of which the surgeon can directly inflate the patient's chest through the tracheal tube, without incurring any risk from contact with the secretions of the part. This instrument, or a double-acting bellows, as recom- mended by Dr. B. W. Richardson, should be employed in case suffocation is threatened by false membrane accumulating below the opening in the trachea; or, if neither of these lie at hand, an ordinary hand-ball syringe (reversed) may be used, as sug- gested by* Dr. Green, of Brooklyn. Mr. R. W. Parker has devised an ingenious apparatus for freeing the trachea from blood or false membrane by suction, infection being prevented by the interposition of a bunch of iodoformed or carbolized cotton wool between the tube and the mouth of the operator. Choice of Operation.—The relative advantages of laryngotomy and Fin. 219 —Tracheal tube with bail- valve. Fio. 220.—Wire retractors for use after trache- otomy. FOREIGN BODIES IN THE PHARYNX OR OESOPHAGUS. 383 tracheotomy are still a matter of dispute among practical surgeons. Trache- otomy is preferred in all cases bv Mr. Marsh, and laryngotomy or laryngo- tracheotomy by Mr. Holmes, especially* among children. Mr. Erichsen recommends laryngotomy for adults, and tracheotomy*, above the thyroid isthmus, for children ; while Mr. Durham considers that the advantages of opening the trachea below the isthmus, as compared with its risks and difficulties, are greater than those afforded by making the opening higher up. While I do not believe that any rule of universal application can be safely laid down upon this question, I would advise, in general terms, that tracheotomy below 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, laryngotomy, which may readily be converted subse- quently into laryngo-tracheotomy, should be performed instead. When the operation is required by the presence of a foreign body in the wind- pipe, 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 circumstances 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 result- ing from a continuance of the disease rather than from the operation. The result of the procedure, in my own hands, has been to save nineteen out of forty-one patients. Injuries op the (Esophagus. Wounds.—These have already been alluded to in describing penetra- ting wounds of the neck, the treatment of which injuries is complicated by the oesophageal wound, through the difficulty* thence arising in administer- ing the necessary amount of nutriment. A patient with weund of the gullet may be fed through an elastic gum catheter, introduced through the mouth, or, if, with 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 twe or three times a day, until the power of deglutition returns. If the wound is above the position of the larynx, suffocation may occur from the supervention of cedema of the glottis—an accident which would call for the immediate performance of laryngotomy. Rupture of the (Esophagus is a rare form of injury of which Charles, of Belfast, has collected 15 cases; to these may be added one observed by Dr. William Hunter, and others recently reported by Howse, Stanley Boyd (two cases), Purslow, J. S Bailey, of Albany, and G. 0. Allen, of Boston. The accident has usually occurred during the act of vomiting, and the symptoms are intense pain with collapse, followed by death in the course of a few hours. According to Fitz, the affection is still rarer than would be indicated by the above figures, many of the reported cases being, in the opinion of this author, really instances of post-mortem softening and perforation. Foreign Bodies in the Pharynx or (Esophagus__Foreign bodies not unfrequently become impacted in some portion of the food-passage (usually, according to H. Allen, either at the position of the cricoid carti- lage, or just above the crossing of the left bronchus), and produce not only great irritation and difficulty of swallowing, but may even induce suffoca- tion by pressure on the windpipe. The symptoms vary with the nature, size, and position of the foreign body. A fish-bone, bristle, or pin may be caught between the tonsil and half-arches of the palate, and give rise to 384 INJURIES OF THE FACE AND NECK. much discomfort, with tickling cough, dysphagia, and nausea. A pointed body* in this situation may even perforate an imjiortant vessel, and thus cause death by hemorrhage. 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, pro- duce ulceration of the oesophageal 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 with a well-oiled probang. In some cases the laryngoscope may be used to facilitate the examination of the upper portion of the gullet. Though the foreign body can thus usually be discovered, if present, a small substance, such as a fish- bone, may, from the peculiarity of its position, elude detection even after Fio. 221.—Burge's oesophageal forceps. careful and repeated exploration; on the other hand, the sensations of the patient may continue to indicate the impaction of a foreign body for a Fia. 222.—Swivel probang. long period, when none is really present, and oesophagotomy has actually been performed, on more than one occasion, without any substance being found which could account for the patient's symptoms. Treatment.—If suffocation be threatened, unless the foreign body can at once be seized and removed, trache- otomy should be resorted to without 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 the finger (if lodged in the pharynx), or by the cautious use of oesophageal forceps (Fig. 221), or of the horse-hair or swivel pro- bang. Dr. Lamm, a Swedish surgeon, has succeeded in washing out a foreign body from the oesophagus by syringing through a flexible catheter. Dinsmore has succeeded by forcibly depressing the base of the tongue, and thus causing retching, with dislodgment and ejection of the offending substance. If the foreign body be of such a nature that it will not be likely to produce injurious consequences in the stomach or bowels, as a lump of meat, or even a small coin, it may, if its extraction prove difficult, be pushedonwarda Fio. 223—Horsehair pro- bang, or Ramoneur. CESOPHAGOTOMY. 385 into the stomach, with a sponge or ivory-headed probang.1 If, as occa- sionally though rarely happens, a foreign body in the gullet can be neither extracted nor otherwise disposed of, it should be removed through an ex- ternal incision by the operation known as pharyngotomy or ozsophagotomy? (Esophagotomy__If the foreign body can be felt externally, the operation should be done on that side which is the most prominent; other- wise the left side is to be chosen, as the oesophagus naturally inclines somewhat in that direction. The patient should be anaesthetized, and placed in a supine position, with the head and shoulders a little raised, and the face somew'hat averted. An incision, four or five inches long, is made in the space between the trachea and the sterno-mastoid muscle, beginning above, on a level with the top of the thyroid cartilage. This incision is cautiously deepened, the omo-hyoid muscle, and the outer fibres of the sterno-hyoid and sterno-thvroid, being divided, if necessary; the carotid sheath is carefully drawn outwards, and held with a blunt hook, the trachea and thyroid gland being similarly drawn inwards. If the foreign body can now be felt, the oesophagus may be incised directly upon it; otherwise a sound or curved forceps should be introduced through the mouth, and made to project in the wound, thus affording a guide to the point at which the gullet should be opened. The incision may be subse- quently enlarged either upwards or downwards, and the foreign body extracted with the finger or forceps. Special care must be taken in this operation not to wound either the inferior thy'roid artery or the recurrent laryngeal nerve. The incision should be allowed to heal by granulation, the patient being fed through a catheter, as after an accidental wound of the oesophagus. This operation is essentially that which has been successfully performed by* Syme, Cock, and Cheever, and seems to me in every way preferable to that by a median incision, which was recommended by Ne'Iaton. The results of oesophago- tomy for the removal of foreign bodies are quite encouraging, 129 cases to which I have references having given 95 recoveries and only 34 deaths. Cases of CEsophagotomy for Removal of Foreign Bodies. No. Operator. Result. No. Operator. Result. 1 Albertoni, Recovered. 18 Billroth, Recovered. 2 Alexander, " 19 Id. a 3 Alsberg, a 20 Id. a 4 Aiitoniesz, a 21 Id. a 5 Arnold, a 22 Id. Died. 6 Arnott, Died. 23 Id. " 7 Atherton, Recovered. 24 Bose, a 6 Id. ,, 25 Butlin, it 9 Barton, " 26 Castresana, Recovered. 10 Begin, u 27 Cazin, k 11 Id. u 28 Cheever, n 12 Berns, (C 29 Id. a 13 Id. Died. 30 Id. a 14 Bille, " 31 Id. Died. 15 Id. Recovered. 32 Cock, Recovered. 16 Billroth, a 33 Id. n 17 Id. ii 34 De Lavacherie, n 1 An English surgeon, Dr. Stewart, has recorded a case in which a live fish was thus successfully disposed of. 2 Wheeler, of Dublin, insists upon a distinction between these operations, and prefers the former. 25 386 INJURIES OF THE FACE AND NECK. Cases of (Esophagotomy for Removal of Foreign Hodies.—Continued. No. Operator. Result. No. Operator. McLean, Result. 35 De Lavacherie, Died. 83 Recovered. 36 Demarquay, ii 84 Id. Died. 37 Esmarch, It sr> Marcacci, i< 38 Id. Recovered. 86 Markoe, ii 39 Fischer, " 87 Id. Recovered. 40 Id. Died. 88 Martini, Died. 41 Flaubert, a 89 Maunder, Recovered. 42 Frew, Recovered. 90 May, ii 43 Giommi, <( 91 Monastyrski, u 44 Goursauld, u 92 Id. ii 45 Hacker, a 93 Monnier, Died. 46 Id. a 94 Navratil, Recovered. 47 Id. a 95 Nikolaysen, " 48 Halsted, u 96 Nussbaum, Died. 40 Haywood, ii 97 Pean, Recovered. 50 Helwig, it 98 Pye, Died. 51 Hitchcock, ti 99 Ricchi, Recovered. 52 Hodgen, ic 100 Richet, Died. 53 Id. ii 101 Rhine, k 54 Holmer, u 102 Roland, Recovered. 55 Howell, " 103 Roser, u 56 Inzani, i< 104 Rossi, ti 57 Justi, ii 105 Rupprecht, !< 58 Knie, ii 106 Schede, II 59 Kolaczek, Died. 107 Schmidt, II 60 Konig, " 108 Schonborn, Died. 61 Kronlein, i< 109 Socin, ii 62 Id. Recovered. 110 Sonnenberg, Recovered. 63 Kiister, Died. 111 Sonrier, ti 64 Lagarde, Recovered. 112 Span ton, Died. 65 Lange, " 113 Stadler, Recovered. 66 Langenbeck, <( 114 Stamm, n 67 Id. a 115 Stanley, Died. 68 Id. a 116 Stinson, Recovered. 69 Id. Died. 117 Strom, k 70 Lawrie, Recovered. 118 Studsgaard, ii 71 Lawson, " 119 Syme, ii VI Lediard, << 120 Thomas, !l 73 Leisrink, " 121 Tobin, Died. 74 Lindenbaum, if 122 Ungefug, Recovered. 75 Lisensko& Kieber, a 123 Westmoreland, Died. 76 Lundgren, Died. 124 Wheeler, Recovered. 77 McArdle, Recovered. 125 Id. ii 78 MacCormac, 126 Id. ii 79 McKeown, a 127 Id. " 80 McLean, ti 128 Wright, ii 81 Id. a 129 ii 82 Id. it Note.—Twenty-two of the above cases are derived from Cheever, and forty-nine from G. Fischer. In several cases no foreign body appears to have been found. I have not included two operations by Mr. Syme, in which the foreign bodies had already made their way through the oesophagus by ulceration, nor Dr. Gay's interesting case in which the foreign body was by manipulation made to cut its own way through the gullet, which was not incised—the operation, therefore, not seeming to me, with due respect to Dr. Gay, to have been, properly speaking, an cesophagotomy. I have also omitted a somewhat apocryphal case to be found in Dr. Eve's Remarkable Case* in Surgery, and attributed by Fischer to Scott. In Billy's fatal case, gastrotomy was also performed. In case 129, the foreign body appears to have been subsequently found in the larynx. CONTUSIONS OF THE CHEST. 387 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 with broad strips of adhesive plaster, precisely as in a case of fractured ribs. An occasional consequence of severe contusion of the chest is the formation of an abscess beneath the pectoral muscle ; suppura- tion 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 swell- ing of the whole pectoral region ; should, however, these symptoms follow an injury, and coincide with the constitutional evidences of the existence of deep-seated suppuration, the proper treatment would be to cut down in the direction of the muscular fibres, enlarging the exploratory* incision subsequently as much as might be necessary. Contusion Accompanied by Rupture of the Thoracic Vis- cera, without corresponding fracture, and without external wound, is a rare and dangerous accident, which may result from the contact of a spent ball or piece of shell, from being run over, from falls from a height, etc. Rupture of the Lung has been occasionally* observed under these cir- cumstances, and cases are recorded by several writers, in which, in spite of the severity of the injury, the patients recovered. The symptoms are those of wounded lung—pneumothorax, with, perhaps, emphysema, haemo- thorax, haemoptysis, and, at a later period, pleurisy and pneumonia, with accumulation of pus or serum in the pleural cavity. The mechanism of the lesion in these cases is, doubtless, as pointed out by Gosselin, that, at the moment of injury*, the lung is distended by inspiration, and the glottis spasmodically closed, thus preventing the lung from y-ielding to the sudden pressure. I have seen three cases of this kind—two at the Pennsylvania Hospital, one under the care of Drs. E. Hartshorneand C. C. Lee, in which the left lung was ruptured, and which proved fatal on the third day, and one under the care of Dr. W. Hunt, fatal on the second day ; and a third under my own 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 hsemothorax, 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; 39 cases which I have collected, and which resulted from various forms of violence other than gunshot in- jury, having given only 12 recoveries, while 25 cases recorded by Dr. Otis as having occurred during our late war, gave 11 recoveries. The treatment of this form of injury is that which will be presently described as appropriate to wounds of the lung. 1 In a discussion at the Clinical Society of London, reported in the British Medical Journal for March II, 1882, a number of cases of spontaneous rupture, causing pneumo- thorax, were referred to. 388 INJURIES OF THE CHEST. Cases of Rupture of the Lung without Parietal Injury. No. Reporter. Result. No. Reporter. Result. 1 Adams, Died. 21 McDonnell, Died. 2 Ash hurst, " 22 Id. " 3 Bermond, ii 23 Marsh, " 4 Bouilly, Recovered. 24 Nelson, [ed. 5 Butlin, Died. 25 Norton, Utidetermin- 6 Id. " 26 Poland, Died. 7 Id. Recovered. 27 Pollock, Recovered. 8 Churchill, " 28 Saussier, u 9 DaCosta, <' i 29 See. ii 10 Gosselin, " ! 30 Senfft, e hemorrhage, which may prove almost instantly fatal; punctured wounds are, however, often attended with little or no bleeding, owing chiefly to a peculiar arrangement of the muscular fibres of the heart, described by Pettigrew, by which a wound which is transverse to one layer of fibres is in the direction of another layer, and therefore, to a certain extent, necessarily valvular. Suncope is often observed in cn^ of heart-wound, occurring not unfrequently at the moment of injury. Pain, when present, is, according to Fischer, due to the pericardial lesion. WOUNDS OF THE ANTERIOR MEDIASTINUM. 397 If effusion of blood or serum take place into the cavity of the pericar- dium, the sounds of the heart and the cardiac impulse are diminished in intensity. A systolic bellows sound is the most usual abnormal murmur observed in cases of heart-wound. Precordial anxiety, dyspnoea, and other symptoms are not distinctive, and, indeed, are occasionally entirely wanting. The diagnosis, which, as may be inferred from what has been said, is often obscure, may be additionally complicated by the coexistence of a wound of the lung, as happened in a case which I observed some years ago. The prognosis should, of course, be very guarded. Recovery*, how- ever, may occasionally follow, and instances have been recorded by Ferrus, Latour, Fournier, Randall, Carnochan, Balch, Hamilton, Hopkins, Gal- lard, Tillaux, Conner, Peabody, and others, in which patients have sur- vived heart-wounds for considerable periods, even though with foreign bodies lodged in the substance of the organ. Callender and Hahn have recorded remarkable cases in which they* successfully removed needles which were fixed in the substance of the heart. Stelzner opened the peri- cardium, and attempted to extract a needle introduced into the heart with suicidal intent, but the foreign body slipped entirely into the organ and eluded his grasp; the patient recovered. The treatment of a suspected wound of the heart would consist in keeping the patient at absolute rest, and in the application of cold, the administration of opium, digitalis, vera- trum viride, etc., and, if death were threatened by pericardial effusion, perhaps the performance of paracentesis. Block, of Dantzic, suggests that the heart might be temporarily* withdrawn from the chest, and emptied of blood by compression, while the wound was closed with sutures. The operation has succeeded with dogs and rabbits, but even in Germany no one appears as yet to have attempted it in the human subject. If death be threatened by hemorrhage into the pericardium (what Rose calls heart-tamponade), venesection should be resorted to, with absolute rest and the local use of ice. Rose recommends laying open the pericardium, but does not appear to have put his suggestion in practice. Paracentesis Pericardii may be performed in the fourth or fifth left intercostal interspace, with the same precautions that were recommended for the operation of tapping the pleural sac. Rouse and Barlow are disposed to prefer tapping on the right side of the sternum. Of 41 cases collected by Dr. J. B. Roberts, of this cit}*, 22 proved fatal, but mostly from causes unconnected with the operation, and of 97 cases collected by Dr. Grainger Stewart, only 38 terminated favorably. Rosenstein records a case of purulent pericarditis successfully treated by free incision, an operation which is said to have been originally practised by Romero, in 1801. Other cases have been recorded by S. West, Kummell, Dickinson, Michailoff, Minin and Hindenburg, and Part- zevsky; and Gussenbauer has successfully evacuated pus from the peri- cardium, after exposing the part by the resection of five ribs. Lanne- longue has recorded a remarkable case of congenital ectocardia successfully treated by a plastic operation. 3. Wounds of the Aorta and Vena Cava are almost invariably fatal. Cases are, however, recorded by Pelletan, Heil, and Legouest, in which patients survived wounds of the aorta for from two months to several years. 4. Wounds of the Anterior Mediastinum are less serious than any other penetrating wounds of the chest; the symptoms are often rather obscure, being, indeed, in many instances, chiefly* negative, and the diag- nosis depends on the absence of those signs which characterize wounds of the lung. Some of these signs may, however, be present; thus emphy- sema, and, according to Fraser, even tromatopncea, may accompany wounds 398 INJURIES OF THE ABDOMEN AND PELVIS. of the mediastinum which do not involve the lung or pleura. The chief dangers of these injuries are hemorrhage (from the internal mammary artery), diffuse inflammation, and suppuration. Death may result from pressure of the accumulated pus on the heart or lungs, or from pyaunia. The treatment of a wound of the mediastinum is that which has been directed for other penetrating wounds of the chest; if suppuration occur, the matter should be evacuated where the abscess tends to point, at one or the other side of the sternum. Injuries op the Diaphragm. The diaphragm may* be ruptured by external violence, as by a fall on the chest or abdomen, by violent squeezing, as in railway accidents, or (as in a case referred to by Mr. Pollock) by spasmodic contraction of the part itself. The usual seat of laceration, in these cases, is the left side, in the fleshy portion of the muscle. If the injury be uncomplicated by lesion of abdominal or thoracic viscera, the prognosis is not as unfavorable as might be supposed ; unless, however, the laceration be very limited in extent, protrusion of the stomach or other abdominal viscera into the cavity of the chest will almost inevitably occur, constituting the condition known as Diaphragmatic Hernia. Wounds of the diaphragm, resulting from stabs, gunshot injuries, etc., are usually complicated with other serious lesions, and it is from these, rather than from the wound of the diaphragm itself, that the danger in these cases chiefly arises. The symptoms of a wound of the diaphragm are very* obscure ; in most instances there is great dys- pnoea, breathing being principally carried on by the subsidiary muscles of respiration. The late Dr. C. T. Hunter, however, recorded a case of gun- shot wound, in which the ball, after perforating the stomach, bowels, and diaphragm, lodged in the thoracic cavity, but in which there was no diffi- culty of breathing until shortly before death, the dyspnoea even then evi- dently* resulting mechanically, from gaseous distention of the intestines. Hiccough occurred in a case which was under my care in the University Hospital. The treatment of a wound of the diaphragm is essentially the same as that recommended for penetrating wounds of the chest. Pos- tempski has successfully treated a wound of the diaphragm, complicated by hernia of the omentum which protruded through the external opening between the eleventh and twelfth ribs, by enlarging the outer wound, forc- ing the ribs apart, ligating and cutting off the omentum and returning its stump to the abdomen, and finally closing both the wound of the diaphragm and the external wound with sutures. CHAPTER XIX. INJURIES OF THE ABDOMEN AND PELVIS. Contusions of the Abdomen. Contusions of the Abdomen, unattended by Lesions of the contained Viscera, are rarely attended with much risk. It is popu- larly believed that sudden death not unfrequently results from a blow on the epigastrium, no morbid appearance being discoverable on post-mortem inspection; the possibility of such an occurrence has, however, been shown, CONTUSIONS OF THE ABDOMEN. 399 by Mr. Pollock's researches, to be at least doubtful, though there can be no question that rapid death may* follow these injuries, either from con- comitant shock, or from a condition of the solar plexus analogous to cere- bral concussion. In either case, however, there would probably be physical lesions which could be recognized after death. Rupture of the Abdominal Muscles may occur without the ex- istence of any external wound; these ruptures have usually been observed in the recti muscles, though they may occur in any portion of the abdominal parietes. The accident is very apt to be followed by a form of ventral hernia, which may sometimes attain a very large size, as in the patient whose case is represented in the annexed figure, and who received his injuries by being run over by the wheel of a cart. The treatment of such a case consists in the application of a truss with a broad and somewhat concave pad, to restrain the protrusion. There is little risk of strangulation, on account of the large size and yielding character of the hernial aperture. I have several times seen, in soldiers, a ventral hernia in the median line, resulting from separation of the tendinous fibres in the linea alba, and caused, apparently, by the fatigue of long marches and the weight of the knapsack. The treatment consists in the application of a pad and elastic bandage. Abscess of the Abdominal Pa- rietes occasionally follows contusion of the part, and may cause great destruction of tissue by extending between the muscular"planes. The treatment consists in early evacuation of the pus, by means of free incisions so arranged as to permit drainage. Contusions of the Abdomen, attended with Lacerations of the Abdominal Viscera, are very grave injuries. Rupture of the liver, spleen, kidney, omentum, or mesentery, or of any of the large vessels, may prove rapidly fatal from internal hemorrhage ; while lacerations of the hollow viscera, as the stomach, bowel, or gall-bladder, or of the parietal peritoneum, are principally dangerous on account of the peritonitis which almost inevitably results. Intestinal obstruction occasionally follows ap- parently slight contusion of the abdomen, doubtless from injury to the peritoneum covering the affected portion of bowel. Encysted dropsy re- sulted in a case recorded by Duplay. The degree of risk attending lacera- tion of the solid viscera depends entirely upon the extent of the lesion ; thus a superficial laceration of the liver may cause merely localized perito- nitis, from which the patient may recover j1 injuries of the spleen are more dangerous, on account of the profuse bleeding which attends even slight lesions of this organ, and death usually results, if not from hemorrhage, yet at a later period, from the supervention of diffuse inflammation and suppuration. Spontaneous rupture of the spleen is said by Peterson to be a not infrequent occurrence in cases of relapsing fever. Barrallier reports 1 Schraorl and Zenker have recorded curious cases in which ruptures of the liver were followed by venous, cardiac, and pulmonary embolisms of hepatic tissue. Fio. 224—Ventral hernia, following rupture of the abdominal muscles. (From a patient in the Episcopal Hospital.) 400 INJURIES OF THE ABDOMEN AND PELVIS. two cases of malarial origin, and malarial enlargement of the spleen ren- ders it liable to rupture from the application of very slight violence. Laceration of the kidneys offers a comiiaratively favorable prognosis; as was mentioned in Chap. XVI., slight lacerations of these organs are not infrequent in cases of spinal injury, and do not appear necessarily to entail any serious consequences. Ruptures of the stomach or bowel1 are almost invariably fatal: 149 cases collected by Chavasse gave 14:5 deaths—a mor- tality of 9(> per cent.; if the seat of laceration should be such that extrava- sation of the contents of these viscera should take place elsewhere than into the peritoneal cavity (as between the layers of the mesentery, in the case of the bowel), it would be just possible that the resulting inflammation might terminate in an abscess which would point externally, and that re- covery might thus follow.; but it maybe given as a general rule, that ruptures of the stomach or bowel are fatal injuries. Spontaneous rupture of the stomach, the result of excessive vomiting, has been observed by Chiari and Lantschner. Rupture of the gall-bladder is almost always followed by death, bile being found in the peritoneal cavity on post-mor- tem examination; that recovery is at least possible, would, however, appear from a case recorded by Dr. Fergus, in which the patient was considered convalescent, and was walking about, when, on the seventh day, peritonitis was suddenly developed, and proved fatal two days subse- quently. Rupture of the ureter is a very rare injury ; Mr. Poland has col- lected four cases, one of which ended in recovery, after the evacuation by puncture, at intervals, of about two gallons of fluid resembling urine, the other cases terminating in death during the first, fourth, and tenth weeks, respectively. In none of the cases does it appear that peritonitis was present, the urinary extravasation having occurred into the cellular tissue behind the peritoneum. Ruptures of the abdominal bloodvessels, without other injuries, are seldom met with. Legouest has recorded a case of laceration of the aorta; and Dr. Otis has collected five cases of a similar lesion of the vena cava. I have myself seen death follow an unrecognized rupture of the external iliac artery (see Pig. 97). Symptoms.—The symptoms of these various forms of injury are rather obscure. There is usually marked shock, with pain, and a sensation of impending dissolution—but not more than is often observed in cases of abdominal contusion unaccompanied by visceral lesion : the persistence of collapse, however, with other evidences of intestinal hemorrhage, would give reason to suspect rupture of a solid viscus, or of a portion of the peritoneum which contains large vessels; while the immediate development of peri- tonitis would indicate rupture of one of the hollow viscera. Pain in the right hypochondrium, with increased hepatic dulness, and, at a later period, bilious vomiting, clay-colored stools, and the presence of sugar in.the urine, would afford evidence of laceration of the liver; hematuria would indicate lesion of the kidney, though its absence would by no means prove that this organ had escaped; haematemesis would be a symptom of ruptured stomnch, and bloody stools of ruptured intestine—a lesion, the existence of which might also be suspected, if the abdominal wall were the seat of emphysema, the diagnosis of which from emphysema due to thoracic injury, and from gase- ous putrefaction, might be made by observing the history of the case, and the coincident symptoms. The history may also serve, sometimes, to dis- tinguish between gastric and intestinal laceration, rupture of the stomach rarely occurring except when that organ is distended by a recent meal. 1 Dr. Whitney has pointed out that, in cases of ante-mortem rupture of the intfstine, the mucous membrane is invariably found everted; this is not the case as regar ruptures produced after death. TRAUMATIC PERITONITIS. 401 Treatment.—As these injuries are in the majority of instances neces- sarily fatal, their treatment must, of course, be often merely euthanasial. As far as any curative influence can be exerted by remedies, it must be (as Sir Thomas AVatson puts it) in obviating the tendency to death. Hence the surgeon's first efforts must be directed to arresting the internal hemorrhage which is the source of immediate danger, and at a later period to combat- ing the peritonitis which is the common cause of death in those cases which survive the early periods of the injury*. The patient should be put to bed, and kept profoundly quiet; if the symptoms of shock be very prominent, cautious efforts may be made to induce reaction, preferably by the applica- tion of external warmth, for it must be remembered that internal stimulation might increase the risk of hemorrhage. Opium may* be freely administered, both to relieve the sufferings of the patient, and as an anti-hemorrhagic remedy ; to increase its efficiency in the latter respect, it may be advantage- ously combined with acetate of lead. The older writers recommended venesection in these cases, on the same principle for which it was employed in the treatment of penetrating wounds of the chest; but I imagine that there are few surgeons at the present day who would employ bleeding under these circumstances. The local treatment should consist (at this stage) in the application of cold to the abdomen—dry cold applied by means of an ice bag or box (see page 55), or, if these be not at hand, clothes wrung out of cold water and frequently renewed. The diet should be mild and unirritating, and if there be reason to suspect laceration of the stomach or bowel, the patient should be exclusively fed by means of nutritive enemata. If great suffering should be caused by gaseous distention, the surgeon would be justified in punc- turing the bowel with a fine trocar, through the linea alba, as recommended by T. Smith. It does not appear that this little operation is in itself attended with any particular risk,1 and it would certainly be permissible as an eutha- nasial measure. Retention of urine should be obviated by the use of the catheter. An exploratory operation, to seek for the laceration and close it by sutures, has been suggested in these cases, but, it seems to me, with questionable propriety, unless there should be strong reason to believe that a hollow viscus was injured. Of 18 such cases to which I have references, only two appear to have been successful, and in one of these (Croft's), death occurred four weeks subsequently*, after an attempt to close a fecal fistula left at the first operation. If laparotomy should be resorted to, Curtis's advice seems judicious, that the ruptured bowel should be secured in the wound so as to permit the formation of an artificial anus, which may be dealt with on another occasion. Traumatic Peritonitis— It is probable that slight and circumscribed peritonitis occurs in almost every case of severe abdominal injury which recovers, but it is the existence of diffuse peritoneal inflammation, attended with the effusion of turbid serum, or with suppuration, that constitutes the chief danger to be apprehended in the later stages of these injuries. The symptoms of traumatic peritonitis do not differ from those of the idiopathic variety of the affection, and for their description I would therefore refer the reader to works on the Practice of Medicine. The course of traumatic peritonitis is very rapid, death from this cause sometimes occurring in less than twenty-four hours from the time of reception of the injury. The treatment varies with the general condition of the patient, and the supposed ' Fonssagrives has collected 84 cases of puncture of the bowel for tympanites, show- ing that the operation is not particularly dangerous ; but his views are contravened by Piorry and Frantzel, who regard the procedure as one which is full of peril. 402 INJURIES OF THE ABDOMEN AND PELVIS. nature of the internal lesion. I have never had occasion to employ gene- ral bleeding in these cases, but I have applied leeches or cups (in cases occurring among those of robust health and vigorous constitution), and, I am sure, with advantage. The amount of blood drawn may vary from s to 12 ounces, or even more, and the immediate mechanical relief thus afforded to the inflamed peritoneum is sufficient, I think, to compensate for.the evils which inevitably attend all forms of bloodletting. In an old or feeble per- son, however, or in a very young child, I should consider even local bleed- ing highly improper. The application of a large blister is usually recom- mended in these cases, and 1 have myself employed it. I am not sure, however, that a jacket-poultice, enveloping the whole abdomen, might not be equally efficient, as it would be probably more agreeable, to the patient. I have found advantage from the use of the veralrum viride, in doses of 3 or 4 drops of the tincture, every three hours, simply as a means of reducing the rapidity of the heart's action and the force of the circulation; the remedy is, however, a dangerous one, and its effects should be carefully watched, its administration being suspended as soon as the pulse falls to the normal average. Opium is an invaluable remedy in cases of traumatic peritonitis, and may be freely given in every instance. Dr. Alonzo Clark's rule was to give two grains, more or less, every two hours until the patient's respiration had been reduced to twelve in the minute. Unless laceration of some part of the alimentary canal be suspected,1 this drug may be suitably combined with small doses of calomel; but in cases of intestinal rupture, the effect of the latter substance would be to increase the risk of fecal extravasation, and in such a case, if mercury be used at all, it should be employed by inunction. In cases of septic peritonitis, such as is apt to occur after abdominal section, Tait advises the administration of a brisk cathartic, and "Wylie suggests that in these cases the unfavorable symp- toms, vomiting, ty*mpanites, etc., are due rather to obstruction from forming adhesions than to actual inflammation. Milk diet is that which is best adapted to cases of traumatic peritonitis, wine or brandy being added if necessary. If the stomach or bowel be lacerated, nutritive enemata, of beef-tea, eggnog, etc., must be substituted. If serous effusion persist after the subsidence of acute symptoms, an attempt may be made to promote absorption by the use of blisters, and by the administration of iodide of potassium. Paracentesis may ultimately be required, or, if the effusion he purulent, even incision and drainage, which have proved successful in cases recorded by Schmidt, Treves, Marsh, AValsham, and Taylor. Laparotomy for peritonitis has likewise succeeded in the hands of Mikulicz, Kronlein, Ceppi, Leucke, Heuser, Gay, Roberts, Studenski, Wylie, and Burchard. In Oberst's case, relief was afforded by* the operation, but the patient died in 9 weeks from pneumonia and bedsores. Laparotomy for peritonitis proved unsuccessful in eases recorded by Drs. Shimmel, and F. J. Sheppard, and in my own hands, in a case which I saw with Dr. Baldwin, of this city. Lapa- rotomy* for tubercular peritonitis has, according to Ceccherelli, been cm- ployed in 88 cases ; in 5 of these the result is unknown, in 6 some relief was afforded, death ensued in 25, and 52 ended in recovery. The mortality in terminated cases was thus 30 per cent. Retro-peritoneal Suppuration, resulting from rupture of the inter- tine between the layers of the mesentery, might require incisions to 1 According to Dr. Flint, if there he perforation the peritoneal cavity will contain gM, and the normal liver dulness will be replaced by resonance. The same authority recommends aspiration to evacuate the peritoneal gas and bring the opposing serooa surfaces in contact, thus favoring adhesion. PENETRATING WOUNDS. 403 evacuate the pus ; and similar treatment would be indicated in the event of Urinary Extravasation occurring from laceration of the kidney or ureter. Wounds of the Abdomen. Non-Penetrating Wounds of the abdominal parietes present few peculiarities requiring special mention. Foreign bodies are to be removed, and the wound cleansed, as in other localities. Hemorrhage in these cases cannot safely be controlled by pressure, simply because there is no surface to furnish counter-pressure, while closure of the external wound will not suffice, because it would allow interstitial bleeding to continue, and thus dissect up the inter-muscular spaces ; therefore, if, in any case, the hemor- rhage be greater than mere oozing, the part must be freely exposed (the wound, if necessary, being enlarged for this purpose), and the bleeding vessel secured by ligature, torsion, or acupressure. These wounds are apt to gape, and, hence, if extensive, require the use of sutures, muscular relaxation being secured by position. . Ventral Hernia may occur after cicatrization, and will require the application of a truss or bandage. Penetrating Wounds.—These may be divided into—1. Those with- out protrusion or wound of the abdominal viscera ; 2. Those without pro- trusion, but with wound of such viscera; 3. Those with protrusion of unwounded viscera; and 4. Those with protrusion and wound of viscera. 1. Penetrating Wounds of the Abdomen without Protrusion or Wound of the Contained Viscera, may result from stabs, bayonet thrusts, or gun- shot injuries. The diagnosis from non-penetrating wounds is often difficult, and any exploration with a probe would be manifestly improper. The surgeon may, however, cautiously enlarge the external wound, cutting down layer by layer, to ascertain if the peritoneum is really divided. The escape of bloody serum, or the occurrence of emphysema, may like- wise be taken to indicate penetration of the peritoneal cavity, and the diagnosis would be confirmed should peritonitis subsequently occur. The treatment to be pursued in a case of this kind should consist in cautiously enlarging the wound, so as to permit an inspection of the vis- cera immediately beneath, when, if there be neither visceral wound found nor extravasation of blood, the parts may be gently, but thoroughly, washed with warm distilled water, or a weak antiseptic solution, and the wound accurately closed with carbolized silk sutures, carried through all the tissues of the abdominal wall, including the peritoneum. Prof. Senn recommends, as a means of determining whether or not there be any wound of the stomach or bowel, that hydrogen-gas should be introduced into the rectum in such quantity as to distend the intestinal canal; if this be perforated, the gas will escape externally, and can be lighted at the abdominal wound. The same test may be applied after the abdomen has been opened, to insure that no wound of the bowel has been overlooked. I his very ingenious aid to diagnosis has been successfully adopted bv sev- eral surgeons, but has not always been found infallible, and has the dis- advantage that the intestinal distention, which it causes, in itself sometimes becomes a serious complication. 2. Penetrating Wounds, with Wound of the Abdominal Viscera, but without Protrusion.—The diagnosis of these cases from those of the last category may be made by observing the flow of the visceral contents through the external wound, or by noting a very rapid development of peritonitis, which, when resulting from extravasation of the visceral con- tents occurs more quickly than under other circumstances. In a case of gunshot wound of the stomach, recorded by Culbertson, the diagnosis was 404 INJURIES OF THE ABDOMEN AND PELVIS. rendered clear by the detection of several shot in the matter vomited bv the patient immediately after the reception of the injury. Semi's test, by inflation of the bowel with hydrogen gas, has already- been referred to. In any case of doubt, and particularly in eases of gunshot wound, the sur- geon should open the abdomen, either by enlarging the original wound, or, which is usually preferable, by making a median incision, and then care- fully and systematically inspect all the viscera lying in the line of injury. In the treatment of these cases wounds of the stomach or bowel should be carefully- sutured, in the way that will presently be described, or if a num- ber of wounds be found close together in a small segment of intestine, it may be better to excise a portion of the gut (entercetomy), and bring the ends to the surface so as to establish temporarily an artificial anus. If, how- ever, the jejunum be the part involved, to do this would render useless such a large part of the alimentary canal, that it will be better to resort to im- mediate enterorraphy, so as to restore the continuity of the bowel. Suture, or partial or complete excision, may likewise be required in case of wound of the solid viscera. Before closing the external wound, the abdominal cavity should be thoroughly freed from blood and extravasated materials, with soft sponges and gently applied, warm, antiseptic douches, and one or more drainage tubes, preferably of glass, should be introduced. The neck of the tube may be surrounded with a square of rubber tissue (a rub- ber dam), which is folded up over its mouth, and may be lightly filled with antiseptic absorbent cotton, which should be changed as often as it becomes saturated; when the serous discharge ceases, usually in three or four days, the tube may be removed. 3. Penetrating Wounds, with Protrusion of Unwounded Viscera.— Portions of almost any* of the abdominal organs may* protrude, if the wound be a large one, and instances are not wanting in which recovery has fol- lowed the protrusion, under such circumstances, of parts of the stomach, liver, spleen, or other viscera. In these eases, the wound being large, there is commonly not much difficulty in reduction, which should always be prac- tised in the case of such organs as have been mentioned. If the bladder protrude, reduction may be much facilitated by* the use of the catheter. If, as occasionally happens, a portion of a solid vLscus, such as the liver, spleen, or pancreas, be strangulated and already gangrenous when first seen by the surgeon, a strong ligature should be applied, when the slough- ing mass may be either cut away or allowed to separate spontaneously. Recoveries under these circumstances have been reported by several sur- geons, and Dr. Otis has collected a number of such cases in the second volume of the Surgical History of the War. The following Table, condensed from one given by Edler and quoted by MacCormac, shows the mortality which attends injuries of the solid abdo- minal viscera :— Statistics of Injuries of Solid Viscera of Abdomen. Viscera Affected. Liver and gall-bladder Spleen ..... Pancreas .... Kidneys .... Subcutaneous Ruptures. ! Ginshot Wou.idb. Cases. Eecov- med. Mortality \ Cases. Recov- Died. ' ered. per cent, i ered. 189 27 ! 162 85.8 I 289 130 | 159 '>■>■" 83 11 3 1 90 45 Aggregates . . 365 84 72 86.7 | 42 7 35 83.3 2 : 66.6 6 15 -'-3 45 ; 50.0 ! 50 | 28 | 22 44-" 281 77.0 :3h7 166 221 . 57.0 PENETRATING WOUNDS. 405 Totals. Cases. Recov- Died. Mortality ered. per cent. 543 180 363 66.8 160 47 113 70.6 13 6 7 53.8 152 80 72 47.3 868 313 555 63.9 The parts which are liable to protrude through small wounds are the bowels, mesentery, and omentum. The treatment of such cases should depend upon the condition of the extruded viscera. If Bowel protrude, and be found healthy, or only moderately congested, it should at once be returned. This may sometimes be effected by drawing down a further portion of the gut, and gently pressing upwards the fecal contents, so as to diminish the tension of the protruded mass. In other cases it may be necessary to enlarge the wound—just as in the analogous case of operation for strangulated hernia. This debridement, as it is called, should be made in an upward direction, and should be confined, if possible, to the skin and muscular tissues, the peritoneal aperture usually yielding without incision. If reduction be rendered impossible by gaseous distention of the protruded bowel, the surgeon would be justified in puncturing the part with a grooved needle, as has been successfully done by* Mr. Tatum and others. Dr. Storrs, of Hartford, Conn., recommends that the lips of the wound should be drawn upwards and separated by means of blunt hooks or ligatures, pre- viously introduced. Reduction should be aided by placing the patient in such a position as will insure relaxation of the abdominal walls, and the portion of bowel which has last descended must be first returned. The surgeon must take care that reduction is really accomplished, and that the protruding part is not merely thrust up between the planes of the abdomi- nal parietes. If the protruded bowel be gangrenous, it would not be safe to attempt reduction, and, in such a case, the part should be freely* incised, and the patient allowed to recover, if possible, with a fecal fistula. What course should be adopted, if the bowel, though not absolutely gangrenous, be intensely inflamed ? It is usually advised, under these circumstances, to effect reduction and close the wound, but I am not sure that it might not sometimes be better to allow the part to remain in situ, after dividing any constricting bands that might threaten strangulation. The risk of peritonitis would, at least, not be increased by this plan, while, if the bowel should subsequently give way, there would be less danger of fecal extrava- sation. The course to be pursued in case of Omental Protrusion likewise depends upon the state of the part; if this be healthy, it should at once be returned, but if violently inflamed, or if gangrenous, it should be excised— the part immediately* above being first transfixed and tied with a double ligature, to prevent hemorrhage, and the stump being secured in the deeper portion of the wound, by fastening the ligatures, with adhesive strips, to the abdominal wall. Morisani records an interesting case in which a mass of omentum entered the colon through an ulcerated opening, and passing downwards protruded from the anus ; excision was performed with all antiseptic precautions, but death from septic peritonitis followed on the sixth day. The treatment to be pursued after reduction, consists in accurately- closing the wound with numerous sutures (which should embrace the Viscera Affected. Liver and gall-bladder Spleen..... Pancreas .... Kidneys .... Aggregates . . Punctured and Incisre Wounds. Cases. Recov- Died. Mortality ered. per ceut. 65 23 42 64.6 35 29 6 17.1 4 4 12 7 5 41.6 116 63 53 45.6 406 INJURIES OF THE ABDOMEN AND PELVIS. whole thickness of the abdominal wall, including the peritoneum), and in adopting means to moderate the peritonitis which may be expected to occur. If omentum have been excised, the cutaneous wound should be closed over the ligated stump, the ligatures being brought out between the points of suture. If bowel have been left in the wound, with anticipation that a fecal fistula will follow, the part should be covered with protective and lightly dressed, so as to exclude the air, and keep the wound as nearly as possible in an aseptic condition. 4. Penetrating Wounds, with Protrusion and Wound of Viscera.—It a solid viscus be affected, the treatment would consist in reduction, or in partial excision, according to the rules above laid down. Postempski and H. C. Dalton have successfully closed wounds of the liver with sutures. Complete excision may be required by extensive injuries of the spleen or kidnev. Hemorrhage from a mesenteric artery should be arrested by torsion or ligature. Wounds of the stomach1 or bowel require the appli- cation of sutures, the part being subsequently returned into the abdominal cavity, and the after-treatment being conducted as in eases of the previous category. The suture employed should, in case of a large wound, be the continued or glover's suture (Fig. S3), applied through all the coats except the mucous; or, which is preferable, if the wound be transverse, Lembert's, Gely's, or Appolito's modification. These have for their object the inver- Fi<*. 225. Lembert's suture Fio. 226 Gely's suture Fiu. 227.—Appolito's suture. sion of the edges of the wound, and the consequent coaptation of the serous surfaces (Figs. 225-227), and seem to me, upon the whole, quite as satisfactory as the more complicated methods of Vezien, Bouisson, and Berenger-Feraud. The suture being applied, both ends are to be cut short and the whole replaced in the abdominal cavity. The suture (which should be of fine silk) gradually finds its way into the inferior of the bowel, and is eventually discharged per anum. For small longitudinal wounds the common interrupted suture may suffice, while a mere puncture mav lie closed by simply throwing around it a ligature, the wounded point bein? raised for the purpose with tenaculum or artery-forceps. If, on the other hand, a transverse wound involve the whole calibre of the bowel, it ^ probably better to secure the edges of each extremity of the gut to the external wound, and allow the formation of a fecal fistula. This course will usually be safer than an attempt to restore the continuity of the bowe i Successful gastrorrhaphies in cases of penetrating wound have been recorded J Reichenbach, Prieto, Facilides, Burckhardt, Dalton, Ball, Black, and Jones. r» gastrorrhaphies have been recorded by Billroth (two cases), Mikulicz, Bnddon, Lawsou. PENETRATING WOUNDS. 407 bv means of sutures, unless the wound involve the upper portion of the small intestine, when enterorraphy would be indicated. In the after-treatment of all these cases the free administration of opium is of the highest importance. The patient must be kept perfectly quiet, purgatives strictly interdicted, and food given as much as possible in the form of nutritive enemata. In accordance with the teachings of modern surgery*, I have in the pre- ceding pages advised a resort to abdominal section, or laparotomy, in the treatment of penetrating wounds of the belly*, with suture of stomach or bowels (gastrorraphy, enterorraphy), and, if necessary, excision of a por- tion of the intestine, or enterectomy. The description of the operations of laparotomy and enterectomy will be given in the chapter on Diseases of the Intestinal Canal. I have advised this mode of treatment because it is that advocated by the immense majority of operators and surgical writers of the present day, and because, in a large number of cases, it offers, I be- lieve, the best chance of recovery; and yet I am by no means sure that a few years hence the consensus of surgical opinion may not change, and tend more strongly in the direction of expectancy in the management of these injuries. Every hospital surgeon whose experience extends over many years must have seen cases of penetrating wound of the abdomen which ran a favorable course without interference, and in my own field of observation, while I can recall not a few such cases, the instances in which, on the other hand, laparotomy for abdominal wounds has proved success- ful, have been, with rare exceptions, such as might have been expected to recover without operation. The statistical results of laparotomy for ab- dominal injury have been investigated by several writers, including Sir W. MacCormac, Mr. Barker, Dr. Dalton, Dr. Coley, and Dr. T. S. K. Morton, of this city*, who has courteously permitted me to examine his tables, yet unpublished; to the cases collected by these gentlemen I have been able to add a number of others, and the annexed table shows the re- sults of 259 operations:— Statistics of Laparotomy for Abdominal Injury. Nature of Injury. Cases. Recov-ered. Died. Undeter-mined. Mortality per cent. Rupture of urinary bladder Rupture of bowels or other viscera Punctured, incised, or lacerated wound (runshot wound ..... 28 18 89 124 10 2 55 41 18 16 33 82 "l 1 64.2 88.8 37.5 66.6 Aggregates .... 259 108 149 2 57.9 Prof. Postempski is said to have operated 23 times with 17 successes, but I have not been able to obtain the details of more than one of his cases. If the others were added, we should have 281 cases with 155 deaths, or over 55 per cent. In order to compare these figures with those of abdominal injury treated without operation, I have asked Dr. Walter D. Green to examine the re- cords of the Pennsylvania Hospital, which has always been the great "ac- cident-hospital" of Philadelphia, and he finds that, omitting all doubtful cases, there have been treated without operation1 in the wards of that insti- tution, during the last sixteen years, 55 undoubted examples of penetrating 1 In a few cases the external wound was slightly enlarged to permit the reduction of protruding viscera, but no exploratory operation was performed. 408 INJURIES OF THE ABDOMEN AND PELVIS. wound of the abdomen, of which 25, or over 45 per cent, proved fatal. Adding these to the cases reported by Dr. T. (J. Richardson, from the Charity* Hospital, New Orleans, we have a total of 118 cases of wound of the abdominal cavity, treated without operation, the results of which may be seen in the following table :— Table showing Results of Penetrating Wounds of the Abdomen treated without Operation. Charity Hospital, New Orleans . Pennsylvania Hospi- tal, Philadelphia Aggregates Punctured, Incised, a.ni. c;CNSHot Wounds. Lacerated Wounds. I 24 23 60 47 ' 13 ° a. 22.5 | 32 13 19 j 59.3 20.7 26 7 19 73.0 21.6 I! 58 I 20 38 65.5 1 Totals. >-.- 00 o~ t !r £ - » O 63 37 a 26 K — 41.2 55 30 25 45.4 118 67 51 43.2 Two cases, one each of ruptured bowel and ruptured bladder, treated at the Pennsylvania Hospital during the same period, both proved fatal. Laparotomy for abdominal injury has been employed in the Pennsylvania Hospital 20 times, with 7 recoveries and 13 deaths, or 65 per cent.; in 16 cases for incised, punctured, or lacerated wounds, with 11 deaths, or 68 per cent.; and in 4 cases for gunshot wound, with 2 deaths, or 50 per cent. These cases are included in the general table. From these figures it will be seen that the evidence, as far as statistics £0, is in favor of expectant measures, and that a resort to laparotomy has, thus far, added to rather than lessened the mortality in these injuries. I am disposed to think, however, that some of the deaths after abdominal section in these eases have been attributable to recklessness on the part of thesurgeon in unnecessarily prolonging the operation, and in disregarding the dangers of shock from exposure and chilling of the viscera, and that, if executed with skill and care, laparotomy, at least in well-selected cases of penetrating wound of the abdomen, is a proper mode of treatment. Cases of Laparotomy for Abdominal Injury. I. FOR RUPTURE OF URTNARY BLADDER (28). No. Operator. Result. No. Operator. Rex n It. 1 Blum, Recovered. 15 Lyell, Died. 2 Briddon, Died. 16 MacCormac, Recovered. 3 Brown, i> 17 Id. " 4 Bull, <( 18 McGill. Died. 5 Duncan, <( 19 Morison, " 6 Fox, << 20 Robson, (< t Grant, Recovered. 21 Socin & Keser, Recovered. 8 Halstrom, " 22 Sonnenburg, Died. 9 Heath, Died. 23 Staunton, " 10 Hitchcock, " 24 Svmonds, ii 11 Id. a 25 Teale, k 12 Hofmokl, Recovered. 26 Walsham, Recovered. 13 Holmes, " 27 Walter, [. 14 Keyes, Died. 28 Willett, Died. PENETRATING WOUNDS. 409 II. FOR RUPTURE OF BOWELS OR OTHER VISCERA (18). No. Operator. Result. No. Operator. Result. 1 Atkinson, Died. 10 Fitzgerald, Died. 2 Billroth, " 11 Girdlestone, " 3 Bouilly, (t 12 Gregory, a 4 Chauvel, u 13 McBurney, Recovered. 5 Chavasse, K 14 Mackellar, Died. 6 Croft, <( 15 Owen, ti 7 Id. Recovered. 16 Robson, 8 Demons, Died. 17 Waggoner, a 9 Dixon, d 18 Willett, n III. FOR PUNCTURED OR INCISED WOUNDS (89). No. Operator. Result. No. Operator. Result. 1 Allis, Died. 46 Gualco, Recovered. 2 Ashhurst, >< 47 Hedden, it 3 Id. u 48 Hunt, Died. 4 Id. Recovered. 49 Huntington, Recovered. 5 Avery, a 50 Jersey, Died. 6 Ball, it 51 Jobert, " 7 Barker, !< 52 Jones, Recovered. 8 Barton, (( 53 Koenig, ' a 9 Baudens, Died. 54 Kwiecinski, u 10 Benisovitch, Recovered. 55 Lawson, Died. 11 Bennett, tt 56 Morton, k 12 Bernays, it 57 Id. !< 13 Id. Died. 58 Id. Recovered. 14 Black, Recovered. 59 Id. it 15 Boone, " 60 Molitor, it 16 Brooks, u 61 C. Nelaton, it 17 Burckhardt, (< 62 Packard, it 18 Id. articularly where two 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 Fio. 245.—Mucous patches. (Mii.lbb.) rarely between the toes, on the inside of the thighs, and on other parts of the bodv. 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 jireviously removed. On the mucous membranes they are less elevated, and, in the mouth at least, the exuda- tion takes the form of a whitish pellicle, constituting the so-called "opaline patch." Condylomata usually first appear as reddish spots, effusion taking place beneath the cuticle, which drops or is rubbed off, the surface being then soon covered with the characteristic exudation. Occasionally a chan- cre is directly transformed 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 ulcer- ated, and are occasionally confluent. At the angles of the mouth, on the tongue, and at the margin of the anus, 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 ex- istence of any recognizable ulceration, are, as pointed out by Hammond, Morgan, and H. Lee, occasionally met with as symptoms of secondary syphilis, and are probably more often the source of contagion than is com- monly supposed. Enlargement of Lymphatic Glands—This is a very constant and significant manifestation of secondary syphilis. The glands most com- monly affected are the posterior cervical, though others are occasionally SECONDARY SYPHILIS. 491 involved. The cervical engorgement is most marked when a pustular erup- tion 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 develop- ment of this characteristic system is, according to Bumstead, from six to eight weeks after the appearance of the chancre. Alopecia, or Falling of the Hair, is an early symptom of second- ary syjihilis. 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. This form of alopecia is amenable to treatment, and, according to Bumstead, is often absent when mercury has been taken in the primary stage. There is another form met with in connection with tertiary syphilis, which is usually incurable. Affections of the Eye___Conjunctivitis, the conjunctiva being thick- ened and granular, with auricular and post-cervical adenitis, resulting from syphilis and cured by the administration of mercury, has been described by Goldzieher; Sattler has reported a similar case. Iritis is not unfre- quently met with during the secondary stage of syphilis, from two to nine months after infection, though the worst form of the disease is that which occurs in the tertiary stage. The latter, according to Gascoyen and other authors, is certainly* due to syphilitic contamination, while the variety met with during the secondary stage often presents no clinical characteristics dif- ferent from those of simple plastic iritis, except its tendency to throw out lymph. The vascular sclerotic zone around the margin of the cornea, and pain, are sometimes comjiaratively insignificant symptoms. The iris changes its color and becomes muddy, nodules of lymph soon appear, especially around the pupil, and the aqueous humor often becomes turbid; the cornea is occasionally involved. The pupil is sluggish and contracted, and becomes fastened by synechie to the capsule of the lens, but there is little photo- phobia. Both eyes are attacked in probably two-thirds of the cases, though not usually simultaneously. According to Nettleship, relapses in the iritis of secondary syphilis are rare. This form of the disease is much less in- tractable than the parenchymatous variety which occurs in tertiary syphilis. Retinitis and Choroiditis, often seen together, but occasionally occurring singly, are met with in syphilis, and may appear as a concomitant or sequel of iritis. They set in from six 'months to two years after the primary in- fection, but their appearance has occasionally been delayed as late as ten years. Next to the iris, the choroid is affected more frequently by syphilis than any other jiortion of the eye. The symptoms consist of mistiness of vision, micropsia, a diminution of the visual field, with a feeling of fulness in the eye and some circumorbital pain. Photophobia is usually, but not in- variably absent. It is sometimes possible, according to Wells, to distin- guish these affections from those which are not syphilitic by their ophthal- moscopic ajmearances, even if no other symptoms of syphilis are present. Hutchinson has, however, jiointed out that while in the vast majority of cases the discovery* of the results of choroiditis disseminata points strongly to the existence of a syphilitic taint, its symptoms should not be entirely relied upon, unless supported by other facts. Syphilis is, according to Cowell, by far the most frequent cause of diffuse neuro-retinitis and exu- dative retinitis, which are the ordinary forms of the disease. The former is quite amenable to treatment, and is fortunately much commoner than the exudative variety. Keratitis, exactly similar to that which is seen in in- herited syphilis, is of extremel}* rare occurrence in the acquired disease, but occasionally appears in the secondary stage. Syphilitic affections of 492 VENEREAL DISEASES. the lachrymal apparatus have been described by R. W. Taylor, of New York. Affections of the Ear___Acute myringitis, or inflammation of the membrana tympani, sometimes occurs in secondary syjihilis, and may cause permanent deafness from inflammatory thickening of the part. Dr. F. H. Sturgis has reported two cases of inflammation of the middle ear due to secondary* syphilis, and syjihilitic disease of the internal ear has been ob- served by Roosa and by Moos. Affections of the Nervous System.—Hemiplegia, with or with- out loss of consciousness, often jireceded by jiersistent headache, mydriasis, and perhajisjtfose's, is occasionally observed in connection with the secondary stage of syphilis. The explanation of these cases (in which no appreciable lesion may be found after death) is, according to Dr. E. L. Keyes, of New 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 conges- tions of the skin and mucous membranes which occur in secondary syjihilis. Affections of Joints and Bursas—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 which belong to the secondary stages occur with a certain degree of regularity (the exanthematous, for instance, usually preceding the papular eruptions), and last, with occasional intermissions, for a period varying from one to six months. They are general symptoms, 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 abso- lutely 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 occa- sionally produce great disfiguration. They* begin as small, solid, cutaneous tumors, of a dusky-red color, and with a firm base, and are frequently devel- oped 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. TERTIARY SYPHILIS. 493 The ulcerated syphilitic tubercle occa- sionally produces great ravages, and may be mistaken for lupus, rodent ulcer, or serpiginous chancroid. It heals with a characteristic white and depressed cicatrix, if the ulceration have extended deeply, or with 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 dis- ease ; 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, which occurs in connection with tertiary syphilis, differs from that seen in the secondary* stage merely in the greater depth to which ulceration extends. In fio. 246.—syphilitic ulceration of face. 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 connection with the tubercular eruption already described. Fio. 247.—Syphilitic rupia. (Druitt.) Syphilitic Onychia, or ulceration in the matrix of the nails, which become drv and distorted, and are finall)* thrown off, is a concomitant of the squamous erujitions, 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 ephithelium—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 lyniphv deposit, causing stiffness, contraction, and distortion of the organ. The tongue may also be the seat of gummatous tumors. The ulcerated form of lingual syphilis may cause great destruction of the part, and has been mistaken for epithelioma; the latter affection attacks particu- larly the side of the tongue, is solitary, and involves the submaxillary ganglia; while the lingual syphilitic tubercle is commonly multiple, occu- pies the dorsum and base of the tongue, and is not attended by enlarge- ment of the lymphatic glands. The syphilitic gumma may*, however, occupy any part of the organ. 494 VENEREAL DISEASES. The tonsils, fauces, and palate suffer in tertiary syjihilis from ulcera- tion, which may be circumscribed or phagedenic. The latter variety usu- ally results from the ulceration of syphilitic tubercle, and may produce very wide destruction of parts, involving the soft palate and uvula, pillars of the fauces, and orifices of the Eustachian tubes, and causing difficulty of swallowing, with perhaps regurgitation through the nostrils, deafness, and difficulty of articulation. The discharge is very offensive, and the ulcera- tion may extend to the nose, larynx, or oesophagus, or may even involve the cervical vertebre. The larynx and trachea may be affected with a deposit of syphilitic tubercle, which may undergo ulceration, causing dyspnoea, often of a par- oxysmal character, and perhajis requiring tracheotomy for its relief. Con- traction of the windpipe 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 oesophageal stricture may result after cicatrization. The colon may be, according to Paget, affected in tertiary syphilis with a form of ulcera- tion analogous to the ulcerated tubercle of the skin. Cullerier has de- scribed a syphilitic enteritis, which he considers analogous to the erythema of the skin, and as therefore belonging to the secondary period ; his views 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 jiart. The urethra may' be involved in tertiary syphilis, and H. Lee believes that many cases of stricture are of syphilitic origin. Eye.—The worst form of syphilitic iritis is that which 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 dej>osit of yellow tubercles, which are shown by the microscope to be identical in structure with the gummatous tumors found in other parts of the body. The nodules are usually* situated at the pupillary mar- gin, but occasionally at the jieriphery ; from one to four may be jiresent. Cyclitis of a severe type may appear in acquired syphilis, and may lead to detachment of the retina. Gunimata involving the ciliary body are comparatively rare; Ayres, of Cincinnati, has recently reported six cases. The deeper seated structures are occasionally involved, and perma- nent disorganization may then occur. Optic neuritis, as an indirect result of syphilitic disease of the eye and of the nervous sy*stem, is common in syphilis; as a primary* affection it is rare, though it may be caused by a gummatous inflammation of the trunk of the optic nerve. Simple optic atrophy occasionally occurs as a direct consequence of syphilis, but more frequently* results indirectly from syphilitic diseases of the eye such as re- tinitis and choroiditis, or is consecutive to a papillitis caused by coarse ter- tiary syphilitic intracranial lesions. Rankin, of New York, has reported a remarkable case of syphilitic atrophy of both optic nerves, cured by large doses of mercury, strychnia, and iodide of potassium ; and C. S. Bull has observed optic neuritis and paraly*sis of the ocular muscles as a result of syphilis. Progressive atrophy* of the disks and external ophthalmoplegia of syphilitic origin, associated with locomotor ataxia, are not unfrequently recorded. R. W. Taylor reports cases of tertiary as well as of secondary syphilitic disease of the lachrymal apparatus. 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 particularly mentioned the testis, liver, spleen, kidneys, mesenteric TERTIARY SYPHILIS. 495 glands, lungs, and heart. The limits of this work will not permit a de- scription of the changes jiroduced 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 translated for the New Sydenham Society*, and which gives a very complete account of visceral syjihilis. 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 for- mation of a contractile lymph, which 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 painless, and giving annoyance only by its weight. Hydro- cele often accompanies this form of the disease, which is very chronic, and rarely followed by suppuration. The Circumscribed or Gummy Orchitis was first described b}* Hamilton, of Dublin, as Tubercular Syphilitic Sar- cocele. 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, with fatty or cretaceous degeneration, and not unfrequently lead to suppuration, with the forma- tion of fistulous openings, and occasionally a fungous protrusion of the testicle itself. Under the microscope, these yellowish masses are found to differ from ordinary lymph, in containing a large amount of cells and fat- globules, with crystals of margarine. 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 ly*mphy or gummy nature taking place in the sub- stance of those organs, or in their membranes, and giving rise to various nervous disturbances, such as Epilepsy, Paralysis (which may be local or general), Chorea (a rare manifestation of syphilis of which Dr. R. H. Alison has collected 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 dis- tinctly recognizing the existence of syphilitic lesions of the central nervous system is due, I believe, to Reade, of Belfast, Ireland, whose 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 works the reader is respectfully referred. A few cases are on record in which 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 sy*philis has long been recognized, but the change has been supposed to be identical with atheroma. According to Heubner and Ewald, however, it differs from that condition in affecting exclusively the smaller arteries, and in having no tendency to gelatinoid or cartilaginoid change, or to fatty or calcareous degeneration. 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 followed 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 496 VENEREAL DISEASES. tertiary syphilis. These usually occur as hard, round, indolent, subcuta- neous nodules, which gradually undergo softening and become adherent to the skin ; ulceration finally takes jilace, and, after the extrusion of a slough, the part heals, leaving a depressed scar which is at first purple, but subse- quently becomes white. When cut open, these nodules or gummatous tumors present a tolerably firm cystic investment, containing a semi-solid gelatinous or gummy substance, whence their name. Their size varies from a half inch to two 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, gran- ules, and nucleated cells, with a few elastic fibres, free nuclei, and capillary bloodvessels. When situated in the submucous tissue, gummata give rise to troublesome ulcerations, 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; Bursse__Gummatous Tumors occur in the voluntary muscles, tendons, and fasciae, interfering with the functions of the parts, and sometimes causing deep and painful ulcers. They may also, according to Keyes, affect the burse, either primarily or by ex- tension from other tissues. In the fingers and toes, in which situation they* may involve either the superfi- cial tissues, or the jierios- tuem and bone (when dis- organization of the joints may follow), they give rise to the troublesome condi- tion known as Syphilitic Panaris or Whitlow (Fig. 248), or Syphilitic Dactylitis, the latter name being preferred by Taylor, of New York, who has given an excellent ac- count of the affection. Ricord and others state that syphilis may cause rigid muscular contraction (as of the biceps), without organic change. The so-called congenital tumor of the sterno-mastoid muscle ajipoars 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 which are subcutane- ous 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 jieculiarity of being aggravated by the warmth of bed. Syphilitic perios- titis is usually circumscribed, and gives rise to the formation of oblong swellings, called nodes, which are commonly hard and indolent, being due to lyniphv deposit in and beneath the periosteum, but which in other cases are fluctuating and tender, and apparently due to the deposit of gumma- tous material. They may often be dispersed by treatment, but occasion- ally jiersist, becoming converted into exostoses. Suppuration rarely occurs, unless the bone itself be involved. Syphilis affects the bones by produc- ing chronic osteitis, leading to hypertrophy and induration, or to caries and necrosis. These may affect any bones, but are most frequent in the Fio. 248.—Syphilitic panaris. (From a patient at the Chil- dren's Hospital.) HEREDITARY SYPHILIS. 497 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, fall- ing in of the nose, or grave cerebral disturbance. Syphilitic necrosis may, according to Yirchow, be recognized by observing that the sequestrum has a perforated and worm-eaten appearance, which he attributes to the pre- vious 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 ac- quired variety, chiefly in having no primary stage. A foetus may be in- fected 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 con- ception, but may acquire syphilis during pregnancy, and transmit it to her offspring ; and (4) the father may transmit the disease to the foetus, with- out directly infecting the mother, who, 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 syjihi- litic embryo very* often dies before the full term of intra-uterine life is Fio. 249.—Syphilitic permanent teeth. (Hutchinson.) accomplished, and abortion then follows. Oc- casionally, though rarely*, a child presents mucous patches and other unmistakable evi- dences of syphilis at the moment of birth, and the disease is then properly called con- genital. More often, however, the child is apparently healthy when born, or if cachectic, presents no definite morbid lesions. Heredi- tary syphilis is usually developed from a fortnight to two months after birth, but may* appear at any time within the first y*ear. It is very doubtful whether the first manifesta- tion 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 which the early symp- toms have been overlooked. The early manifestations of hereditary syphilis belong to the secondary period of the disease, those which are most characteristic being mucous patches, syphilitic pemphigus, and coryza—the snuffles of the popular vocabulary. Larnygitis may also occur in this stage, with inflammation of the buccal 32 Fig. 250. Bone-disea«e in hereditary syphilis. 498 VENEREAL DISEASES. mucous membrane, or syphilitic stomatitis. If the latter exist, the tempo- rary teeth are apt to be ill-formed and carious, and often drop before the usual time. The child becomes sallow and withered, and seems jiroina- turely old. If death do not occur from mal-nutrition 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 cicatrices at the corners of the mouth, and a peculiar notched condition of the permanent teeth (Fig. 249), particularly* of the ujiper 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 oftbecornee, which often remain jiermanently opaque in sjiots. (See Chap. XXXY.) Iritis is much rarer in the hereditary, than in the ac- quired form of the disease. Inflammation of the choroid,1 retina, and optic nerve, and deafness, are also sometimes observed as a re- sult of hereditary syjihilis. The viscera affected in these cases are chiefly the liver and lungs, the brain and thymus gland being very rarely in- volved. The bones may* be affected in hereditary syphilis, the lesions par- ticularly* deserving attention being the syphilitic panaris or dactylitis (p. 496), and a peculiar inflammatory condition of the epiphyseal extremities of the bones, sometimes attended with suppuration and caries, and, from the loss of function which attends the disease, called by Parrot the pseudo- paralysis of inherited syphilis. A person who 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. Ac- quired infantile syphilis does not present any marked difference from the same disease 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 apparent 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, who, if ordinarily intelligent, 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 jiatient. Apart from wilful deception, or concealment, to which there is of course unusual temptation in many cases of syphilis, there is another difficulty, which is that, the symptoms being sjiread over a term of y*ears, 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 constantly apt to mislead the surgeon by giving erroneous answers to such questions as are propounded. The most important point for consideration with reference to the diagnosis of pri- mary syphilis, is the mode of distinguishing the chancre from the chan- croid. 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 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. diagnosis of syphilis. 499 symptoms presented at an)* one period. The diagnostic marks between chancre and chancroid may be conveniently presented in parallel columns:— 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 phagedaenic. 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. 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 sur- face, and furnishing a copious auto-inocu- lable 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. 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 jierson from whom the disease has been contracted, and its value depends upon the fact that chancroid can only* jiroduce 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 diag- nostic means of great value. Inoculation of either chancroid or chancre should never be practised except upon the patient's own person; if the suspicious sore be a chan- croid, 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 pro- duce an ulcer, though not, probably, one of a chancrous nature (see p. 486). 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 with white 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 would 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 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 chancroid, which, in such a case, would naturally* appear to the patient to be the actual cause of syphilitic infection. 500 VENEREAL DISEASES. Chancre may occasionally have to be diagnosticated from cancer, epi- thelioma, or similar affections. This is particularly the case when chauere occurs in unusual situations, as on the fingers, lij>s, or tongue. The syphi- litic nature of the disease may usually be recognized by observing the early implication of the neighboring lymphatic glands, and the effect of anti- syphilitic treatment, which should always be tried before resorting to operative measures in any doubtful case. Syphilitic Bubo is not likely to be mistaken for any affection excejit chronic scrofulous adenitis. If there be no concomitant signs by which 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 sur- geon must rely not upon any one or two symptoms, but upon the coexist- ence of a number, and especially upon their course and order of de vehe- ment ; in other words, he must rely upon careful clinical observation and his general knowledge 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 would 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 erujitions of various forms, post-cervical engorgement, alopecia, and occasional development of mucous patches; or from osteocojiic pains, indolent nodes, and gummatous tumors of the areolar tissue—even tbough such a patient should appear as virtuous as Josejih, 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 ulceration. 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 conjectural. 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 which it shares with other diseases,1 to become less virulent by frequent transmission. A 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 mer- cury, which was formerly so common in cases of syphilis, and which undoubtedly exercised an untoward influence on the course of the disease, has now given way to a more moderate and philosophical employment of this powerful remedy. In any individual case, the prognosis will depend upon several circum- 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 with humanized virus. TREATMENT OF SYPHILIS. 501 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 with secondary lesions. A deep chancre usually indicates a graver infection than a sujierficial 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 who will probably* take due care of his health during the course of treatmeut. 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 eiythema, or roseola, indicating a milder form of syphilis than one of the other varieties. When the tertiary stage has once appeared, the chances of comjilete recovery become very* doubtful; though the disease, however, can rarely, under these circumstances, be entirely eradicated, its manifesta- tions may, in most instances, be, by judicious treatment, held more or less in check, and life may* be prolonged with considerable comfort to the patient. Death from acquired syphilis is rare. The prognosis of hereditary syphilis, if properly treated, is usually favorable 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 op Syphilis. Treatment in Primary Stage__As syphilis is a constitutional dis- ease, 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 dis- appear more quickly* when mercury is given, than when it is withheld, but that the development or evolution of secondary- symptoms is, if not pre- vented, at least retarded and favorably* modified by the administration of the remedy during the primary* 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 applica- tions alone, yet, 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, taking care, of course, to guard against salivation, and discontinuing the remedy if it ajipear 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 prot- iodide (hydrargyri iodidum viride of the 17. S. Pharmacopoeia), which may 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 absorp- tion—elimination of the syphilitic virus, whatever that may be, and absorption of the lyinphy and gummy deposits which characterize the later manifestations of the disease. 502 VENEREAL DISEASES. be conveniently combined with opium, as in the following formula: R. Hydrarg. iodid virid. gr. iij-iv; Ext. opii gr. ij ; Confect. opii 9j. 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 discon- tinued as soon as any tenderness of the gums is perceived. With 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 cica- trization, when healing has begun, by occasional light touches with 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 believe 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 were situated at the extremity of the jirojmce, circumcision would lie justifiable, though it could hardly be exj>ected to exercise any curative influence over the course of the disease. Excision of chancres has recently been practised somewhat extensively by Auspitz, Kolliker, Lassar, and other surgeons, and in a few cases with alleged suc- cess. In the large majority* of instances, however, it has proved of no service whatever, and, personally, I have no confidence in it as a curative measure. If a chancre be attacked with pha.gedsena, 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 j>atient require it. Mercury may be given cautiously, and, as it were, tentatively, being; discontinued if the phagedasnic action continue to spread under its employment. Cauterization with nitric acid, which, it will be remembered, is the great remedy for phagedasnic chancroid, is rarely needed in the treatment of phagedaenic chancre. If the surgeon suspect the existence of a mixed chancre, he should treat the case as one of simjile 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 discutient apjilications, 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 suit- able truss. If the patient remain in bed, a weight, or bag of shot, may be simply laid upon the groin. Inunction with mercurial or iodine ointment, combined with the ointment of hyoscyamus, or of stramonium, may some- times be advantageously 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 ajiplication of tincture of iodine, around, but not over, the enlarged glands, in the way 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, Aquas fgj. M.). If suppuration occur, troublesome sinuses will probably be left, which must be treated on the general principles laid down at page 42G ; while if, as is often the case, the patient give evidence of struma, mercury must be abandoned, and iodine and cod-liver oil substituted. Secondary Stage.—By the course of treatment above described, it is possible, though not probable, that the development of secondary symp- TREATMENT OF SECONDARY SYPHILIS. 503 toms may be prevented. In Secondary Syphilis the use of mercury* is generally acknowledged to be proper, though, even here, its employment will occasionally* be forbidden by the constitutional condition of the patient, or by injurious 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 sys- tem, and that salivation should be carefully avoided.1 In the secondary stage, mercurial inunction is, I think, preferable to the internal adminis- tration of the remedy ; half a drachm of mercurial ointment, or, which Berkeley Hill prefers, an ointment containing twenty jier 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 infantile cases, a few grains of the ointment may* be smeared upon a strip of flannel, which 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 probabl}* 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 con- veniently* combined with the bitter tonics, with the muriated tincture of iron, or (dissolved in ether) with cod-liver oil. The following formulae, the second and third of which are imitated from Bumstead, will usually prove satisfactory*:— R. Hydrarg. chlorid. corrosiv. gr. j ; Tinct. gentian, comp. f^ij : Syr. zingiber's f^j ; Aquae f§v. M. Sig. Tablespoonful three times a day. R. Hydrarg. chlorid. corrosiv. gr. vj-viij ; Tinct. ferri chlorid. f^j. M. Sig. Ten drops for a dose, in water. R. Hydrarg. chlorid. corrosiv. gr. j-ij ; Etheris fgj ; 01. morrhuae f§viij. M. Sig. Tablespoonful for a dose, in the froth of porter. The red iodide of mercury is also a good preparation, in cases of secon- dary* syphilis, and may be given in combination with the iodide of potas- sium, 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 inclosed in a suitable framework, covered with oil-cloth, steam is introduced, together with the fumes derived from the slow volati- lization 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 Dr. T. F. Maury, of Wash- ington (Fig. 251). The use of mercury* by hypodermic injection has been of late success- fully resorted to, in cases of syphilis, by Lewin, of Berlin, R. W. Taylor, of Xew York, and others, and this mode of exhibiting the drug may be employed when other methods are for any reason contra-indicated. From one-twelfth to three-eighths of a grain of the corrosive chloride, dissolved in 15 minims of water, or, which Staub prefers, in a chlor-albuminous solution, made with muriate of ammonium, common salt, and white of 1 Dr. Keyes, of New York, has shown, by actual counting, that small doses of mer- cury actually increase the number of red corpuscles both in healthy persons and in the subjects of syphilis. 504 VENEREAL DISEASES. egir,1 may be injected once or twice daily; or Bamberger's pejitonized solution, which contains the bichloride and common salt: or, which is pre- ferred by llaggazzoni, half a grain of the biniodide, dissolved withalittle iodide of potassium in half a flui- drachm of distilled water. Pick and Streitz employ a preparation known as "iodo-pejiton," which is a peptonized solution of the corrosive chloride with iodide of potassium, and Zeissland Neumann, on the suggestion of Liebreich, use the formamide of mer- cury, as least likely to pro- duce salivation or local dis- turbances. Any of these methods I should consider upon the whole 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 as- tringent and detergent mouth-washes freely employ-ed. The treatment may subsequently be cautiously resumed, or the iodide of potassium may be used instead. The occurrence of Mercurial Eczema, which, however, 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 applica- tion of nitrate of silver, or, which I prefer, the solution of nitrate of mer- cury, with black-wash as an after-dressing. Conradi and Charon recom- mend the use of nitrate of silver, followed instantly by the application of metallic zinc. Syphilitic Sore Throat may be treated with chlorate of potassium gar- gles, or with caustic applications, if there be any phagedasnic tendency. The use of dilute muriatic acid, by means of the atomizer, may occasion- ally be advantageously resorted to. Iritis demands the unsparing instillation of atropia, which may with advantage be combined with cocaine. The great risk is from occlusion of the pupil, and, in this affection, the local is even more important than the general treatment. Leeches may be emjiloyed to relieve the pain. Mercury, preferably by inunction, may be freely used, or, which is sometimes better, 1 Staub's solution may be made according to the following formula:— R. Hydrarg. chlorid. corrosiv., Ammonii muriat. aa9j ; Sodii chlorid. 5i ! Aq. dest. f §iv. Misce et cola, deinde add. Ovi alb. no. j, Aq. dest. q. s. pro f Jfiv. Of this solution 15 minims, containing about TJj grain of the sublimate, may be injected twice daily. Fio. 251 —Maury's fumigating apparatus. TREATMENT OF SECONDARY SYPHILIS. 505 Carmichael's plan of treatment may be adopted. This consists in the administration of drachm doses of the oil of turpentine, in addition to which may be given (in the iritis of the tertiary stage) the iodide of potas- sium. The following formula will be found satisfactory, in most cases:— R. 01. terebinth, f^iss ; Tinct. opii f3ss ; Acaciae, Sacch. alb. aa 3'j ; 01. gaul- theriae, gtt. iv ; Aquae f§iv. M. Sig. Tablespoonful three times a day. Alopecia is sometimes the source of a good deal of annoyance, and may be treated with washes 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 may be given if the patient is used to its employment. 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 disappear- ance of the premonitory signs, but should then be continued regularly, and with 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 mild- ness, 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, Langelbert 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 (preferably by inunction) for the dry tubercular and squamous eruptions, and for the interstitial form of syphilitic orchitis; but for the other mani- festations 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, or even very much larger doses, three times a day, either alone or in combination with the bitter tonics, mineral acids, or cod-liver oil. In obstinate cases what is called the mixed treatment—which consists in the simultaneous administration of mercury and potassium iodide—will be preferable to the use of either drug separately. The corrosive chloride may thus be given, making by* double decomposition a biniodide of mercury, or the latter preparation may be given directly, in the form of the " Sirop Gibert."1 As a Local Application to syphilitic ulcers, black-wash, or iodoform, either in powder or in solution with glycerin and alcohol, may be com- monly employed ; 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 which will keep the symptoms in check, and let that be constantly employed. The same hygienic rules should be observed in the tertiary as in the secondary* stage of the disease. Hereditary Syphilis, in its early* manifestations, is best treated by mercurial inunction, in the way already described. In the later stages, 1 The following formula will be found satisfactory :— R. Hydrarg. iodid. rubr. gr j ; Potassii iodid. Jj ; Aquae fjjj ; Syrupi fijv. M. Sig. From a dessertspoonful to a tablespoonful, thrice daily, after meals. 506 TUMORS. iodide of potassium, with tonics, and esjiecially iron and quinia, will be found of service. The sac.charated iodide of iron is particularly recom- mended by Monti. A syphilitic infant need not be weaned if its mother be able to nurse it, since, as long ago pointed out by Colics, a mother, even if apparently herself free from syphilis, is never infected by her own child. It should not, however, be put to the breast of any other woman, lest the latter should be infected by contact with secondary* lesions in the child's mouth. If a pregnant woman 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, was first recommended 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 world, and the opinion of the profession is almost unanimously ojiposed to its employ-ment. Its use as a means of projihylaxis is clearly- unjustifiable, for there is no evidence that the artifically inoculated disease is more tract- able than that which is acquired in the ordinary way ; and as to the cura- tive effect of sy*philization, the testimony of most unprejudiced observers tends to show that (1) it is very* doubtful whether it exercises any beneficial influence, 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 with chancroidal pus (which is sometimes practised under the imjiression that the chancroid is a syphilitic lesion) is quite unjustifiable, as moi-ely* adding another disease to that from which the patient is already suffering. I do not recommend a resort to syjihilization under any circum- stances, and have 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 with 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 which they* occur, they have, in a certain sense, an independent organic life, growing or withering without regard to the state of nutrition of the rest of the body. They may be more or less strictly limited by an investing membrane, or may be widely diffused, or infiltrated among the surrounding tissues. Their anatomical elements may be the same as those of the tissue in which they grow (homologous, homomorphous), as in the case of a fatty tumor growing amid fat, or may be quite different (heterologous, heteromorphous), alway*s, however, preserving a certain analogy to normal tissue elements, from which, though in character they may deviate, they never entirely depart. Tumors may be either solitary or multiple ; if the CLASSIFICATION OF TUMORS. 507 latter, they may be of the same or of different kinds. When two or more tumors of the same nature coexist, they* may have been developed simul- taneously, 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 ly*mphatic 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 adventi- tious bursa, is directly traceable to the effect of jiressure. In most instances, however, no direct cause of the occurrence of a tumor can be detected, while 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 fit notional activity of anv* particular organ, sometimes exercise a causative influence 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 which 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 sy*stem ; mammary tumors thus sometimes appear to be caused by uterine disturbance. 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 with the functions of adjacent parts, having no tendency 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-malig- nant. This general division, founded upon the clinical characters of mor- bid growths, has many advantages, but is obviously not as accurate or scientific as would be a classification of tumors founded strictly upon their anatomical peculiarities. Such a classification has been proposed by Yir- chow and other authors, and would doubtless have been generally adopted by surgical writers as well as bv* pathologists, 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 jioint of view) the most important matter for consideration. The classification adopted in the following pages, 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 growths. 1 A remarkable case has, however, been recorded by Hayem and Gtraux, 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. 508 TUMORS. CLASSIFICATION OF TUMORS. Non-Malignant Tumors. 1. Cystic Tumors or Cysts; Cystomata. A. Simple, or Barren. B. Compound, or Proliferous. (1) Si-rous ; hygromata. (8) Complex. (2) Synovial. (9) With intra-cystic growths. (3) Mucous. (10) Cutaneous. (4) Sanguineous. (11) Dentigerous. (5) Oily. (fi) 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. Skmi-Malignant or Recurrent Tumors; Sarcomata. (1) Recurrent fibroid tumor or spindle-celled sarcoma. (2) Myeloid tumor or giant-celled sarcoma. (3) Round-celled and other sarcomata. Malignant Tumors or Cancers ; Carcinomata and Epitheliomata. 1. Carcinoma. (1) Scirrhous or hard cancer (Scirrhus). (2) Medullary or soft cancer (Encephaloid). (a) Melanoid. (d) Villous. (b) Haematoid. (e) Colloid. (c) Osteoid. (/) Fibrous. 2. Epithelioma. (Epithelial cancer or skin-cancer.) Non-Malignant Tumors, as a rule, disjilace without involving, sur- rounding tissues ; they* possess considerable vitality, and hence may per- sist for a long period without 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, which they gradually replace or appropriate to themselves; they possess comparatively little vitality, and hence tend to ulceration and destructive degeneration ; they exhibit, in the same mass, a considerable number of diverse structural elements; and though removed with the greatest care, almost invariably recur. The Semi-Malignant or Recurrent Tumors occupy an intermediate position ; they often grow rapidly and cause ulceration of the over-lying integument; they frequently contain, in the same tumor, a great variety of structural elements; and, though they do not commonly spread to dis- tant organs, they mostly have a strong tendency to recur after even appa- rently complete removal. These remarks, though generally, are not universally, applicable. It SIMPLE OR BARREN CYSTS. 509 occasionally happens that a tumor, which is undoubtedly cancerous, does not recur after removal, while, on the other hand, a growth which, struc- turally, is such as would be placed among the non-malignant tumors, may recur indefinitely, and eventually cause death. The special characters and appropriate treatment of each variety of tumor which comes under the observation of the surgeon, will now be briefly described. Cystic Tumors, or Cysts. Cysts may originate in several ways. The most common is from the distention and enlargement of ducts or sacs, as is usually the case with 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 bursas are formed, as well as cystic developments in solid tumors. A third mode of origin is from the direct growth of newly-formed elementary* structures, cells, or nuclei—the cysts thus formed being sometimes called primary, or autogenous, as dis- tinguished 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-brown, or olive hue; this liquid sometimes contains crystals of cholestearine, and in other cases is fibrinous, and coagulates when removed. The cyst walls are of connective tissue, adherent to surrounding structures, not very vascular, and lined with a tessellated epithelium. The cysts may be single or mul- tiple, and, in the latter case, may intercommunicate, or may be merely aggregated. When found in external parts, they may commonly be diag- nosticated 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 fluc- tuate, or, if very tense, are at least found to be elastic and resilient on pressure. The treatment may consist in puncture (which may also be used as an exploratory measure), the application of tincture of iodine, the injec- tion of the same substance after tapping, the use of a seton, incision with or without cauterization, or partial or complete excision. Iodine injections, or the seton, are 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 with 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, 1 When occurring in the neck, they constitute the so-called hydroceles of that part. 510 TUMORS. in order to prevent any portion of the diseased structure from remaining. Serous cysts are occasionally connected with vascular mevi, in which cast; 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 syniovial bursas: or may be adventitiously developed in abnor- mal 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 walls, and which are composed of a dense con- nective-tissue substance. The treatment of synovial cysts consists in the use of external irritation, 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 connec- tion with the mucous glands,where they result from distention of obstructed ducts or follicles. They are met with in connection with Cowjht's or Duverney's Glands, in the antrum, and beneath the tongue, where they constitute a form of ranula. Their general characters are those of the serous cysts, from which they differ chiefly- in the nature of their contained fluid (which resembles mucus), and in their locality. The treatment con- sists in free incision, or in cutting away a portion of the cyst-wall, the cavity being allowed to heal by granulation. Sanguineous Cysts, or Haematomata, may result from accidental hemorrhage into the cavity of a serous cyst (just as haematocele from hemorrhage into the sac of a hydrocele), from transformation of a vascular nsevus, from occlusion and dilatation of a jiortion of a vein, or from effusion of blood which subsequently becomes encysted by the condensation of the surrounding areolar tissue. They are chiefly met with in the cervical and parotid regions (in the former locality constituting haematocele'of the neck), though they also occur in other parts of the body. These cysts contain blood, which may be clotted and partially decolorized, or which may be liquid. In the latter case it may have been fluid from the first, and will then coagulate when evacuated, or may have been clotted at first and sub- sequently re-liquefied. The walls of these cysts may be simply mem- branous, 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, with which indeed they* may coexist. The treatment ordinarily to be recommended for sanguineous cysts, is excision, with precaution against hemorrhage if the cyst be connected with a naevus or bloodvessel; or, if the tumor be very large, it may be reduced in size by repeated tap- pings, and then laid open, as has been successfully done by Erichsen. Amputation may occasionally be required, as in a remarkable case reported by Moore, in which the cyst was developed in the course of the popliteal nerve, and in which loss of blood during an attempt at excision necessitated removal of the limb. Oily Cysts—Cysts containing oil or fatty matter alone are very rare, though fatty substances not unfrequently occur in cysts, as the result of degeneration of other materials, or as a curdy residue from milk. Oily cysts do, however, occasionally occur in the orbital and superciliary re- gions, and in the breast. The treatment should consist of excision. Colloid Cysts occur in the kidney and thyroid gland, in the latter situation constituting a variety of goitre. Their contents vary in con- COMPOUND OR PROLIFEROUS CYSTS. 511 sistencv 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 in the formation of a seton. Seminal Cysts.—This is the name used by Paget for most examples of the affections usually* known as encysted hydrocele, encysted hydrocele of the cord, and spermatocele. Seminal cy*sts possibly arise in some cases from dilatation 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 with tessellated epithelium, and they contain a milky fluid in which spermatozoa are commonly found. The treatment consists in the injection of iodine, or in the use of a seton; or, if these fail, in free incision of the sac, which is then allowed to heal by granulation. B. Compound or Proliferous Cysts. These are such as have the power of producing vascular or other organ- ized structures, which may be inclosed within the original cyst wall, or may7 project from its surface. It is sometimes very difficult to distinguish a true proliferous cyst from a mass of simple cysts closely aggregated together, the latter, indeed, constituting a considerable 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 cy*sts are probably merely secondary formations (see p. 517). Complex ovarian cysts present a parent cyst with numerous secondary cysts variously arranged, which project into its cavity (endogenous), or from its surface (exogenous growths). Dr. Wilson Fox has carefully investigated the mode of origin of these tumors, and believes that the parent cyst originates, like the simple ovarian cyst, in the Graafian vesicle. Into the interior of the parent cyst, tubular gland structures, or villous or papillary growths (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 cy*sts occurring in other parts of the body could hardly be distinguished from multiple simple cysts aggregated together, antl would require the same treatment, viz., total excision. Proliferous Cysts -with Vascular Intra-cystie Growths occur in connection 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 adher- ent to surrounding structures. Their contents at first are fluid, but sub- sequently a vascular growth, apparently of glandular structure, which may be well formed, rudimentary, or degenerate, springs from some point of the interior, and, increasing more rapidly* than the cyst, gradually encroaches on its cavity, which it afterwards entirely fills, sometimes at last perfora- ting the cyst wall, 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 nodulated cauliflower-like masses, sometimes as clusters of delicate leaf-like processes, and again as masses of closely-packed 512 TUMORS. lobules. Their color, consistency, and degree of vascularity, are equally- various. The course of these tumors is very chronic. The diagnosis from cancer may be made by observing the slow 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 neighboring lymjdiatie glands. Even when ulceration takes place, and the intra-cystic growth jirotrudes as a fungous mass, the surrounding integument has not the infiltrated appearance which it has in case 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 con- sists 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 w*hen 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 metas- tatic growths existed in the lungs, mediastina, liver, ribs, vertebra?, jielvic 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 growths, 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 "cy-sts within which, in the typical examples, a tissue grows, having more or less the structures and the jiroductive properties of the skin." In the Fig. 252.—Sebaceous tumor and horns. (Bryant.) majority* of cases, no true cutaneous lining can be recognized, but the cysts are found to contain epidermal scales, sebaceous matter, fat granules, cho- lestearine, and rudimentary hairs.1 These cysts are chiefly met with in the ovaries and subcutaneous tissue, but have also been seen in the testicle, lung, kidney*, bladder, brain, and tongue. Among those in the subcuta- 1 A cyst of this kind, which I removed from the cheek of a medical man, was found on dissection to contain two long hairs (evidently from the beard) closely coiled to- gether. This condition is analogous to that seen in the coccygeal or pilo-nidal fis- tulse met with in the neighborhood of the rectum. (.See Chap. XLII.) 75 NON-MALIGNANT SOLID TUMORS AND OUTGROWTHS. 513 neous tissues, such as are congenital approach most nearly to the ty*pical 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-wall, of a more or less cutaneous structure, pretty tightly filled with oily or sebaceous matter, with or without hair. These cysts are sometimes deeply seated and may adhere to the periosteum, or even erode, or possibly perforate, the subjacent bone. The treatment con- sists in total excision, which, in the orbital region, requires careful dissec- tion. 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-wall with 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 walls, owing 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 jirobe can be introduced, and through which the contents of the cyst may perhaps be evacuated. In these cases, it is prob- able that the cyst has originated from obstruction of a sebaceous duct, though in other instances these growths appear to be autogenous forma- tions. Sebaceous tumors may become inflamed, when the cyst, if small, may be loosened and thrown off by suppuration ; in other cases, ulceration takes place, and the contents of the cyst protrude, becoming dry by expo- sure, 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, which 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 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 oc- casionally jirove fatal by perforating the skull, and inducing meningeal and cerebral inflammation. Hence, early excision is particularly impera- tive in these cases. Dentigerous Cysts, or cysts containing teeth, occur in the ovaries and testes, but are chiefly interesting to surgeons when met with in the upper or lower jaw. These cysts ajipear 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 Outgrowths. The term Outgrowth is here used in the sense in which it is employed by Paget, to denote the " Continuous Hypertrophies" which are occa- sionally met with, in which the limiting and investing capsule of a Tumor or " Discontinuous Hypertrophy" is absent. These outgrowths differ from the infiltrations of malignant disease in that, in the former, the new mate- rial is homologous with that which surrounds it, while in the latter it is quite different, causing indeed degeneration and wasting 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 various names, such as Lipoma, Steatoma, etc. The Fatty Out- 33 514 TUMORS. growth consists of an accumulation of fat in the subcutaneous tissue of some jmrt of the body, and may be either single or multijile. 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 known as a double chin. It also occurs in the abdominal walls, and may be met with in other situations. Brodie succeeded in jiro- curing 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 scarcely be advisable, for the resulting scar would probably be as disfiguring as the disease itself. The Fatty or Adipose Tumor, or Lipoma Circumscriptum of systematic writers, much more commonly comes under the surgeon's observation. 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 in the scalp, 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 abdominal wall to the thigh. Fio. 253.—Structure of a fatty tumor ; a, iso- Fio. 2.14.—Fatty tumor; the lobated appear- lated cells showing crystalline nucleus of mar- ance well shown. (Miller.) garic acid. (Bennett.) The usual seat of a fatty tumor is in the subcutaneous 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, sejita pass inwards, dividing the tumor into lobes of various size. When the septa are unusually thick and numerous, the growth may be called a fibro-fatty tumor, or fibro-lipoma. The capsule is dry, and supplied with bloodves- sels, 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 which the septa pass off than at other parts, thus giving a dimpled appearance to the- mass when it is lifted away from the subjacent structures. The fat of an adipose tumor does not differ materially from the ordinary* normal fat by which the mass is surrounded, though, according to Butlin, the individual cells of the tumor are much larger than those of adipose tissue in general. The develojiment of fat in a tumor is like that of natural fat, the gradual formation of fat-cells from connective-tissue cor- puscles being, according to Weber, as quoted by Paget, traceable in these tumors. Fatty* tumors derive their vascular supply chiefly from arteries FIBRO-CELLULAR TUMORS AND OUTGROWTHS. 515 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 R. P. Harris, of this city. They are most common in early adult and middle life, and, as a rule, grow very slowly. They occasionally attain a very large size, one being referred to by Gross which weighed not less than seventy pounds, and one estimated to weigh eighty* pounds having been removed by Dandridge, of Cincinnati. Fig. '2f>5, from the photograph of a patient who consulted me some time since, shows a fibro- fatty tumor of enormous size, and of about twenty-five years1 duration. Fatty tumors are usually, though not always, painless. They occasionally inflame and ulcerate (particu- larly such as are pendulous), and may contain oily cysts, or bony or calcareous nodules. The diagnosis can commonly be made by observing the smooth, indolent, lobated char- acter of the swelling, the sen- sation of elasticity or semi- fluctuation communicated to the touch, and the peculiar dimpling, corresponding with the position Of the interlobar Fio. 25).—Fibro-lipoma 01 twenty-five years' standing. septa, when the skin is rendered tense by* compressing and lifting the mass. Another point, insisted on by I/abbe*, is that by thus manipulating the skin the general surface becomes red, while 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 ujion the surface of the tumor. The treatment consists in excision, which mav 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. In other cases an S-sloped incision will be preferable. Occasionally*, prolongations of the tumor may extend into deeper parts, and require more careful dissection. The cure is usually permanent, though, if any jiortion of the tumor be left, reproduction may possibly occur. In the case of jiendulous growths, and particularly* if ulcerations 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 Xordhausen, and by Schwalbe, of Weinheim. Fibro-Cellular Tumors and Outgrowths (Soft Fibromata) are such as in their anatomical characters resemble the ordinary areolar or connective tissue. The Outgrowths are more common than the tumors, and constitute most of the softer and more succulent kinds of Polypus, as well as 516 TUMORS. the Cutaneous Outgrowths, or Wens, which are so frequently met with in the generative organs, and other parts of the body. In the jxdypi, the fibro-cellular is commonly associated with glandular structure, wbile in the cutaneous outgrowths the skin itself appears to be hypertrophied. Closely connected with these fibro-cellular outgrowths are the cases of Elephan- tiasis Arabum, Scleroderma, etc., which are chiefly* observed in the scrotum and lower extremities, and which are occasionally accompanied with a dilated state of the lymphatics, with or without lymi>horrhoea, and more rarely with a nsevoid condi- tion of the skin and adjacent tissues. If these wens are of moderate size, they may be readily removed, but if very large, the operation, though justifiable, becomes a rather formidable proceed- ing. When met with in the I form of " Barbados leg," attempts may be made to re- duce the swelling by the continued use of firm com- pression by means of the elastic bandage, and, as ad- vised by Olavide, of Madrid, by the internal and external use of iodine; and if these fail, it may occasionally be proper to resort to ligation of the main artery of the limb1—an operation which F,o.256.-Fibro-cellular tumor of labium. (Holmes.) haS been performed Under these circumstances with good results by Carnochan, Crosby, and numerous other surgeons, but which is, according to Fayrer, usually productive of only temporary bene- fit. The statistics of this mode of treatment have been particularly studied by Casati, Wernher, Fischer, Leonard, and Leisrink, the latter of whom has collected about 30 cases, from an examination of which he concludes that, though the operation frequently fails, yet it is often productive of benefit, and occasionally 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 was afforded; and only 16 were totally unsuccessful. Casati has analyzed 24 cases as follows:— Disease Ligation of— Cases. Recovered. Relieved. returned ; do benefit. Died. Iliac artery 5 2 3 Femoral artery 12 5 A 1 2 Popliteal " . . 1 1 ... ... Spermatic " . . 2 2 Axillary " . 1 ... 1 Brachial " . . 3 2 1 ... 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 termi- nated fatally five months after the operation. FIBROUS TUMORS AND OUTGROWTHS. 517 Fibro-cellular Tumors are comparatively rare affections. They are chiefly met with 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 with a thin capsule of areolar tissue. In this resjiect they markedly differ from the cutaneous outgrowths met with in the same regions, for these are continu- ous with the surrounding structures. On laving open a fibro-cellular tumor, it is found to consist of opaque white, intersecting bands of con- tractile tissue, the interspaces being filled with a more or less viscid serous fluid, of a yellowish-green or y*ellow 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 distention than by absolute growth. They are usually* painless, giving trouble only by their position and weight, which sometimes exceeds forty pounds. 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 Yirchow to a rudimentary form of fibro-cellular tumor, which on section has a quivering, jelly-like appearance, the con- tained yellow fluid readily flow- ing away, and the microscopic appearances of the tumor present- ing oval, elongated, or branched corpuscles, with indistinct fibril- lar, and imperfectly formed fila- ments. The structure of the tumor resembles, in fact, embry- onic connectivie tissue, or the so- called mucous tissue of the um- bilical cord. Myxomata occur in the connective tissue of the brain, eye, nasal septum, breast, nerves, neck, or extremities, and in suit- able'cases may be excised with a prosjiect of permanent relief. When met with in the eye, they require extirpation of the globe. The disease of the chorion known as the hydatid mole, is believed by Yirchow 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, probably not essential, but merely secondary formations (see page 511). Fibrous Tumors and Outgrowths (including Fibro-muscular, Fibro-cystic, and Fibro-calcareous Tumors; Hard or Firm Fib?'omata).— Fio. 2)7.—Structure of myxoma. (Holmes.) 518 TUMORS. Fibrous or fibroid tumors and outgrowths (also called desmoid, chondroid, and tendinous) are such as anatomically resemble the ordinary fibrous or ligamentous tissue. Under the head of fibrous outgrowths, may be in- cluded most of the firmer polypi met within 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, however, of gravity or pressure, they deviate from the normal form, becoming j>vri- form when pendulous, and when confined in a cavity, becoming gradually moulded to its shajie. Fibrous tumors are usually surrounded with a cap- sule of connective tissue, and when cut into present a basis-substance, com- monly of a yellowish or bluish-gray* color, intersected with very numerous opaque white bands. These white fibres are variously arranged, some- times in concentric circles, sometimes in undulating bundles which interlace with each other, and sometimes 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 Fio. 2o9.—Structure of fibro-muscular tumor of the uterus. (Bennett.) vascularity of the growth being greatest in those tumors which are most loosely* arranged. Beside the characteristic fibres seen in sections of these tumors, there are commonly fusiform cells and nuclei perceptible; and elastic fibres, plates or spicula 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 with non-striated mus- cular fibre as to entitle the tumor to be called Fibro-muscular; if the muscular fibre be in excess, the tumor becomes a Myoma (Yirchow), the Muscular Tumor of Yogel. The Fibro-cystic and Fibro-calcareous varie- ties 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 which Cooper gave the name of "hydatid testis." The occurrence of calcareous degeneration in fibrous tumors is chiefly seen in those met with in the uterus, and indicates a cessation of growth in the morbid mass. Fatty degeneration occasionally, though rarely, occurs in fibrous tumors. Fig. 258.—Structure of fibrous tumor. (Erichsen.) CARTILAGINOUS TUMORS. 519 The favorite seats of fibrous tumors are the uterus, the nerves (where they constitute the disease called neuroma),1 the bones and periosteum (especially about the jaws), the subcutaneous areolar tissue, that in the neighborhood of joints, the tendinous sheaths, the testes, and the lobules of the ear, when pierced in order to wear earrings ; they are also met with, though more rarely, in the breast, prostate, subjieritoneal areolar tissue, 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 growth, 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 cedematous, 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 can- cerous ajipearance. 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 surround- ing tissues. When growing in, or connected with, bones, the diagnosis from other forms of tumor is often very difficult, and sometimes almost imjiossible, until after removal of the growth. The treatment consists in excision, in situations admitting of this opera- tion, 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 surface to which it is attached. Recurrence is rare, except in the case of the tumors met with in the ear, where the growth presents some analogies to the keloid seen in cicatrices. Occasionally, however, fibroid tumors occur which are truly malignant, and which resemble cancerous growths in every point except their structure ; these have indeed been called Fib- rous 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 char- acters of these growths are essentially those of foetal cartilage. Enchon- dromata are commonly 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 pre- sent a glistening, bluish, or pinkish-white apjiearance, and differ from other non-malignant growths in that they show, 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 Fibrocartilaginous 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 speci- mens, occasionally seeming shrivelled, or containing oil globules, or having a granular appearance. Cartilaginous tumors are commonly hard and resisting, though some- times soft and compressible ; they are always elastic. They interfere but 1 Or the false neuroma. (See Chap. XXVIII.) 2 The "loose cartilages'1'' met with in joints present certain analogies to enchondro- mata, but will be more conveniently considered in another part of the volume. 520 TUMORS. little with surrounding structures, which remain healthy, though displaced by the growing mass; if the part be exposed to friction, a bursa some- times forms over the prominent part of the tumor. Knchondromata usu- ally occur at an early jieriod of life. These tumors are most frequently- seen in connection with bones (when they may grow beneath the jieriosteum, or in the medullary cavity), but also occur in or near the parotid gland, in the testis or mamma, and occasionally 261.—Large enchoudroma of scapula. Fiu.260.—Structure of encboudroma. (Erichsen.) in other localities. Their rate of increase, and the size to which they may attain, are both extremely variable ; Paget mentions a carti- laginous tumor which, after four years, was but half an inch long ; and another which, in three months, occupied nearly the whole length of the thigh, and was as large around as a man's chest. The principal changes which occur in en- chondromata, are ossification and degenerative Fl() liquefaction. Ossification may take place in the older portion of a tumor, while the rest is still growing, or may occur in the form of detached bony* nodules scattered through the mass. Asa result of degeneration, or possibly of arrested de- velopment, 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 the result of inflammation and ulceration, an enchondroma may protrude and slough, leaving a large sujipurating 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 soli- tary, 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 occa- sionally* seen in almost every bone of the body. When growing near the articular extremity of a long bone, a cartilaginous tumor is usually* seated Fig 262.—Multiple enchondromata hand. (Druitt.) OSSEOUS TUMORS AND OUTGROWTHS. 521 between the periosteum and bone, gradually eroding the wall of the latter, and involving it in its own mass. The articular extremity itself is proba- bly never involved. Enchondromata 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 yielding, and the tumors coalescing. In the hand, enchondromata arise within the bone, the walls of which they grad.ually 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 situa- tions, as within the jaw, the diagnosis from other innocent tumors may be impossible 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 rudimen- tary structure; when mixed with cancer, the latter affection runs its course independently. A case has been recorded by Moore, in which a pure en- chondroma gave rise to secondary deposits in the lungs by a process anal- ogous to embolism. Osseous Tumors and Outgrowths; Osteomata ; Exostoses. —Osseous Tumors are very* rare except in connection with bone, and may be defined, in the words of Paget, as exostoses or bony outgrowths, "whose base of attachment to the original bone is defined, and grows, 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 nor,^a,l bone, from Fio. 264—Ivory-like exostoses of the skull. the periosteum or other fibrous tissue. They are usually solitary*, and when multiple are often symmetrical and hereditary. Two varieties of bony tumor may be re- cognized, the cancellous (consisting of a thin layer of compact substance, with cancellated structure and mar- row internally), and the compact, hard, or ivory-like, bony tumors, which consist, as their name implies, of hard and solid bone. The cancellous tumors usually constitute the ultimate stage of the cartilaginous tumors already described • Fig. 26.1—Cancellous exostosis, growing from the lower part of the femur. (Druitt.) they are indolent, and when thoroughly ossified rarely grow ; they are situated outside of the bones with which they are connected, and in suit- 522 TUMORS. able 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 inner margin of the bone, lifting up the nail and causing troublesome ulceration of the skin; it is very seldom that any but the great toe is affected. The treatment consists in excision, taking care to remove, with the growth, the bony surface from which 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 with the cranial bones (Fig. 264), where they* may be small, superficial, and ]>er- haps pedunculated, or may originate in the diploe or frontal sinus,1 etc., where they may grow both inwardly and outwardly, in the form of large; nodulated masses, involving the orbit, causing jirotrusion 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 growths, attempts at excision are not to be recom- mended, but as a cure has sometimes followed necrosis and sj>ontaneous separation of the mass, it may be proper to expose the most prominent jiart of the tumor, and apply nitric acid or caustic jiotassa, as recom- mended by Stanley, in hope of in- ducing exfoliation. Those exostoses which are not pe- dunculated, and which, therefore, are properly called Outgrowths (Osteo- mata), 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, whence they may spread to other bones of the face, causing great deformity*, or even death, by inter- ference with the brain. If limited to the jaw, and to one sidej excision of the bone might properly be tried; but if bilateral, or involving neigh- boring parts, no operation should be attempted, except, perhaps, the appli- cation of caustics, as in the frontal and orbital growths already referred to. Fig. 265, from a photograph, illustrates a case of multiple osteoma of the cranial and facial bones, under my care at the University Hospital. 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 ductless glands. The prin- cipal localities of adenoid tumors are in or near the mammary, the pros- tate, the thyroid, the labial, and the lymphatic glands, though they also occur in the parotid, sebaceous, and sudoriferous glands. Glandular struc- ' 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 surrounding parts are then very slight, and their enucleation comparatively easy. Colignoti reports a case in which such a growth was successfully removed by Demarquay from the maxillary sinus. Fig. 265.—Multiple osteomata of the bones of the head and face. (From a patient in the University Hospital.) LYMPHOID TUMORS. 523 ture, moreover, forms an important part of the submucous fibro-cellular tumors which constitute mucous polypi, as well as of the complex ovarian cvsfs. The mammary and jirobably some other glandular tumors, some- times appear to originate as proliferous cysts, which become solid by the extension of intra-cystic growths. Glandular tumors have usually a regularly curved outline, are some- what lobulated, 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 elas- ticity, and are frequently- in- termingled with 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 without operation, upon the restoration of the suspended functions of the mammary* gland itself, or of the uterus. The treatment consists in the use of pressure, with the application of sorbefacients, and, when 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 equiva- lent to the Lymphoma of Yirchow, "to exjiress those new formations which, in their essential structure, are composed of corpuscles like the round, pale corpuscles that form the characteristic cell-elements of the Fig. 266 —Adenoma of the mamma. (Rindfleisch.) X300. a* c$fc ?<£/ Fig. 267.—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.) lymphatic glands." In most cases these lymphoid tumors occur in parts where lymphatic glands are known to exist, but in other instances they have been met with as entirely independent formations. They are fre- quently multiple. They have been observed by Yirchow in the liver and kidney, by Church in the mesentery 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 524 TUMORS. both internally and by parenchymatous injection ; excision is occasionally justifiable Vascular or Erectile Tumors (Angeiomata) are of most fre- quent occurrence in the skin and subcutaneous tissue, though they may also be found in any structure which is itself vascular. They an; subdi- vided, according to their structure, into the capillary, arterial, and venous vascular tumors. The arterial variety constitutes the disease known as Aneurism by Anastomosis, while the capillary and venous vascular tumors are what are commonly designated as Nvvi. The diagnosis and treatment of these affections will be considered in the chapter on diseases of the Yascular Svstem. Lymphatic Vascular Tumors, erectile, and usually congenital, have been occasionally 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 ordi- nary papillae of the cutaneous and mucous tissues. They occur in the skin where they form the common cutaneous warts, and some of the so-called horns, met with chiefly about the face and head; and in the mucous mem- brane's, where the papillary structures may occur in connection with fibro- cellular growths, in the form of mucous polypi, may be scattered over a considerable extent of surface, giving the part a villous appearance, or may be aggregated 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 attribu- ted to the patient's habit of smoking stumps of segars which he picked up in the street, According to R. W. Taylor, the warty form of lingual ichthyosis is a true papilloma. Finally, papillary growths may occur in serous tissues, particularly* the arachnoid; the Pacchionian bodies are, according to Yon Luschka, merely enlargements of the villi normally existing in this part. The papillary tumors above described, are of a non-malignant character, and must not be confounded with Villous Cancer, which will be referred to presently. The treatment of papillomata consists in excision, ligation, or the application of caustics, according to the size and situation of the growths. Neuralgic Tumors__This is a group embracing such tumors as are, without any perceptible reason, the seat of intense neuralgic pain. They are usually fibrous or fibro-cellular in structure, though adipose, fibro-carti- laginous, 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 diameter, has a round shape, and is firm, tense, and elastic. It is usually single, and is much more common in women than in men—in both respects differing from the ordinary neuroma, which 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 connection between these tumors and nerve-fibres, though it is believed by many writers that the painful subcutaneous tubercle is really a "true neu- roma" (see Chap. XXYIIL), containing an excessive formation of nervous elements. 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 SEMI-MALIGNANT OR RECURRENT TUMORS. 525 compared to an electric shock. During the paroxysm, the tumor itself commonly becomes sensitive and swollen. Fig. 268.—Painful subcutaneous tubercle on the forearm. (Smith.) The treatment consists in excision, which operation may be expected to afford permanent relief. As a palliative measure, circumferential pressure, with 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 (aneu- rism by anastomosis), the myeloid, and the encephaloid—the two latter pulsating only when the tumors are partially surrounded by bone. The chief interest pertaining to pulsating tumors" is the liability of mistaking them for aneurisms, an error which has occasionally been committed by the most distinguished surgeons. " • Floating Tumors are tumors felt in the abdomen, which change then- 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 van- ishes spontaneously, and which usually consists of a partially and spas- modically 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 circum- stances. The usual seat of phantom tumors is in the abdomen, thon°-h they are occasionally seen in other localities. Semi-Malignant or Recurrent Tumors ; Sarcomata. Recurrent Fibroid Tumor (Spindle-celled Sarcoma). — It has been remarked, in describing almost each form of non-malignant tumor, that under certain circumstances it may recur after removal, and occasion- ally with such persistence as to make the tumor clinically malignant. There is one common characteristic of all these recurrent tumors, and that is the rudimentary or embryonic state of their component tissues: thus the majority (which belong to the fibro-cellular and fibrous varieties of tumor, and are hence called by Paget the Recurrent Fibroid) contain a large number of elongated, caudate, or spindle-shaped cells, like the granu- 526 TUMORS. lation or fibro-plastic cells, and correspond to what Yirchow calls the " Spindle-celled Sarcoma." These recurrent tumors differ in general character from the non-recur- rent growths of the same varieties, in being softer and more friable, rather more juicy, and somewhat more glistening on section. Under the micro- scope they exhibit a large proportion of cells, and fewer formed fibres, with large and often free nuclei and nucleoli. Fig. 270—Recurrent fibroid tumor of thigh (spindle-celled sarcoma) containing a large cyst. (From a patient in the Uni- versity Hospital.) Under the name of Fibro-nvcleated Tumor, is described by Bennett a form of recurrent tumor which is very analogous to the recurrent fibroid of Paget, and which, under the microscope, exhibits filaments, with elon- gated, oval, nucleolated nuclei. The treatment of recurrent fibroid tumors consists in excision, which may be repeated 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, which commonly returns with a shorter interval after each opera- tion. Esmarch is said to have prevented the redevelopment of recurrent tumors by the administration of large doses of iodide of potassium. Myeloid Tumors (Giant-celled Sarcomata) are such as in their micro- scopic characters resemble foetal marrow. The characteristic myeloid cells are round, or irregularly oval, clear, or slightly granular, from y^Vu *o 3^7 of an inch in diameter, and containing from two to ten, or even more, nucleolated nuclei. Beside these, there may be free nuclei, and lance-shajied, caudate, or spindle-shaped (fibro-plastic) cells, whence the name some- times used of Fibro-plastic Tumor, though this is more appropriate to the recurrent fibroid variety. These tumors are rarely found except in the bones, where they usually occur as internal growths. When not so situated, they have commonly a firm, fleshy feel, but are occasionally soft and easily broken. On section, they have a yellow or gray, glistening appearance, marked with spots of redness, which do not seem to depend upon their vascularity. They not Fig. 269—Recurrent fibroid tumor, or spindle- celled sarcoma. (Green.) ROUND-CELLED AND OTHER SARCOMATA. 527 unfrequently* contain cysts, and are often partially ossified. Myeloid tumors commonly originate in early adult life, and are usually* single, of slow growth, and indolent; the surrounding structures are, as a rule, healthy, though perhaps greatly distended and displaced. Fig. 271.—"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 ; 6, to a focus of ossification. (Billroth.) The diagnosis from purely non-malignant tumors of bone is rarely pos- sible before operation : when seated on the surface of a jaw (almost the only locality in which it occurs externally*), a myeloid may perhaps be distinguished from a fibrous tumor by its greater softness and elasticity. The treatment consists in excision (with the surface of bone from which it grows), or, in the long bones, in amputation at a higher jioint -1 as a rule, recurrence is not as much to be feared as with the other tumors of this class, provided that early* extirpation has been resorted to. Secondary myeloid tumors have, however, 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 carriers of the infecting material which produces the secondary growths. Round-celled and other Sarcomata__The term sarcoma is used by Yirchow and other German pathologists to designate a group of tumors which possess an analogy " not only* with granulations, but also with true flesh of recent formation, or in process of development." (Yirchow.) Connective-tissue tumors " become, under certain circumstances, richer in cells, and enlarge, whilst 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 which . . . . ought to be designated by the old name of sarcoma." (Yirchow.) The following are Yirchow'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. 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. 528 TUMORS. (b) Spi ndle-celled Sarcoma; containing fusiform or fibro-jilastic cells; corresponds with fibro-plastic, recurrent fibroid, and fibro-nuclealed tumors. Cells often arranged in lamelhe, bundles, or trabecula; (lamellar, fasciculate, and trabecular sarcomata). or if with mucous Inlerctllulur Large Jfound - Cell or Lympho Sarcoma Mya.o Sarcoma Fig. 272.—Several varieties of sarcoma. (Bryant.) (c) Globo-cellular or Round-celled Sarcoma ; often mistaken for medul- lary* carcinoma, but can be distinguished by observing that the cells of the sarcoma are in constant relation with an intercellular substance, whereas those of carcinoma are intimately connected with 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 within the cranium. Complete and early extirpation of the eyeball is the only treat- ment to be recommended, though even this will not always prove success- ful (d) Colossal-celled, Giant-celled, or Gigantic-celled Sarcoma; con- tains very large cells, with 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 growth thus closely resembling those of carcinoma ; and a pigmentary or melanotic sarcoma in which the cells contain pigment matter. Butlin describes also a lympho- sarcoma (resembling the lymphoma) ; a plexiform sarcoma or cylindroma (a variety of round-celled sarcoma) ; a mixed-celled sarcoma ; a nest-celled sarcoma, psammoma, and pearl-tumor (associated forms of sarcoma which he is disposed to consider of endothelial origin, and for which he suggests ROUND-CELLED AND OTHER SARCOMATA. 529 the name of endothelioma) ; a hemorrhagic sarcoma ; and a myxosar- coma or net-celled sarcoma. Fio. 273—Alveolar sarcoma. (Billroth ) 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 carcinomatous, and a mixed va- riety of tumor results, which might properly be called Car- cinomatous Sarcoma. The intercellular substance, in sarcomata usually contains albu- men, casein, or mucin (whence another subdivision might be made into albuminous, caseous, and mucous sarcomata), and, under the microscope, appears homogeneous, granular, or fibril- lar. Finally, sarcomata are distin- guished by the vascularity upon which depends their characteris- tic succulence. They are often the seat of parenchymatous extra- vasations, these "hemorrhagic infarct us" sometimes giving rise to new productions of pig- ment matter. The treatment of sarcoma consists in excision, but the growth almost invaria- bly* recurs, and ultimately leads to a fatal termination. For further information upon the subject of sarcomata, the reader is referred to the nineteenth lec- ture of Yirchow's work on Tumors, from which this account has been principally taken, and to Mr. Imtlin's excellent article in the fourth volume of the International Encyc- lopaedia of Surgery. 34 Fio. 274.—Sarcoma of arm and shoulder. patient under the care of Dr. Massey, Chester.) (From a of West 530 TUMORS. Malignant Tumors or Cancers; Caucinomata and Entiieliomata. The division of tumors into malignant and non-malignant is, as has been already observed, not perfectly satisfactory ; for some of those which, from their structure, we should class as benignant growths, are in their clinical characters almost, if not quite, as malignant as some of those to which we apply the latter name. A Lymphoma may, for instance, run a more ma- lignant course than an Epithelioma. The terms Malignant Tumor and Cancer are used by Paget, Moore, Pemberton, and other writers, as syn- onymous with Carcinoma, and Epithelioma is by them considered to be merely a variety of that disease. It is, however, upon the whole, better, I think, to separate ejnthelioma from carcinoma (from which, indeed, it differs in a good many* points), though its clinical characters are such as to make it jiroper to retain it among malignant tumors. Carcinoma__There are two principal forms of carcinoma, the hard or scirrhous, and the soft or medullary—the terms melanoid, haemal aid, etc., being applicable to varieties of these, rather than to distinct and in- dejiendent forms of disease. Hard and soft carcinoma may coexist in the same patient, and even in the same tumor; but they are not interchange- able—that is to say, a mass of scirrhous tissue never becomes medullary, nor vice versa. 1. Scirrhus, or Scirrhous Carcinoma, is the most common form of the disease, and is more frequently 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 usu- ally* supposed that the development of scirrnous carcinoma is in some way connected with the cessation of the menstrual flow, but statistics do not sujiport such a view. Scirrhus is sometimes predisposed to by inherit- ance, and its development is sometimes directly traceable to the reception of an injury, or other local cause. It appears to be proportionally more common among married than among single women. Scirrhus usually occurs in persons wbo are otherwise healthy, and is at first unattended with much pain; so that it may frequently exist for some time before its pres- ence is discovered. Course.—Scirrhus originates as a small nodule, and grows with very variable rapidity in different patients, or even at different times in the same patient. Scirrhus is infiltrated1 among the tissues in which it occurs, and increases in size by* gradually involving the surrounding structures. Even when to the naked eye, and to the touch, the parts around a scirrhous tumor a|ijiear quite healthy, the microscojie may reveal the presence of cancer elements, so that, scirrhus is said to be often surrounded with a halo of cancerous matter. In the first stage, a scirrhous tumor is, as has been said, very small; in- deed, it sometimes renders the part in which it occurs smaller than normal, by inducing contraction of the neighboring tissue. Even in its earliest stage, however, scirrhus has usually its characteristic hardness, a peculi- arity* which is so marked as to have given the disease its name. As a scirrhous tumor grows, it becomes painful, the jiain commonly being of a 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 CARCINOMA. 531 lancinating, "electric" character. Though the growth is in itself not sen- sitive to the touch, the pain in the tumor is aggravated by handling. As the scirrhous mass in its growth approaches the skin, the latter becomes traction of the nipple. After a time, ulceration occurs, either (1) sujierfi- cially, when the adherent skin having become infiltrated and congested, be- comes excoriated or cracked, a small, superficial, indolent ulcer resulting (Fig. 276); or (2) as the result of disintegration of the carcinomatous tissue at a deeper point, when a yellowish-gray mass, consisting of cancerous debris with ill-formed pus, works its way, abscess-like, to the surface, and is evacu- ated, leaving an excavated ulcer, which constantly* enlarges as the tumor itself grows, and continues to discharge an ichorous and offensive fluid, which often excoriates the neighboring parts. The latter form of ulcera- tion has certain features, such as elevated, knobbed, and everted edges, a hard and nodular base, cancerous walls, and a peculiarly* offensive dis- charge, which, when combined, serve to characterize the so-called Cancerous Ulcer (Fig. 27 T). The ulceration of a scirrhous tumor may persist for a long time, and even cicatrization may occasionally occur, the cicatrix be- ing thin, red or livid, with an irregular surface, and much disposed to re- ulcerate. More commonly the ulcer, as has been said, constantly enlarges, though not as rapidly as the tumor itself; considerable portions of the growth may- become, from time to time, inflamed, and slough, and hemor- rhage may occur from the fungous granulations, or from the ulceration invading neighboring vessels, until finally* the patient dies exhausted by the profuse and fetid discharge, jiain, and loss of blood. Scirrhus (which is at first usually solitary) not only grows in the locality it which it first occurs, but becomes diffused, by multiplication, in other parts of the body.1 The most frequent seat of secondary deposits is 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 growth. 532 TUMORS. unquestionably the lymphatic vessels and glands in the neighborhood of the original tumor ; next, in the tissues around, but not immediately con- nected with, the point of original disease ; and lastly, in distant organs, especially the liver, lungs, and bones. T. W. N unn believes that in cases Fio. 277.—Carcinoma of both breasts ; ulcerated on left side ; on right side showing lardaceous appearance of skin. (From a patient in the University Hospital.) i,'/,,., i.i,t" of multiple carcinoma, the disease has originated in the superficial lymph- atic plexus, or network, 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 carcinomatous deposits to a process analogous to embolism, but more often the effect only is seen, without the mode of its production being recognizable. According to Cohnheim and Maas, embolic transference of fragments of malignant and other tumors is constantly going on in pa- tients thus affected, but the embola do not persist and form new growths except in jiar- ticular states of the constitution; the dis- ease thus remaining a local affection until some deterioration of the patient's health permits the development of secondary growths. Colomiatti believes that carcinoma sometimes spreads along the nerves of a part before the lymphatics become affected. When any of the imjiortant internal viscera are affected by secondary carcinoma- tous deposits, a marked state of constitutional depression is often produced, which has re- ceived the name of Cancerous Cachexia; the older writers, indeed, looked upon this cachexia as a condition peculiar to this malady, and described it as occurring in almost every case of the disease. Sir Charles liell'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 —Secondary growths of scir- rhus. (Miller.) SCIRRHUS, OR SCIRRHOUS CARCINOMA. 583 he speaks, are undoubtedly seen in cases of scirrhus, but probably not more often than in other exhausting and painful diseases ; in fact, while cases of external cancer often run on to a fatal termination without the development of any cachexia whatever, the cachectic state which accompa- nies 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 jier- sons in whom the disease had lasted six and eight years. The large majority, however (about three-fourths), of patients with scirrhous tumors, die within four years from the time when 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 a 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 into, it is found very hard and resisting, and the growth creaks, 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 somewhat glistening, bleeds rather freely* at first, is of a pale grayish-white hue, sometimes with a slight purjile tint, and is often marked with white or yellow* lines and spots. The tumor appears evenly tough and resisting in all directions, 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 carcinomatous matter, mingled with the softened tissue of the part, and with the exuded contents of the neighboring vessels; this constitutes the so-called cancer-juice, the denser structure which re- mains being called the stroma. Under the microscope, the carcinomatous elements may often be seen to be clearly infiltrated among the interstices of the normal tissues of the part. These elements themselves consist of two portions, viz., a pellucid, dimly granular, or fibrillar basis-substance, and somewhat cloudy cells, of varia- ble size—usually round or oval, but sometimes angular, caudate, fusiform, lanceolate, etc.—commonly containing one, but often two, large nuclei, and occasionally 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 T^V^ to j^u 0I* an incn iQ diameter, the most usual size being about jsVo or T^o of an inch ; the average length of the nucleus is about jgta of an inch. It is thus seen that there is no distinctive cancer-cell; the nature of the growth 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, in spaces or alveoli of the stroma, without the intervention of any recognizable intercellular substance. Beside these, which may be regarded as the normal elements of scirrhus, cells are often seen which are withered, or in various stages of degene- ration; the cells maybe shrivelled, containing oil-globules and granular matter, or may be completely disintegrated, the nuclei being set free, and appearing to be mingled with granular matter and molecular debris. In addition to the carcinomatous elements themselves, a scirrhous tumor shows, 534 TUMORS. under the microscope, various structures, glandular, muscular, fibrous, areolar, etc., which belong to the tissues in which the neoplasm bapjiens to be growing, and which are present in varying quantities, being least apjiarent when the cancer-structure itself is most abundant. Fio. 279.—Cells from a scirrhus of the mamma. X 25°- (Green.) The anatomical characters of scirrhus, when occurring as a secondary deposit, as, for instance, in the lymphatic glands, do not differ in any essen- tial resjtect from those above described. The surface, however, does not commonly become concave on section, nor are the white fibrous lines as well marked as in the primary tumor. Scirrhus, in some cases, appears as a sjireading, 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 deejier planes of tissue, but always at last involving both sujierficial and deep structures, and surrounding the chest with a mass of disease, appropriately called, by the French, " squirrhe 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 when ulce- ration is present; partial cicatrization 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 imjilies, a quicker course than the average. Acute scirrhus occurs at a compara- tively early age, and forms to a certain extent a connecting link with me- dullary carcinoma. 2. Medullary or Soft Carcinoma (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, inter- muscular spaces, mammary gland, lymphatics, etc. It is rather more fre- quent 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 external medullary carcinoma 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 carcinoma, while the proportion of cases in which j>revious injury is sup- posed 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 with scirrhus. Course.—Medullary carcinoma appears as a solitary growth, except in the subcutaneous tissue, where it is often multiple. I had under my charge in the wards of the Episcopal Hospital, many years since, a man fifty-one years old, who, beside a large encephaloid tumor of the left Fia. 2S0.—Microscopic appearance of scirrhus. (Green.) MEDULLARY OR SOFT CARCINOMA. 535 shoulder, had smaller masses of the same kind upon the neck, chest, abdo- men, back, arms, and thighs. The growth of medullary carcinoma is com- monly 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 the disease is spontaneously arrested, the tumor remaining with- out change for a number of years. Medullary carcinoma may occur, like scirrhus, as an ill-defined infiltration, or as a distinct tumor invested 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 me- dullary carcinoma 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 characters which have been described as belonging to the "cancerous ulcer." When ulceration has occurred, however, the tumor being freed from the restraining pressure of the skin, appears to grow with in- creasing rajiidity, and soon protrudes through the opening—the exuberant mass usually becoming inflamed, sloughing, and bleeding, and consti- tuting the bleeding fungus, or Fungus Haematodes, of the older writers. Me- dullary carcinoma occurring in bone is sometimes attended with a distinct pulsation (see p. 525). The course of medullary* carcinoma is commonly towards an early death, but occasionally—even after ulceration —large masses of encejihaloid matter may slough away, cicatrization fol- lowing, and thus leading to at least a temporary recovery*. Medullary carcinomata sometimes wither, becoming shrivelled and concentrated, and finally temporarily disappearing ; in other cases they undergo fatty degene- ration, ceasing to grow, and becoming " obsolete." Usually, however, while this change occurs in one tumor, others continue to increase. Cal- careous 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 carcinoma has already been men- tioned. More rarely, inflammation of such a growth ends in suppuration, and in this way, too, temporary disajipearance of the tumor may be effected. Medullary, like scirrhous carcinoma, tends to multiplication in various parts of the body, and there is reason to believe that, in many cases, frag- ments of the primary growth are detached and carried by the general circulation to remote organs, where they lodge and grow as independent centres of disease. The pain of medullary carcinoma is usually much less than that of scirrhus ; indeed, when pain is observed it appears to be refer- able to the organ affected, rather than to the diseased mass itself. The general health fails in many cases of medullary carcinoma 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 jtatient quickly regaining flesh and strength. The average duration of medullary carcinoma is decidedly less than that of scirrhus, more than Fin. 281.—Medullary carcinoma in stage of ulceration, tumor protruding. (Druitt.) 536 TUMORS. 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 carcinoma is, as its name implies, commonly a soft, compressible tumor, giving a deceptive feeling of fluctua- tion, though it is sometimes eonijiarativoly firm and elastic, approximating in character to the acute variety of scirrhus. The tumor has a rounded or oval outline, but is often markedly lobulated, the lobes extending through muscular, fibrous, or bony interspaces, to a considerable distance from the position of the princijial' mass. These outlying projections are apt to acquire deep attachments, or may surround and inclose important struc- tures, such as the carotid artery, jugular vein, or phrenic nerve. The superficial veins, over a soft carcinoma, are usually enlarged and tortuous. When a medullary carcinoma is surrounded with a eajtsule, 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 ca]>sule is vascular, tense, and may or may not be adherent to surrounding structures. AVhen cut into, the con- tained tumor protrudes, or, if very soft, oozes out like a thick fluid. When laid J<$^0^^^£:^B^4^ open, a medullary carcinoma has com- ©r^rS^F^^^^^-S^^^^P monly a lobated appearance, the various '$&-J^&fY fci^^^^^- lobes, with their investing septa, being ^f^-iy, l~''''?"^^, often distorted by mutual compression, "-"^-^^^^^;-^^v%5^ anc- i)av'nr!' the appearance of a mass of ^-^.z'My^yff^^'^-^ cysts filled with intra-cystic growths. The substance of a medullary carcinoma Fin. 2*<2.—Microscopic appearance of me- . , , •>., . . duiiary carcinoma. (Gkekn.) varies in color, being usually grayish white, but sometimes tinted with yellow, pink, or violet. In the softer tumors it has but little consistency, being friable or puljiy, like softened brain-matter, or grumous and shreddy ; while in the firmer varieties it is compact and resisting, is somewhat glis- tening on section, and occasionally presents a fibrous appearance. By pressing or scraping a medullary carcinoma, a considerable quantity of a turbid, creamy "cancer-juice" is obtained, which is readily diffusible in water—the "stroma" which remains being in comparatively small amount, and apjiearing filamentous, spongy*, and quite vascular. The structure of the infiltrated form of medullary carcinoma does not differ essentially from that above described. The microscopic appearances of encephaloid are even more variable than those of scirrhus. The normal or typical form of the cell of medullary carcinoma is a nucleated cell, closely resembling that seen in scirrhus, but differing in its mode of arrangement—the cells in encephaloid being not closely packed together, but loosely aggregated in a comparatively soft or fluid basis-substance. The following are among the chief variations observed in the corpuscular structure of medullary carcinomata: (1) there may be free nuclei, with few or no cells, scattered through a nebulous or granular basis-substance: the nuclei are usually oval, 5g\jff to 2JJVo or* a11 inch long, bright, well-defined, and containing large and often double nucleoli; (2) large elongated^r caudate nuclei, containing granular matter, or one or more large nucleoli; (3) large round or oval nuclei, resembling lvmph-corpuscles, and containing numerous shining granules, but no dis- tinct nucleoli; (4) very numerous, elongated and caudated cells, resem- bling those of the recurrent fibroid tumor, and giving the mass a fibrous OSTEOID CANCER. 537 appearance on section; (5) large round cells, containing granules, and either no jierceptible nucleus, or one which is smaller and more granular than that of the ordinary* encephaloid-cell; and (6) multi-nucleated cells, or parent cells containing numerous smaller cells. These various forms of 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, which may* be homogeneous, may present imbedded nuclei, or may* have a fibrillated appearance; while in other cases again, there may be a distinct framework, or skeleton, of deli- cate filamentous, fibro-cellular, fibrous, or even osseous structure. Still further variations in appearance are caused by the occurrence of fatty degeneration, giving rise to yellow, scrofulous-looking masses, or by the intermingling of cartilaginous, cystic, or other morbid growths. 3. Other Varieties of Carcinoma.—Of the other forms of carci- noma mentioned in the classification on page 508 I shall say but little, as they are comparatively rare, and are indeed probably* but modifications of those already described. Melanoid or Melanotic Cancer is medullary carcinoma, with the super- addition of black jiigment in the elemental structure of the growth ; it bears the same relation to ordinary encephaloid that the pigment or mela- notic sarcoma does to the other varieties of that group of tumors (p. 528), Fig. 2S3.—Melanoid Cancer. (Bryant.) or that melanoid does to ordinary* epithelioma. Melanotic cancer usually occurs as a separable 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, nucleusdike corpuscles; it corresponds with the normal pigment of the choroid coat of the eve, 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 tissue, as well as to involve internal organs. It is peculiarly* apt to grow beneath pigmentary* cutaneous moles. Hasmatoid Cancer is simply* carcinoma (usually medullary) which con- tains clots of blood, the result of interstitial hemorrhage; when protruding through ulcerated skin, it constitutes the Fungus Haematodes of Hey, Wardrop, and other writers (Fig. 284). Osteoid Cancer.—"I believe," says Paget, "the most probable view of the nature of osteoid cancers would be expressed by calling them ossified fibrous or medullary cancers, and by regarding them as illustrating a cal- careous or osseous degeneration." 538 TUMORS. Fio. 2S4.—Hsematoid cancer of breast. (Miller.) Osteoid cancer usually occurs in bone (particularly in the lower jtart of the femur), but is also seen in the inter-muscular sjiaces, the lymphatic glands, etc. AY hen met with in bone, it may oc- cujiy either the interior or exterior, or both, and has usually an elongated oval or bi-convex shajie, accord- ing 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 which is unossified, and differs from ordinary bone in being chalk-like and pulverulent, in having small and irregular bone-corpus- cles, in containing no me- dulla (its intersjiaces being filled with 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 ineomjiressible, 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 with ordinary carcinoma-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, resjioctively*. When early death occurs, it is due to the development of secondary growths, which are sometimes of the nature of ordinary medullary carcinoma. Villous Cancer.—Under this name have been included many innocent growths which have a villous or papillary structure (see |»age 524), 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 carcinoma. Colloid, or, as it is also called, Alveolar, or Gum Cancer, occurs as a primary affection, chiefly* in the alimentary canal, uterus, mammary gland, and peritoneum. It is also met with, as a secondary growth, in the lym- phatic glands, lungs, and other parts of the body. Colloid cancer consists of a stroma of more or less delicate white fibrous tissue, forming alveoli NATURE OF CARCINOMA. 539 or cy*sts of various sizes, which 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 (g^Vo*to 20W of an inch in diameter) being granular, of irregular shape, and containing small nuclei, if any—they are probably ill-formed carcinoma-cells; (2) large oval, round, or tubular mother-cells, -^0- to ^l^ of an inch in diameter, Fig. 2S3.—Colloid carcinoma. Showing the large alveoli, within which is contained the gelatinous colloid material. X 300. (Rindfleisch.) sometimes with a lamellar surface, and containing one or more nuclei, with granules, and sometimes complete nucleated cells; and (3) large laminated spaces, TT^ to £■$ of an inch in diameter, with elongated nuclei between the lamellae of their walls, small nucleated cells and nuclei in their inter- spaces, and brood-cells in their internal cavities. The diversity* in structure between colloid and other carcinomata is at- tributed by Paget, and, apparently, with good reason, to the occurrence of colloid cystic disease in ordinary encephaloid growths. Colloid cancer occurs as an infiltration, and sometimes attains an enor- mous size, particularly in the peritoneum. Its course is much the same as, though rather slower than, that of medullary carcinoma. 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 re- ferred to under the name of Malignant Fibroid (p. 519). Nature of Carcinoma.—I do not purpose to enter into anv discus- sion as to the Nature and General Pathology of Carcinoma, 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 origin" theory of cancer, while Sir James Paget, 1 See also the works of Virchow, Billroth, and Rindfleisch, 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 Ge'nerales de Medecine for October, 1873. 540 TUMORS. after mature consideration of the whole subject, adheres to the doctrine of a cancerous diathesis. That a local cause, traumatic or otherwise, can, without any previous predisposition on the jiatient'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 carcinoma, the prevailing views are : (1) that of Yirchow, who believes that the carcinoma-cells originate in a transformation of connective-tissue corpuscles; (2) that of Thiersch and Waldey*er, who maintain, on the other hand, that carcinoma can only origi- nate in tissue of an epithelial tyjie ; (3) that of Maier, of Freiburg, who holds an intermediate opinion, believing that fibrous growths may be trans- formed into sarcomata, and these in turn into carcinomata ;x (4) that of Koester, who believes that the carcinoma-cells are derived from the endo- thelium 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. YYhilenone of these views can be considered as positively established, the second and fifth are those which seem to have found most favor with modern jiathologists. Scbeurlen and Kubasoff believe that they have succeeded in isolating a bacillus peculiar to carcinoma, and that by injecting cultures of this bacillus, carcinomatous growths may be produced. The bacillar or parasitic origin of carcinoma is also maintained by Mr. Butlin and Dr. P. J. Hall. Diagnosis of Carcinoma.—The diagnosis of carcinoma, whether scirrhus or encej>haloid, can commonly be made by carefully observing the symptoms, jihysical and rational, which have been described, and by com- paring these, and the history of the case, with those of the various forms of non-malignant tumor—tbus arriving at a correct result by a jirocess of exclusion. Scirrhus is most apt to be confounded with a fibrous or gland- ular 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 diag- nosis, and even this will not always afford certain information as to the innocence or malignancy of the tumor. Thiriar believes that, in the case of abdominal tumors, it is always possible to recognize malignant growths by* the deficiency of urea in the urine. Prognosis.—The prognosis of carcinoma is always unfavorable ; in the very large majority of cases, if not in all, 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, when it does occur, comparatively painless—and may even postpone the fatal termination indefinitely, the patient dying, without return of the disease, from some intercurrent affection. Treatment of Carcinoma__The General Treatment of carcinoma 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 jiossible hygienic conditions. Tonics, and 1 According to Maier and Creighton, the essence of carcinoma consists in its property of infecting the neighboring tissues ; thus a growth which, while confined to a glandu- lar organ, and retaining in structure and function the type of the normal tissue, is an adenoma, becomes carcinomatous as soon as it infects the adjoining tissues. TREATMENT OF CARCINOMA. 541 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, Willard Parker, and W. L. Atlee; silica has been recommended by Mr. Fawcett Battye ; and carbonate of lime by* Dr. Peter Hood. Chian turjientine has been much vaunted as a remedy for cancer, but the evidence in its favor is at least open to question. Anodynes are of great service, particularly in the later stages of carcinoma, when the greatest comfort may be often afforded to the patient by the rejieated 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 potassre, 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 exter- nal irritation bv being covered with a lay*er of cotton-wadding, or with a soft and well-fitting plaster, which may be medicated with opium, bella- donna, or any other anody*ne 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 perman- ganate 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 Broad- bent, under the impression 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* Recamier 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 with regard to the useof electricity, which has lately excited a good deal of attention as a remedy in these cases. The plan recently suggested by some German surgeons to treat cancer bj* inoculation of the virus of ery*sipelas, seems to me entirely* unjustifiable. In cases of ulcerated carcinoma, too extensive to be removed by operation, Kraske covers the surface either by a plastic operation or by skin-grafting. The Radical Treatment of carcinoma 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 carcinoma, in which from the sujierficial extent of the disease, or from its locality, the operation of excision is contra-indicated. Various substances have been used as cauter- izing agents, such as arsenious, nitric, or sulphuric acid, the caustic alkalies (especially the " Vienna paste," or potassa cum calce), and mineral salts, of which the best probably is the chloride of zinc. This may be diluted with four or five parts of flour, and made into a paste with water (Can- quoin's paste), being then laid upon the denuded surface, and allowed to remain from six to twenty-four hours, according to the intensity of the effect which is desired ; a slough having been formed, this may be deeply incised, and the caustic reapplied. Another mode of using the chloride of zinc is by introducing the caustic, in the form of arrows, concentrically around the circumference of the tumor (cauterisation enfleches), as recommended by Maisonneuve—or a caustic solution may be hypodermically injected, as recommended by Sir J. Y. Simpson, and more recently by Richet. Dela- housse has employed the actual cautery as a modification of Maisonneuve's method, while Guerin applies the Vienna paste in a circle around the tumor 542 TUMORS. so as to make a linear slough through the skin and fascia, then cuts through this slough, and completes the operation by tearing with his fingers and dividing any resisting bands with scissors. Excision (or amputation, if this operation be from the position of the tumor 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 carcinoma, is shown by the following circumstances : (1) it is at least possible, if unlikely, that a permanent cure may be obtained ; (2) if the disease return, it will probably run a more chronic, or, at any rate, a not more acute course, than if the tumor had not been removed*; (3) the average duration of life is shown by statistics to be increased by operation, from one to two 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 or- gan, when its course and termination will be comparatively painless; and (5) even if the recurrence of the growth be inevitable, a temporary inter- val of comfort and usefulness will have been secured to the patient—an in- terval 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 "tumor, and the age, general condition, etc., of the patient. But in general terms it may be said that, in the case of a primary growth, 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 complica- tion, though unfavorable 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 justifia- ble. 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 dis- covery of pigment matter in the blood and urine. If, from the age of the patient, the size or loc'ality of the tumor, or any other circumstance, it should be likely that the operation in itself would be attended with un- usual danger, excision should not as a rule be practised—the prospective benefits, in such a case, being insufficient to counterbalance the risks of treatment. Operations for rapidly growing carcinomata are less likely to be attended with benefit than when the disease is chronic, but such cases are jirecisely those in which operative interference is most urgently de- manded. Cases of very chronic and indolent, atrophic cancer, as it is some- times called, may, indeed, do better occasionally without operation ; but these cases should be constantly watched, and the tumor should be removed on the first manifestation of active growth. In all other cases, if an excis- ion 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 of permanent benefit are much greater than if the operation be delayed. Recurrent Carcinoma may be removed by operation under the same circumstances as those which justify excision of the primary growth. Epithelioma, or, as it is called by Paget and others, Epithelial Can- cer, is usually met with in, or immediately below, the skin or mucous membrane, and very commonly at points where these structures join each other, its most frequent locality being the muco-cutaneous surface of the lower lip. It also occurs in the tongue, prepuce, penis, scrotum, labia, and nymphae, and more rarely at the anus, in the buccal mucous membrane or EPITHELIOMA. 543 upper lip, in the mucous linings of the respiratory, alimentary, and urino- genital tracts of either sex, the skin of various parts, the lymphatic glands, bones, dura mater, etc. From its primary seat it spreads, involving in its growth any structures with which it meets. When it occurs as a secondary affection, it may* be in the neighborhood of its original jiosition, 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. Epithe- lioma is most frequent in the male sex, and rarely occurs before middle life, the liability* to its development appearing indeed to increase with the advance 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 pijie; 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-sweepers, it is produced by the irritating contact of soot. It frequently occurs in the seat of indurated and incrusted warts. Epithelioma, following chronic in- flammation, is also seen in the so-called "tar-cancer" which occurs in the workmen employed in coal- tar and paraffine manufactories. 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 with its locality, epitheliomata of the ton<>lle and penis being COllimonlv FlQ- 2S6— Epithelioma of lower lip. (From a pa- the UlOSt, and those Of the Scrotum UeDtin the University Hospital.) and lower extremities the least, rapidly fatal examples of the disease. Ul- ceration 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 exhaustion, without 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 ex- uberant growths, in which case they occupy the cutaneous or mucous struc- tures themselves, involving the papillae to a greater or less degree ; or as deep-seated, fiat, or rounded tubercles, when they occupy only the subcu- taneous or sub-mucous tissues. When first seen by the surgeon, the super- ficial form of epithelioma may appear as a warty excrescence, which soon undergoes ulceration, or as a fissure or small ulcer covered with a dry* scab, and with deeply indurated base and edges. The warty ejiithelionm some- times assumes a truly villous form, and has been regarded as a variety* of villous cancer (see jiage 538). The deep form of ejiithelioma (which is very rare) appears as a round, firm, somewhat elastic tumor, over which 544 TUMORS. the skin or mucous membrane is more or less tightly stretched, finally giving way, and allowing the mass to protrude. Intermediate varieties are more common, in which both integument and subjacent structures an; simultaneously involved. Though, however, the differences between these forms of epithelioma may at first be well marked, they usually soon disap- pear, the sujierficial variety tending to involve the deejter structures, while the deep form of the disease may, at a late period, become exuberant, Occasionally- epitheliomata are quite prominent, forming sometimes even pedunculated and pendulous tumors. The epitheliomatous ulcer, whether originating as a sujierficial excoria- tion 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 warty, florid, and disjmsod 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 thickness, and is due to the infiltration of epitheliomatous material. A vertical section of an ordinary epithelioma shows 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- white hue, is close-textured, firm and rather elastic, and occasionally pre- sents a striped appearance due to its jiapillary structure. Squeezing or scraping brings out a curd}-, yellowish-white material, which resembles the comedones or sebaceous contents of hair-follicles, and which, according to Paget, unlike "cancer-juice," does not readily become equably diffused when mixed with water. This distinction is, however, wanting in the case of very soft epitheliomata. Epithelioma is infiltrated into the tissue in which it occurs, and the normal structures can therefore often be traced into the epitheliomatous mass. Under the microscope, the characteristic structures of epitheliomata are found to consist of (1) cells, which are nucleated, flattened, and scale-like, much resembling the ordinary epithelial cells (whence the name of the dis- ease), from T^oxj to ^v (usually 7*o) of an inch in diameter, and contain- ing a few granules, and a clear, round or oval, well defined nucleus (about 35V0- °f an iucn iQ diameter), which itself contains granules, but rarely a distinct nucleolus; the cells assume very various forms, being sometimes wrinkled, cordate, or elongated, sometimes without nuclei, and sometimes filled with oily particles, as if from fatty degeneration; (2) nuclei, free or imbedded, most abundant in the most acute cases, sometimes like the nuclei seen in the epitheliomatous cells, but sometimes larger, with more distinct nucleoli, and much resembling the nuclei of scirrhous or medullary cancer (see pages 533 and 536) ; (3) brood-cells, or cells containing nuclei under- going development into nucleated cells, the successive 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, containing in the central sjiace granular or oily matter, cells, or free nuclei, and ajiparently resulting from a continuation of the process of endogenous cell-formation described as giving a laminated apjiearanee to the simpler brood-cells. These nets or concentric globes are met with in other epidermic formations, but are better marked in epitheliomatous than in any other structures. The cells of epithelioma above described vary with the nature of the EPITHELIOMA. 545 surface in which the growth occurs; thus, while in the lower lip they resemble the cells of ordinary tessellated epithelium, in the mucous mem- brane of the intestine they have a cylindriform ajipearance. Very rarely, melanoid matter is mingled with the epitheliomatous structure, constituting the melanotic form of the disease. Diagnosis.—The diagnosis of epithelioma from scirrhus and medullary carcinoma may usually be made by observing its locality—com- monly a mucous or muco-cuta- neous surface—its frequent origin from sources of local irritation, its early and wide-spreading ul- ceration, and the absence of any tendency* to involve distant or- gans, or to produce a cachectic condition. When occurring on the fingers, lips, or tongue, epi- thelioma may* occasionally* be mistaken for a chancre in the same situation. In any* case of doubt, the patient should be submitted to antisyphilitic treatment, the effect of yvhich will usually suffice to make the nature of the case apparent. Prognosis. — The prognosis of ejiithelioma, when properly treated, is much more favorable than in the case of other malig- nant tumors. The average gain of life by operation is about two years and a half, and several authentic cases are on record in which no recurrence of the disease was observed for twenty or even thirty years after excision of the primary growth. 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 was thorough, and that caustics had not previously* been used. Treatment.—As a rule, it may be said that glandular comjilication, if extensive, should forbid operation in cases of epithelioma. If, however, the neighboring lymphatic glands be enlarged and irritated merely, with- out being infiltrated, or if the glands, though infiltrated, can themselves be removed, an operation may be proper, though, in such a case, the prog- nosis should always 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 carcinoma: 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 super- ficial extent of the ejiithelioma, the use of the knife would seem to be con- tra-indicated. The best caustics are probably the potassa cum calce, chlo- ride 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 stage 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. Mannino 35 -Concentric glohes of epithelioma. (Green.) 546 TUMORS. and (Jatchkovsky recommend the application of resorcin, and McGuire that of jiyrogallic acid. Excision is the mode of treatment to be preferred whenever it is prac- ticable. 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 lower 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 fear of hemorrhage. In such a case, the part to be removed may be insu- Fio. 2S8 —Ecraseur. lated by means of two or more strong ligatures, when it will slough, and become detached in the course of a few days, or removal may be effected by means of the elastic ligature, as recommended by Dittel, of Vienna; in Fig. 289.—Wire ecraseur. other situations, as in the tongue, the process introduced by Chassaignac, and known as ierasement lineaire, will be preferable. One or more ecra- se urs may be used, the chain or wire of the instrument being passed, if necessary, through the base of the growth by means of a needle. The screw should be slowly worked, being given two or three turns, and then a pause made, so as to allow the parts to be crushed together before they are severed. The galvano-cautery affords a convenient mode of removing epithelio- mata in vascular regions, but its use is apt to be followed by the occur- rence of secondary hemorrhage. Recurrent Epithelioma may be treated in the same manner as the pri- mary growth. Excision of Tumors. Xo 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 growths, there should _<^-" -^^^ usually be but one) should be in the direction of the long ^^-___-^s** axis of the tumor, and should correspond as far as posi-ible fiu. 290. with the natural folds of the part. In the case of non- malignant tumors, no skin need be removed, unless the growth be very* large ; but if the tumor be malignant, it will 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 EXCISION OF TUMORS. 547 (Fig. 290), or in the form of a double S (Pi?- 291). In dealing with congenital growths, too, a portion of skin should be removed, since the integument itself is in such cases congenitallv redundant. If the tumor be encapsulated, it should be removed if possible by enuncleation, the finger and handle of the knife being used in the deeper parts, instead of the cutting edge of the instrument; when it is necessary to resort to dissection, the growth should be loosened first at the part at which its main vessels enter, so that if these are fiq. 291. cut, they may be secured once for all. Hemorrhage from smaller vessels may be controlled with haemostatic forceps (Fig. 292), or Nunneley's clips (Fig. 293), which are allowed to hang from the wound till the removal of the tumor is completed. In removing a non-malignant growth, the knife should be kept close to the tumor, so as to avoid wounding the important structures to which it may be attached; but if the growth be malignant, the surgeon should keep wide of it in all his manipulations, so that no jiortion may be allowed to remain.1 If pos- sible, a tumor should never be cut into until it is re- moved ; neglect of this pre- caution may* lead to hemor- rhage (for the tumor itself may be very vascular), and if it be a malignant growth, particles may escape from it, which will act as germs in promoting the recurrence of the disease. If the tumor be of moderate size, the first incision should be made sufficiently free to allow removal of the whole mass ; in the case, however, of a very large tumor, it is well to exjiose only a portion 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. Pozzi suggests, in order to facilitate the removal of thin-walled cysts, that their contents should be evacuated with a trocar and canula, and that they should then be filled with melted spermaceti; when this has hardened, they can be dissected out like solid tumors. Paraffin has been used for the same purpose. If, when a tumor is exposed, it be found that its deep attachments can- not be safely* interfered with, the best thing left for the surgeon to do is to strangulate the base of the growth with strong ligatures, and cut off the remainder; no operation, however, should be undertaken, unless it appear that the whole tumor can be safely extirpated. After the excision of a tumor, the surgeon should carefully explore with his finger the whole surface of the wound, so as to make sure that no por- Fig. 293.—Nunneley's clips. 1 Ronciere advises that the cellular tissue around a tumor should he blown up with air to facilitate its excision. 518 SURGICAL DISEASES OF THE SKIN. tion of the growth has been allowed to remain : this is particularly impor- tant in dealing with a malignant tumor, and, in such a case, any susjiicious structures that cannot be removed, may be touched with the actual cau- tery, or with a solution of chloride of zinc (gr. xv-f 3j), with which, indeed, I commonly wash out the whole cavity. Drainage tubes should then be so placed—if necessary, through special openings—as to prevent any accu- mulation of fluids in the cavity, when the lips of the wound should be closely approximated with sutures, and a large antiseptic dressing applied, as after other operations. \ CHAPTER XXVII. SURGICAL DISEASES OF THE SKIN, AREOLAR TISSUE, LYMPHATICS, MUSCLES, TENDONS, AND BURS.E. 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 projierly come within the scope of this work; but there are certain morbid conditions of the skin and its ajqiendages which require surgical manijiulations in their treat- ment, and which may, therefore, be here appropriately referred to. Verrueae or Warts—Warts consist of hypertrojdiied cutaneous pa- pillae, which may project, each pa- pilla by itself, or, as is more usual, ensheathed by a common invest- ment of thickened scaly epithe- lium. They occasionally attain a considerable size, constituting some of the so-called horns met with in various parts of the body. Anatomically, they belong to the papillary variety of tumor. The simple warts which ajipear upon the hands and face come without any apjiarent cause, and often dis- appear spontaneously. In other cases, they remain permanently, becoming of a dark color, and oc- casionally forming a nidus for epitheliomatous formations, as do sometimes the analogous growths known as moles. The treatment consists in the application of nitrate of silver in substance, nitric or chromic acid, or the muri- ated tincture of iron—or in liga- tion or excision, if the wart be pedunculated. Warts occasionally have a moist, muco-cutaneous cov- ering, and areirritable and disjiosod to bleed; the glycerite of tannic Fig. 294.—Warts around the anus. (Ashton.) acid will often be found a Useful ajl- ONYCHIA. 549 plication 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, however, necessarily of a venereal origin, but may be produced simply by the irritation of frequent sexual intercourse, or may even result from the accumulation of smegma and want of personal clean- liness. They are particularly apt to occur in persons with congenital phi- mosis. The treatment consists in the application of nitric or chromic acid, or powdered calomel, or in paring or snipping off the growths with a sharp knife or scissors, and cauterizing the surface from which they spring. Unna advises the application of mercurial and arsenical plasters. Boeck suggests the use of resorcin. Pullin commends the administration of ar- senic internally. Warts of the generative organs, and occasionally those of the hand, appear to be communicated by contact. Corns are local indurations and hypertrophies, usually confined to the cuticle, but occasionally involving the papillae of the true skin. Corns result from intermittent pressure, as from wearing badly-fitting boots, and are chiefly* seen on the feet, but occasionally on the hands, knees, elbows, and, according to Hulke, even on the tongue. Hard Corns are such as form upon exposed surfaces, as on the edge of the foot, and are conse- quently dry* and indurated, while Soft Corns are such as occur in situa- tions where they* are kept moist, as between the toes, where they assume a spongy, mucous appearance, not unlike the mucous patch of syphilis. Bursas are 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, which occurs chiefly on the sole of the foot, causing, probably, more acute suffering than any other variety. The treatment of hard corns consists in relieving the jiart from pressure by the use of suitable shoes or the application of a jierforated 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 jiart with a sharp knife, or scissors, after the whole has been softened by the use of a warm water-dressing. Soft corns may* be dusted with powdered oxide of zinc, or touched with nitrate of silver or glacial acetic acid, the toes being kejit 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 jioint 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. SimpAe Onychia, or, as it is vulgarly called, "run-around," consists in an inflamed condition of the matrix of the nail, usually resulting from slight injury, and attended with suppuration and loosening of the nail, which becomes shrivelled and discolored, and is eventually* cast off—the new nail which forms being commonly thickened and distorted. This affection occurs chiefly in the hand, and is almost exclusively confined to children. The treatment consists in the use of poultices, or water-dressing, until the nail has separated. The growth of the new nail may sometimes be advantageously* regulated by the ajiplication of an adhesive strip or a layer of wax. Malignant Onychia results from injuries occurring to persons in a de- pressed constitutional condition, and is usually* seen in the thumb or fore- finger, 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 550 SURGICAL DISEASES OF THE SKIN. occujiied by fungous granulations. The disease has little or no tendency to a spontaneous cure, and sometimes leads to necrosis of the ungual phalanx. The treatment may consist in avulsion of any jiortion of the nail which remains, and thorough cauterization of the matrix with solid nitrate of silver—simple dressing, such as lime-water, being afterwards applied, while the parts are kept well supported with strips of adhesive plaster; or, which I think better, in simply trimming the nail to the level of the ulcer, and then apjtlying powdered nitrate of lead, as advised by Moerloose, Yanzetti, and MacCormac ; the nitrate forms a thick crust, Fim. 295.—Malignant onychia. Fig. 296.—Toe-nail ulcer. (Liston.) (Druitt.) which separates after several days, leaving a healed, or rapidly healing, surface ; the application gives rise to severe pain, which sometimes 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, following Abernethy, advises the application of dilute Fowler's solution, while Yanzetti recommends the enij)loy*ment of powdered quicklime, Babacci the application of charcoal and camphor, and Dulles the use of iodoform. Syphilitic Onychia has already* been referred to at page 493: it requires the application of black or y*ellow wash, with the use of suitable antisyphilitic remedies. Amputation may be required, if necrosis occur in a neglected case of onychia maligna. Ingrowing Toe-Nail is an affection almost exclusively confined to the outer side of the great toe ; it results from wearing narrow shoes, which compress the foot and cause the soft part of the toe to overlap its nail, giving rise to an ulcer which is painful and persistent. A cure may sometimes be effected by dusting the ulcer with oxide of zinc, or interposing a little lint, or a strip of adhesive plaster, between the nail and the inflamed part of the toe; but in many cases it will be necessary to remove a portion, or the whole, of the nail. This may be done (the patient being etherized) by thrusting one blade of a pair of sharji-pointed scissors beneath the nail up to its root, when the whole nail may be divided at a single stroke ;-the segment to be removed is then grasped with forceps, and torn away from the matrix, this process being repeated on the other side, if necessary, and the part then simply dressed. A new nail grows, which is usually straight and well formed. The shoe must, of course, be so arranged as to free the part from pressure. Hypertrophy of a Toe-Nail, usually of that of the great toe, is occasionally met with, the laminae of the nail becoming distorted, and con- stituting a horn-like protuberance which may grow so large as to interfere with walking. The treatment consists in avulsion of the nail, which opera- tion usually effects a permanent cure. RODENT ULCER. 551 Keloid or Cheloid (of Alibert) is an affection met with chiefly, if not exclusively, in the scars produced by burns or by wounds, and espe- cially in those produced by flogging, and is to be distinguished from the disease known as Morphaea or the Keloid of Addison (true keloid), which occurs in healthy* skins, where it produces a scar-like appearance. The former appears in the shape of small and shining, indurated elevations, of a dusky red color, which extend, sending out, as it were, claw-like pro- cesses, and are attended during their growth by* great itching and consider- able pain. In their structure they correspond with the fibro-cellular out- growths 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. According to J. Collins Warren, the two forms of keloid cannot be distinguished by their anatomical features. The treatment of either form of keloid is very* unsat- isfactory. Extirpation with the knife has been tried, but the disease almost invariably recurs. Nussbaum and Andeer advise the local apjilication of resorcin, and Hardawav reports a cure following the employment of electrolysis. 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 Tumor or Warty Ulcer of Cicatrices, an affection somewhat resembling the keloid of Alibert has been described by Caesar Hawkins. Some of these warty ulcers are non-malignant, being of a fibro-cellular character, but others are really epitheliomata of a pajiillary* form. When occurring over the ante- rior surface of the tibia, as in the so-called " Warty Ulcer of Marjolin," they are very often complicated by a carious condition of the bone. The treatment consists in excision or amputation, according to the size and locality of the affection; the operation, even when the disease is epithe- liomatous, often resulting in an apparently permanent cure. Recovery may, according to Collis, be sometimes obtained in the early- stage by the application of bismuth, or of ice. Rodent Ulcer.—This affection, which is also known as Jacob's1 Ulcer, is most often seen in the eyelids, cheeks, upper lip, nose, or scalp, but may also occur in other parts of the body. It is a disease of late adult life, and commonly originates in some tubercle or mole, which may have existed for many years. It is usually* single, at first rounded, but becoming irregular as it spreads, with indurated base and edge, and a somewhat abrupt, and but slightly elevated border ; it very rarely* assumes the character of a tumor. The ulcerated surface is smooth, glossy, and dry, and of a reddish- yellow color. The progress of the disease, though extremely indolent and chronic, is never spontaneously arrested, though partial cicatrization may* sometimes occur. The rodent ulcer produces frightful ravages, exposing the orbit, nasal cavities, pharynx, or even the brain, and thus ultimately* causing death—though the local character of the affection is strictly 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 granulations; Collis classes the disease among myeloid or fibro-plastic growths, while, on the other hand, Billroth, with Moore and J. Collins Warren, who have each written excellent monographs upon the subject, look upon it as a form of cancer. The treatment consists in complete 1 See Dr. Jacob's paper in Dublin Hosp. Reports, vol. iv. pp. 232-239. 552 SURGICAL DISEASES OF THE SKIN. extirpation, which is best accomplished, when jiossible, 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 emjiloyed, the Vienna or Can- Fi«. 297.—Rodent ulcer in an advanced stage. (From a patient in the University Hospital.) quoin's paste, or nitric acid, or acid nitrate of mercury, being resjiectively preferred, according to the deep or superficial character of the affection. Perforating Ulcer of the Foot.—This is a curious affection which ajipears to be less common in this country than in Europe. I have, how- ever, seen two cases of the disease, corresponding in every particular with the descriptions given by Hancock, Duplay, and other writers on the sub- j'ect. The affection consists in an intractable form of ulceration, usually occujrying the anterior part of the sole of the foot, and leading to destruc- tive disorganization 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 exposure to cold, when it may be mistaken for ordinary frost bite. Poncet and Estlander regard it as analogous to the anaesthetic form of ele- phantiasis (Lepra anaesthetic a), 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, adojit a similar theory, and the former describes the disease as a malignant form of neuro-paralvtic ulceration ; but a more recent autojisy recorded by Michaux has failed to confirm this view. Ball, Thibierge, and Handford have seen perforating ulcers in connection with locomotor ataxia. Englisch points out, from a study of 109 cases, that the localization of the disease corresponds with the position of the bursae mucosae of the sole, and concludes that it is caused by a vascular change analogous to the endoarte- ritis obliterans or proliferans of Friedlander and Billroth. Perforating ulcer has been not unfrequently confounded with the Mycetoma, or fungus LUPUS. 553 disease of India (tubercular disease of the foot, of Hancock). The treat- ment 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, friction, 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 which are formed on the back of the toes under the influence of pressure. Despres, Trelat, and Terrillon have described cases of perforating ulcer of the hand, and Handford one of perforating ulcer of the tongue. Lupus___Under this name are commonly included two affections, which may be described as Lupus Non-exedens, or Simple Lupus, and Lupus Exedens, or Ulcerating Lupus. Lupus Non-exedens ajijiears as a red patch on the skin (usually of the face), attended with branny desquamation, and sometimes accompanied with indolent tubercles. It runs a very chronic course, and produces inconvenience merely by the deformity* and scar-like contraction to which it gives rise. It is usually seen in persons of a scrofulous diathesis. The treatment consists in the administration of tonics, esjiecially* of cod-liver oil, with arsenic, and in the local use of a solution of nitrate of silver, gr. x-xx to fjfj. Lupus Exedens, Ulcerated Lupus, or Lupous Ulcer, is usually seated on the tip or alae of the nose, but sometimes on the upper lip, or in other situations, and is chiefly seen in young persons. It begins as one or more reddish papules or tubercles, which soon ulcerate and coalesce. The lupous ulcer may be superficial, when it appears as a fungous, warty, ulcerated surface, with prominent nodular granulations, which 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 affection is liable, at any moment, to assume the deep or phagedasnic form, which was known to the older writers as noli-me-tangere. The phage- daenic lupous ulcer is a very painful affection, attended with great destruc- tion 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 few weeks, and it is to be observed that, when 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 disease, by inducing contraction and distortion of neighboring parts. The microscopic appearances of lupus have been investigated by several pathologists, among whom Essig finds that the corium is infiltrated with round cells which in some specimens follow the track of the vessels and arrange themselves in heaps around them ; sjiindle-shaped and giant cells are also found in some cases. Accord- ing to Thoma and Thin, the cell-infiltration originates in exuded white corpuscles. Lang believes the giant cells to represent the intermediate stage in the process of degeneration of the tissues. Friedlander looks ujion the nodosities of lupus as true tubercles, but Colomiatti considers them essentially distinct. According to Piffard, the superficial or simple lupus presents 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 subcutaneous 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 solution of nitrate of silver, diluted tincture of iodine, or dilute citrine ointment. Riehl advises the employ- 554 SURGICAL DISEASES OF THE SKIN. Fig. 298 —Phagedasnic lupous ulcer. (Drititt.) ment, for from half a minute to two minutes, of a solution of caustic jiotassa (one jiart to two), followed by applications of finely jiowdered iodoform. J. G. Marshall employs' with success an ointment of salicylic acid(3iss-3j),and Bertarcllione of resorcin (.r>0 jier cent.). The phagedaenic variety of lupus re- quires the ajiplication of caus- tics, or of the actual or electric cautery, together with the con- stitutional treatment already recommended. Yolkmann em- ploys erosion, or scraping away the diseased tissue with a sharp spoon or scoop (see Fig. !23.ri, page 425), and Hutchinson pre- fers this mode of treatment to any other; Dr. Piff'ard, Mr. Mal- colm Morris, 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- wine stain." (See Chap. XXIX.) Excision may be resorted to in cer- tain situations, as the upper lip or nose, the resulting gap being closed by a plastic operation, if necessary. Lupus, comjilicated with a syphilitic taint, requires the administration of the iodide of potassium. Malignant Diseases of the Skin.—Both carcinoma and epithelioma may occur primarily in the skin, as was mentioned in speaking of those affections. The treat- ment consists in excision, or amputation, according to the size and situation of the ma- lignant growth. Diseases of the Areolar Tissue. Cellulitis, or Inflamma- tion of the Areolar Tissue, may* be circumscribed or dif- fused: in the former case it gives rise to an abscess, and in the latter to diffused suppu- ration. When depending upon an erysipelatous taint, it constitutes cellular ery- sipelas (see pp. 420, 442). Elephantiasis Ara bum, or Arabian Elephan- Fio. 2?»fl.—Elephantiasis Arahum in the lower extremity : Barbados leg. (Smith.) DISEASES OF THE LYMPHATIC SYSTEM. 555 tiasis, may be described as a hypertrophy of the skin and subcutaneous areolar tissue. In its structure it corresponds with the fibro-cellular out- growths described in Chapter XXYI. It is chiefly seen in the scrotum, and in the lower extremity, where it constitutes the affection known as Barba- dos leg. Its appearances are well shown in the annexed cut (Fig. 299), from a paper by Dr. Isaac Smith, Jr., of Fall River, Mass. This form of elephantiasis is closely analogous to the affections known by modern pathologists as Sclerema or Scleroderma, as well as to that described by Mott and Stokes as Pachydermatocele, the Eiloides of Warren, the Der- matolysis of AVilson, and the Molluscum fibrosum of Pollock and Ford. The treatment consists in the use of pressure, ligation of the main artery of the jiart, excision, or amputation, according to the circumstances of the particular case (seepage 516). Diseases of the Lymphatic System. Angeioleucitis or Lymphangeitis (Inflammation of the Lym- phatic Vessels or Absorbents) ma)* occur as an idiopathic affection, as a complication of erysipelas, or as the result of the irritation produced by a wound, ulcer, or local inflammation, as in cases of gonorrhoea. Its occur- rence is usually preceded or accompanied by marked constitutional disturb- ance, rigors, and febrile reaction. If the inflamed lymphatics be superficial, their course will be marked by a number of fine lines, which soon coalesce into a band about an inch wide, of a vivid red color, running from the point at which the disease originates to or beyond the nearest lymjihatic 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 lymph- atics, the affection of the glands may alone be perceptible. Resolution usually occurs in the course of a week or ten days, though suppuration often takes place in the glands, and sometimes in the lymphatics them- selves ; the prognosis is favorable, though death may occur from the super- vention of erysipelas, pyaemia, or diffuse cellulitis. The only disease with which angeioleucitis is likely to be confounded is phlebitis, from which it may be distinguished by observing that the red line in the latter affection has a dusky hue, and gives a jieculiar cord-like and knotty sensation to the touch. The local treatment consists in the ajiplication of nitrate of silver along the line of inflamed lymjihatics, so as to blacken without blistering the skin ; the limb may then be w*rapjied in carded cotton. If suppuration threaten, poultices may be emjiloyed, and pus should be evacuated by* early incisions. The constitutional treatment consists in the use of saline dia- phoretics and anodynes, with or without stimulants, according to the general condition of the patient. If erysipelas occur, the tinct. ferri chlo- ridi may be given in combination with the liq. ammonii acetatis. Adenitis, or Inflammation of the Lymphatic Glands, always accom- panies angeioleucitis, but may also occur independently, as the result of transmitted irritation (as in sympathetic bubo), or of the absorption of morbid matter (as after poisoned wounds, or in chancroidal bubo), or as the result of direct violence, or of over-exertion in walking or otherwise. The so-called bubon d'emblee is, as already mentioned (p. 482), an instance of this form of adenitis. The symptoms of adenitis are those of circum- scribed, deep-seated inflammation in general, terminating sometimes in resolution, but more often in suppuration, or in chronic induration and hy*pertrophy. The treatment consists in the use of blisters, nitrate of silver, or tincture of iodine, applied around but not over the inflamed gland, with poultices and early incisions if suppuration ensue, together with the 556 DISEASES OF THE MUSCLES AND TENDONS. administration of anodyne diaphoretics during the acute stage, and tonics, such as cod-liver oil and iron, esj)ecially 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, jiarticu- larly the adenoid, and those of a malignant nature. The treatment appro- priate to these various conditions has already been described in the chapters on tin1 several affections referred to. Varicose Lymphatics ; Lymphnageiomata.—A dilated or vari- cose condition of the lymphatic vessels has been occasionally met with, and may form a troublesome complication in cases of Arabian Elephantiasis, when, according to Manson, the lymphatic fluid contains filarial. By svxmtaneous rupture, or accidental wound, a fistulous ojiening may be formed, through which the lymphatic fluid escapes, constituting the disease known as Lymphorrhoea. The treatment consists in the apjilication of caustic, and in the use of pressure. .Diseases of the 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, de- pending upon various lesions of other structures, esjiecially of the bones and joints. Its symptoms and treatment have already been sufficiently consid- ered in the chapters on Inflammation in general. Fatty Degeneration of muscle is a not infrequent sequence of in- flammation of the muscular tissue, conjoined with long disuse, and may probably* in some cases be dependent on the latter cause alone. In sxmie cases, to which 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 eomjilete, the whole muscle being converted into a fatty* and granular mass (necrobiolic or intrinsic fatty degeneration). The latter condition appears to depend upon more complete disuse of the muscle than the inter- stitial form, and is jirobably incurable. The treatment of the milder cases consists in endeavoring to restore, or at least maintain, the nutrition of the part, by passive exercise, friction, etc. Rigid Contraction of Muscles—Another consequence of muscular inflammation, especially in persons of a gouty or rheumatic tendency, is rigid contraction of the affected muscle, giving rise to deformity, and often attended with much pain. This is most often seen in the sterno-cleido- mastoid and splenius muscles, the rigid contraction of which causes the affection known as stiff or wry-neck. The pelvic muscles also often become contracted as a consequence of hip disease. Rigid muscular contraction may likewise result from mere disuse, from long-continued sjiasm, and from paralysis of opjiosing muscles. Examples of the two latter conditions are seen in cases of club-foot. When rigid contraction persists for along 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 in the administration of anodynes, colchicum, iodide of potassium, etc. ; while the more permanent cases require the use of elastic extension, or division of the contracted muscle or its tendon. (See Orthopaedic Surgery.) Ricord and others have described a jieculiar form of muscular contraction which is dependent upon syphilis ; it is chiefly seen in the biceps, and yields readily to the administration of iodide of potassium. PARONYCHIA OR WHITLOW. 557 Ossification of Muscle is a rare affection, of which cases have been recorded by Abernethy- and Hawkins, and which apparently depends on the coincidence of muscular inflammation with a tendency to excessive bony deposit. Miincbmeyer gives 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 application of blisters, with the internal use of colchicum, iodide of potassium, etc. Tumors in Muscles.—Yarious forms of tumor occur in muscular tissue, the most important being the cancerous, sarcomatous, fibrous, cystic, and vascular. Cartilaginous and osseous tumors are also met with, but are comparatively rare. Hydatids are occasionally found in muscle. The treatment of these various affections is to be conducted on ordinary surgi- cal princijiles. Excision usually presents no particular difficulties, and, except in the cases of malignant tumor, may be expected to effect a perma- nent cure. Helferich, of Munich, and Lange, of New York, have filled the gap left after removing muscular tissue affected with a tumor, by trans- planting portions of muscle from dogs. For the cancerous tumors, unless the case were seen at a very early period, amputation (if the tumor were suitably situated) would offer 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 Thecas ( Thecitis), occurs as the result of injury, as well as in cases of gout or rheumatism. This disease, which has been well studied by Hopkins, is characterized 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 becomes chronic. The treat- ment consists in rest, with the use of iodine, stimulating embrocations, or blisters. Terrier, Yerchere, McArdle, and Golding-Bird, describe a tuber- culous form of the affection, which is apt to terminate in suppuration, and which requires excision or erasion of the affected tissue. Paronychia or Whitlow (Panaris) consists in inflammation of the flexor tendons and sheatlis of the fingers. In the mildest form of the dis- ease, the theca is but slightly, if at all, involved, the inflammation being chiefly confined to the dense subcuta- neous tissue of the pulp of the finger, being, in fact, a mere digital abscess. In the true paronychia, or tendinous whitlow, the theca is jirincipally af- fected, suppuration often extending in the course of the tendon beneath the palmar fascia (giving rise to palmar abscess), or even to the forearm, in- volving, jierhaps, the remaining fin- gers, and causing extensive destruc- tion of parts by sloughing. In the worst form of the disease, or felon, the phalangeal jieriosteum is involved, often leading to necrosis and exfolia- tion of considerable portions of bone, with destruction of neighboring 558 DISEASES OF THE MUSCLES AND TENDONS. articulations. The disease commonly originates from some slight jmncture or other injury to the extremity of the finger, and is usually, though not invariably, confined to the palmar surface. Paronychia occasionally occurs as an epidemic, without being traceable to any traumatic cause, and is believed by Erichsen to be uniformly of an erysipelatous nature. The symptoms are those of deep-seated inflammation, with intense throbbing pain and tenderness, much aggravated by the depending jiosition, and with considerable constitutional disturbance. Though sujipuration may occur jiretty early in the disease, fluctuation is not very apparent, on account of the density of the intervening tissues. Gangrene is occasion- ally, but rarely, met with. The treatment consists in the application of leeches, followed by poul- tices, or by soaking the hand in water as hot as can be borne, together with the internal administration of laxatives and anodyne diaphoretics. If relief do not follow in the course of twenty-four hours, a deej) incision should be made on one or both sides of the affected phalanx, so as to relieve tension and evacuate any pus that may be present. The incision should not be made in the centre of the finger, lest the sheath be opened, when the tendon would almost certainly slough ; nor too far towards the side, lest the digital artery be wounded. The incision should be made from above downwards, so that, if the patient withdraw his hand suddenly, he may rather assist than hinder the completion of the operation. If suppuration extend along the sheath of the tendon towards the palm, the surgeon must follow it up with free incisions, repeated as often as necessary. The strength of the patient must be, at the same time, sustained by the administration of tonics, concentrated food, and stimulus. If necrosis occur, the sequestra must be extracted as soon as they are loosened—partial or complete ampu- tation of a finger being occasionally required, though excision of the ]>ha- langeal articulations may sometimes be advantageously substituted. By unremitting care and attention on the part of the surgeon, a hand may often be preserved which will prove quite useful, though somewhat stiff and deformed; but occasionally the destructive process continues in spite of treatment, involving the wrist, and eventually requiring removal of the limb. During the whole after-treatment of a whitlow the hand should be supported on a broad splint, to keep the part at rest and to prevent contrac- tion of the fingers. Some surgeons endeavor to abort whitlow by the application of blisters, tincture of iodine, spirit of camphor, or nitrate of silver ; the plan may occasionally succeed, but, if it fail, cannot but aggravate the affection. Ganglion.—A ganglion is a synovial cyst, developed in connection with the sheath of a tendon. Erichsen distinguishes two varieties, the simple ganglion, which is found on the tendinous sheath, and the compound ganglion, which consists of a dilatation of the sheath itself, and which often involves several adjacent tendons. Ganglia vary in size from a third of an inch to two or more inches in diameter, that of the simple ganglion rarely exceeding three-fourths of an inch. Their shape is round or oval, and they contain a clear fluid, varying in consistence from that of serum to that of honey, mingled sometimes with irregularly shaped melon-seed-like bodies, which have been specially* studied by Beatson; these are formed of a com- pact, fibrinous substance, and appear to have originated from floating masses of fibrin, due to previous inflammation, or to have been sejiarated from the lining wall of the sheath, which is itself often fringed and vascular. Ganglia occur chiefly in connection with the extensor tendons on the back of the hand or wrist, or on the dorsum of the foot, though they are also seen in the palm, extending beneath the annular ligament, or on the side DISEASES OF BURSJ5. 559 or sole of the foot. They occasion, in some cases, a good deal of pain by pressing on adjacent nerves, and sometimes interfere considerably with the motion of the ten- dons on which they are seated. The presence of the melon- seed-like bodies may be recog- nized by the occurrence of a peculiar grating or creaking sound on manipulation. The treatment of the smaller gan- glia may consist in rupture by forcible compression with the thumbs, or by a sudden blow, as with a book; or in puncture, and subsequent compression. If these means fail, the interior of the cyst may be scarified, after punc- ture, with the point of a knife ; or iodine, may be in- jected ; or a seton established. Excision is attended with some risk—diffuse inflamma- tion Occasionally ensuing-- Fio. 301.—Compound ganglion. (From a patient in the and should therefore be em- Episcopal Hospital.) ployed with hesitation. For the larger ganglia, and especially those beneath the annular ligament of the wrist, repeated blisters may be employed, in hope of inducing consolida- tion ; or recourse may* be had to iodine injection, or to the seton. Division of the annular ligament Mas 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 with semi- solid contents. Fatty Tumors occurring in the sheaths of tendons have been observed by Haumann, Sprengel, and Haeckel. . Diseases of Bursae. Synovial bursae exist normally in certain situations, and may be adventi- tiously developed by continued friction or pressure in other localities. The most important bursae, in a surgical point of view, are that between the hyoid bone and thyroid cartilage, and those over the acromion, the con- dyles 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. Bursae 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 sjiace. Bursitis, or Acute Inflammation of a Synovial Bursa, is most frequently seen in the bursa patellae, constituting a variety of the disease ordinarily known as " Housemaid's Knee," from the fact that women who con- stantly kneel in scrubbing are peculiarly exposed to the affection. Similarly, 560 DISEASES OF BIIRS.E. the enlargement of the bursa over the olecranon is known as " Miner's Elbow/' Acute inflam- mation of a bursa is attended with much jiain and considerable constitutional disturbance. The swelling is sujierficial, and in the case of the bursa patellae above the bone—a diagnostic jioint of some importance, as in inflammation of the joint the patella is floated uj> by the articular effusion. The treatment consists in the enforcement of rest, with the application of a suitable splint, a few leeches perhaps, evaporating lotions—or jtoultices and warm fomentations, if more agreeable to the patient—together with the administration of ano- dyne and sedative diaphoretics. If su/gmration occur, a free and early opening must be made, and the case treated as one of abscess. If the incision be delayed, the jms may diffuse itself somewhat widely around the jiart, necessitating numerous counter-openings. Caries of the pa- tella, 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. Simple Enlargement or Dropsy of a Bursa (Hygroma) may result from subacute imflammation, or simply from long-continued pressure. This condition in the bursa patellae constitutes the true housemaid's knee, and sometimes causes considerable inconvenience by the bulk of the swel- ling. The fluid in these enlarged bursae may be of the ordinary synovial character, or may be of a darker hue, containing cholestearine and disin- tegrated blood, when it is not unfrequently mixed with 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 sejiarated by the friction and constant motion to which the part is subjected. Yirchow and others have oliserved intra-bursal bands, attached bv both ends to the wall of the tumor. The treatment consists Fig. 302. — Enlarged hursa over the patella, the result of pressure ; housemaid's knee. (Liston.) Fio. 308.—Formation of seton with trocar and canula. (Erichsen.) in the application of discutients, such as iodine or blisters; or in taj»|>ing, followed by the injection of iodine, or by the establishment of a seton— the thread being passed through the canula as in Fig. ou:-J. Favardin recommends the injection, without emptying the bursa, of a few droj»s of a concentrated solution of calcium chloride. If the bursa contain the rice- like bodies above referred to, they must be evacuated through a tolerably free incision, when the seton may be passed as before; or the whole bursa DISEASES OF BURS.E. 501 may be excised, great care being taken not to open any neighboring joint ■during the operation. Solid Enlargement of a Bursa is caused by the gradual deposit of organized lvmph in the interior of the sac, previously filled with fluid, until the whole or nearly the whole of the cavity is obliterated. A bursa, when cut open under these circumstances, presents a laminated appearance, such as is seen in a partially consolidated aneurism. In some cases, accord- ing 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 anv neighboring articulation, and, in the case of the bursa patellae, not to open the deep fascia which is attached to that bone, lest the structures of the ham should become involved in sujipuration. Annandale has recorded a remarkable case of bony tumor occupying the position of the bursa pa- tellae, and I have myself excised a sarcoma from the same situation. Bunion.—The term bunion is applied to an enlarged bursa occurring in any part of the foot, the most usual seat of the affection being at the side of,"or below, the metatarsal joint of the great toe. Bunions appear to be caused bv distortion of the foot from wearing narrow-soled and high-heeled shoes, by which the weight of the body is thrown forwards, while the toes are crowded together. Dr. Hawes believes that the deformity is caused bv disjilacement of the outer sesamoid bone of the flexor brevis pollicis. The distortion consists in the great toe being thrust outwards, by which 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 develojied, 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 bv a carious condition of the bone and disorganization of the joint, consti- tuting a form of the " jierforating ulcer of the foot" of French writers. (See p. 552.) The treatment consists in the use of poultices or fomenta- tions, 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 accomplished by the use of Bigg's ap- paratus (the action of which may be seen from Fig. 304); or, in more severe cases, by dividing subcutaneously the external lateral ligament of the metatarsophalangeal joint, or the tendons of the adductor or flexor brevis pollicis. Dr. Hawes re- commends removal of the displaced external sesa- moid bone. In mild cases it may be sufficient to protect the part by the application of two or three thicknesses of soap plaster, cut into a horse-shoe form, as recommended by Brodie, and by the adap- tation of a loose and well-fitting shoe. If the bun- ion contain fluid, and be uninflamed, attempts to promote absorption may be made by applying an ointment of the red oxide of mercury (gr. x-gj), 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, while it is certainly a safer method than, exci- sion or incision with cauterization. If suppuration occur, the bunion must be opened and treated as an abscess. If caries and articular disorganiza- 36 Fig. 304.—Apparatus for the treatment of buuion. 5t)2 SURGICAL DISEASES OF THE NERVOUS SYSTEM. tion follow, amputation 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 ojieration has been jierformed 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 ojieration even in cases of simple contraction without caries (hallux valgus). CHAPTER XXVIII. SURGICAL DISEASES OF THE NERVOUS SYSTEM. The affections of the nervous system which 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 rheumatism, etc., from exposure to cold, or from wounds or other injuries. The chief symptoms are j>ain, extending downwards in the course of dis- tribution 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 jihenomena manifested in other portions of the body. The patho- logical apjiearances are swelling and increased vascularity of the neuri- lemma, with softening of the nerve-structure itself. The treatment, in the acute stage, consists in the use of local dejiletion, with the apjilication of ice, or of anodyne and emollient fomentations, as most agreeable to the patient, together with laxatives 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., with counter-irritation, in those of a subacute or chronic character. Neuroma. Neuromata are tumors developed on or between the fasciculi of a nerve. They are usually fibrous tumors, though a few appear to belong to the fibro- cellular variety, a few also 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 with the nerves, while the former, or true neuromata, are " composed entirely of nerve filaments, especially* of those with double contours; they appear to come only on nerves, and are very rare." Billroth is disposed to regard the " amyaline neuromata" of Yirchow as really false neuromata, or in other words, as fibrous tumors. Neuromata are almost exclusively confined to the nerves of the cerebro- spinal system,1 are most common in the male sex, and grow slowly, some- 1 The :: plexiform neuroma," however (a name given by Verneuil), has been found in the solar plexus. NEURALGIA. 563 times attaining a very large size; they are commonly multijile, not less than 1200 sometimes coexisting, according to R. W. Smith, in the same patient. A neuroma is movable trans- versely, but not longitudinally, on the nerve upon which it is developed. Neuro- mata 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 am- putation (see page 111). They are often, but not always, painful, the pain being usually of a paroxysmal character, and sometimes excited only by pressure. In idiopathic neuroma the pain is referred almost exclusively to the peripheral dis- tribution 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, for- tunately, usually painless. The pain- ful subcutaneous tubercle is believed by many writers to be a "true neu- roma" (see page 524). It is advised by Brown-Sequard that, in examin- ing a neuroma, the nerve should be firmly comjiressed above the tumor, so as to diminish the pain caused by the necessary manipulations. The treatment consists in extirpation of the tumor, which should, if possible, be dissected from the nerve without dividing the latter ; if this cannot be done, Notta's plan might be followed, and the cut ends of the nerve ap- proximated by means of a suture (see page 219). For the treatment of neu- romata in stumps, see page 111. In cases of multiple neuromata, opera- tive 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, however, re- ported remarkable cases of multiple painful neuromata of the skin, in which temporary relief was afforded by excision of the nerves of the affected parts. Flu. 305.—Section of a neuroma ; three nervous trunks terminating in it. The fibrous arrangement shown, as observed by the naked eye. (Smith.) Neuralgia. Neuralgia is an affection of the nervous system, characterized by intense pain of a paroxysmal form, usually referred to the course of particular nerves. Any* discussion as to the nature and pathology of neuralgia in general would be out of place in a work such as this, and I shall 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 exposure 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 sur- face, or in particular organs, such as the breasts, testes, or articulations— as in the cases of so-called "hysterical knee-joint." The pain may begin suddenly, or may come on gradually, and is, in different cases, of" every 564 SURGICAL DISEASES OF THE NERVOUS SYSTEM. variety of character and intensity ; it is always paroxysmal, and often absolutely intermittent, and is uniformly aggravated by the sujiervention of any additional source of dejiression. There are almost always tender spots (points douloureux) in the course of the affected nerve, jiarticularly where it penetrates a fascia, or emerges from a bony canal, and very con- stantly there is tenderness over the spinous jirocesses of those vertebrae which correspond to the part of the spinal cord whence the nerve origi- nates. Another peculiarity* of neuralgic pain is that it is almost always unilateral. Neuralgia is sometimes accompanied with sjiasms of the mus- cles supplied by the affected nerve; in other cases the surface becomes red, hot, and even slightly swollen, and there is often an increased secretion from neighboring glands, as the salivary or lachrymal. Though any part of the body may be affected by neuralgia, its most frequent seats are the branches of the fifth pair of cerebral nerves, and the great sciatic; in the former situation it constitutes the disease known as "tic douloureux." The diagnosis is usually sufficiently easy: from inflammatory pain, neuralgia may be distinguished by its jiaroxysmal 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 bv pressure; if, however, as sometimes happens, neuralgia coexist with deep-seated inflammation, it may* be extremely difficult to decide how much of the pain felt is to be attributed to one, and how much to the other 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 existence almost insupportable. The treatment must be both general and local. As the disease is almost always accompanied by debility, tonics are usually required : having first cleared out the bowels by means of a cathartic, the surgeon may begin at once the use of quinia, in doses of four grains, three or four times a day ; this drug, though jiarticularly serviceable in cases of malarial origin, is adapted to all cases of neuralgia in which the paroxysmal element is marked. Arsenic is another remedy of great value, and may be given in the form of arsenious acid, or of Fowler's solution. Iron is particularly adajited to anaemic cases, and valerianate of zinc and assahetida to those which are complicated with hysteria. Advantage may often be derived from sea-bathing, or from the systematic emjiloyment of electricity, the cold douche, etc. In cases in which there is nocturnal exacerbation, the iodide of potassium is found a valuable remedy. The local treatment con- sists in the application of sedatives or counter-irritants, and, in certan cases, in excision of a portion of the affected nerve. Chloroform and aconite liniments, and the veratria ointment, are among the most useful applica- tions, but the hypodermic injection of morphia is unquestionably the most powerful means we possess for controlling neuralgic pain ; from eight to fifteen minims of Majendie's solution may be used at a time, the injection being repeated in the course of three or four hours if the pain be not relieved. Advantage may be sometimes derived from the simultaneous administration, by the hypodermic method, of morphia and atropia. A quarter of a grain of the former with the thirtieth of a grain of the latter mav be used, great care being exercised lest a poisonous effect be induced. Deej) injections of chloroform, carbolic acid, nitrate of silver, and cocaine, have also been employed with advantage in some cases, as has ether, which, when used in this way-, produces, according to Pitres and Vaillard, NEURALGIA. 565 a true Wallerian degeneration of the neighboring nerve, and is therefore in its action equivalent to a neurectomy*. Excision of a Portion of the Affected Nerve, or Neurectomy, has been practised in cases of neuralgia affecting branches of the fifth pair, and occasionally with the happiest results. In many-cases, however, the relief has proved but temporary, the pain recurring after an interval of a few weeks or months in the same or another branch. The Infra-orbital and Mental Nerves may be reached by simply cutting down 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 semilunar flap from over the ramus of the lower jaw, and exposing the dental canal by means of a trephine; the nerve is then picked up with a blunt hook or director, and a portion of it excised. This operation is readily* executed, and in three out of four cases, in which I have employed it, has afforded entire relief. Prof. Gross has, by repeated applications of the trephine, succeeded in exposing and removing the whole extent of the nerve, from its entrance into the inferior dental canal to its exit at the chin—the portions of nerve thus exsected varying in length, in different cases, from two and a half to three inches, and the ojieration having been apparently followed by the best results. Paravicini, Mosetig- Moorhof, Michel, Terrillon, and Glass, recommend an intra-buccal section of the nerve, which, however, appears to me more difficult and less satisfac- tory than the ordinary mode of procedure. Sonnenburg attacks the nerve on the inner side of the jaw by an incision along its lower border, from near the angle to the position of the facial artery*. The nerve is drawn down with a blunt hook, and a portion exsected. Dr. A. Brown effected a cure in one case by thrusting a hot steel wire 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 Yallette, and from within by Nelaton and Panas. The lingual nerve has been suc- cessfully excised by Kusmin. The Superior Maxillary Nerve may be reached, close to the foramen rotundum, by means of a Y-snaPecior simple curved incision, both walls of the antrum being cut away with the trephine, and the lower wall of the infra-orbital canal with cutting-pliers and chisels. The nerve being separated from the other tissues in the spheno-maxillary fossa, and traced beyond the ganglion of Meckel, is divided from below upwards with blunt-pointed curved scissors. This bold and severe opera- tion, which was introduced by Carnochan, of New York, has been at least temporarily successful in several instances; but that the relief is not per- manent, would apjiear from the researches of Conner, of Cincinnati, who has collected thirteen cases, in seven of which the pain is known to have recurred, while in only two of the remainder was the subsequent history of the patient traced for more than a year. Dennis, of New York, how- ever, 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 Sapo- lini, Brinton, Morton, Hodge, Yance, Golding-Bird, Sands, and myself, with at least temjiorary benefit. Gersung has supplemented neurectomy* by transjdantation of a rabbit's nerve to fill the gap caused by the opera- tion. Abbe, in a case of intractable brachial neuralgia, exposed the lower cervical nerves by excising the laminae of the corresponding vertebrae, and divided both roots of the sixth and seventh nerves outside, and the pos- terior roots of the seventh and eighth nerves'inside of the dura mater. The 566 SURGICAL DISEASES OF THE NERVOUS SYSTEM. patient recovered from the ojieration, but did not ajvjioar to have been materially benefited. Alexander recommends excision of the superior cervical ganglion of the sympathetic nerve as a remedy for epilepsy, and reports 6 cures out of 24 cases. If the neuralgia arise from peripheral irritation, so that the affected por- tion 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 jtrevent 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 with cutting-forceps ; and Drs. T. G. Morton and E. Mason have cured neuralgia of the metatarso-phalangeal joints by* excision of the articulation. The ojieration of stretching nerves for neuralgia of traumatic origin has already been referred to at page 219, and the same ojieration has been emjiloyed in intractable cases of spontaneous origin by- Mackintosh, Bramwell, Spence, Kocher, Nussbaum, Pooley, Bartleet, W. J. Morton, Fenger, and other surgeons, myself included. Of It such cases collected by Gen, 10 were successful. The facial nerve has been success- fully* 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 LeDentu 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 Nuss- baum, Weinlechner, and Patruban, and has been successfully resorted to by numerous surgeons, including Hutchison, of Brooklyn, and F. H. Gross, of this city. Of 54 cases collected by Hueter, of Greifswald, only 3 proved fatal. Tetanus. Tetanus is a disease of the nervous systom, characterized by persistent tonic contraction of some or all of the voluntary muscles. In the large 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 evidence is against the employment of the operation in this disease. Gillette has with advantage stretched tlie median and musculo-cutaneous nerves for congenital epilepsy. McLeod, of Calcutta, Lawrie, and Wallace have successfully resorted to nerve-stretching for ancesthetic leprosy, and benefit has been claimed from the operation by Langenbuch in cases of pemphigus and senile prurigo. R. M. Simon reports advan- tage from the same procedure in a case of infantile paralysis, and Blum in one of hys- terical 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. Elaborate tables of cases of nerve-stretching have been published by Chandler, Artaud and Gilson, and Ceccherelli ; 252 cases of all kinds, tabulated by the last-named sur- geon, gave 1S9 more or less complete successes, 16 failures, 10 doubtful results, and 37 deaths—29 of these, however, in cases of tetanus. TETANUS. 567 majority of cases tetanus results from a wound, or is traumatic, though it is also met with (especially in warm climates) as an idiopathic affection. Tetanus occurs in both sexes and at all ages ; excluding, however, cases of Puerperal Tetanus, and of Tetanus Nascentium (which, according to Parrot, has much closer analogies with uraemic eclampsia1 than with true tetanus), it is by far most common in males in early adult life, though, probably, not disproportionately so, in view of the peculiar liability of these to be exposed to traumatic lesions. It occasionally occurs as an epidemic, and appears to be predisposed to by hot weather and by sudden changes of temperature. It is more frequent in the negro than in the white. Traumatic tetanus is the form of the disease which particularlv demands the surgeon's attention. It may follow upon a mere contusion, such as the stroke of a whip, but is chiefly seen after punctured or lacerated wounds, or after burns and scalds; the extent of the wound appears to have no causative influence, the slightest being as often followed by tetanus as the most extensive injuries. It may occur after any surgical operation, without regard to its severity. Brunner records a case of tetanus caused by pressure of callus on the radial nerve. Tetanus is more frequently met with in military than in civil practice, the proportion of cases in the Peninsular war having been 1 of tetanus to 200 wounded, in the Crimean war 1 to 500, in the Schleswig-Holstein campaign 1 to 350, and in our late war 1 to 489. Exposure of the wounded to severe cold, and more particularly a sudden change from heat to cold, has been found a prolific source of tetanus in military surgery*. The disease is apt to occur in those who are depressed or debilitated ; it thus seems occasionally to follow in the wake of secondary hemorrhage. Varieties—Several varieties of tetanus have been distinguished, according to the group of muscles affected : thus Trismus, or Lock-jaw, refers to the clenching of the teeth from tonic spasm of the muscles of mastication ; Opisthotonos, to spasm of the muscles of the back, the 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 Pleurothotonos, to a similar bending to one or the other side. Tetanus may occur very soon, even less than an hour, after the reception of a wound, or not for several weeks; usually, in temperate climates, from the fifth to the tenth day. The earlier the disease is developed, the more likely is it to prove fatal, cases occurring after the third week offering a comparatively favorable prognosis. Acute, tetanus is much more fatal than the chronic form of the disease : of 327 cases of death from tetanus, analyzed by Poland, 79 occurred within two days, 104 in from two to five days, 90 in from five to ten days, 43 in from ten to twenty-two days, and 11 after twenty-two days. The most rapid death occurred in from four to five hours, while the longest duration of a fatal case was thirty-nine days. Symptoms—The symptoms of tetanus may come on suddenly, or may be gradually and insidiously developed; occasionally a feeling of general discomfort precedes for some time the characteristic manifestations of the disease, or there may be gastric and intestinal derangement, or the wound (if it have not healed) may become dry and unhealthy-looking. The first decided symptom is commonly a feeling of stiffness, with pain on motion, affecting the muscles of the lower jaw and tongue, and those of the back of the neck; in other cases, however, the cramps are first manifested in the muscles of the wounded limb. In a short time, great difficulty in chewing ' According, however, to Marion Sims, P. A. Wilhite, and J. F. Hartigan, tetanus nascentium is a traumatic affection resulting from displacement of the occipital or of one of the parietal bones. 568 SURGICAL DISEASES OF THE NERVOUS SYSTEM. or swallowing is felt, and trismus soon becomes fully developed, with 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 now experienced, and forms a very characteristic symptom of the disease; the abdominal muscles become tense, bard, and board-like, and all the voluntary muscles, excejit those of the hand, eyeball, and tongue, become more or less involved. The countenance assumes a jieculiar, old- looking exjiression, being pale, anxious, and distorted into the so-called risus sardonicus or tetanic grin. This distortion of face sometimes jier- sists after recovery, and Poland refers to a case in which it was still apj>a- rent 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; while the muscular sjiasm is tonic, and never entirely disajt- pears, it is paroxysmally* aggravated, and the cramps are occasionally so violent as almost to hurl the patient from his bed; the jiain is greatest during the cramps, which are also accompanied by jtrofuse jiorsjiiration, and great heat of skin (105°-110.75° Fahr., according to Dr. Radcliffe). The temjierature may continue to rise even after death; thus, in a case recorded by Wundcrlicb, the thermometer marked 108° before death, 112.5° at the time of death, and 113.5° a short time subsequently. Ogle and Keen have recorded cases in which the evening was higher than the morning temjierature. As the disease advances, the reflex excitability is much increased, the slightest touch or the least current of air being some- times enough to bring on a jiaroxysni of craniji. Dyspnoea and want of sleeji combine to render the condition of the patient still more dejilorable. 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 imjiortance are constipation, retention of urine, priapism (probably due to sj)inal meningitis), ajihonia, accumulation in the mouth and fauces of viscid saliva, self-inflicted lacerations of the tongue or cheek, and per- manently dilated or contracted pupils. Death may occur in a jiaroxysni, from apnoea; or, at a later period, from simjile exhaustion. There may be a certain degree of muscular relaxation jxrevious 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 jihenomena are manifested, and because the nervous system alone has as yet been found to jiresent post-mortem changes with sufficient constancy to be considered significant. It is, however,-probable, that, as suggested by Travers, J. A. Wilson, Richardson, Humphry, and others, tetanus may eventually prove to be a blood disease, due to the absorption of some sejitic material. It has been found to be communicable by inoculation, by Giordano, Bonome, and others, and according to Fliigge is caused by a bacillus which occurs in many kinds of ordinary earth. There is strong reason to believe that it is contagious, spreading, for instance, from one patient to another in an adjoining bed, and it is shown by Verneuil to be transmissible from the horse to the human being. Bacilli have been found in tetanus by Fliigge, Hochsinger, Nicolaier, and other observers, while Brieger has succeeded in isolating three ptomaines which he calls tetanine, tetanotoxine, and spasmotoxine, respectively. He has rejiroduced tetanus by inoculating the first-named substance, for which he gives the formula, Cl3H.10NzO4, and the disease has also been artificially jiroduced by Kitasato, a Japanese surgeon, by inoculating cultures of Nicolaier's bacillus. The nerve or PATHOLOGY OF TETANUS. 569 nerves in the immediate neighborhood of the wound are commonly, though not invarialilv, found to be inflamed, lacerated, or contused. The muscles have frequently* been found ruptured, and are, according to L. Conor, the seat of fatty* and granular changes, such 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 Glasgow. The first-named writer ascertained, from an examina- tion of six specimens, that there were in several portions of the cord, marked patches of softening and disintegration affecting the gray matter, the cord itself being altered in shape. The structural change varied from mere granular softening to absolute fluidity, and was accompanied by nu- merous extravasations of blood. "In the walls of the bloodvessels there was no morbid deposit nor any appreciable alteration of structure, except where they shared in the disintegration of the part to which they belonged; but the arteries were frequently dilated at short intervals, and in many places were seen to be surrounded ... by granular and other exudations, beyond and amongst which the nerve-tissue . . . had suffered disintegra- tion. We have reason, therefore, to infer that the lesions of structure had their origin in a morbid condition of the bloodvessels, resulting in exuda- tions with impairment of the nutritive process." 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 which recover, or, if jiresent, are so in but a slight degree; (2) these lesions are not the effect of excessive functional activity- of the cord, but result from a morbid state of the bloodvessels; (3) these lesions are not the sole cause of the tetanic spasms, as similar lesions exist in cases of paraly*sis 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 hyper- aemic and morbid state of its bloodvessels, with the exudations and disinte- grations resulting therefrom (this state of the cord being either an extension of a similar state along the injured nerves from the perijihery, or resulting from reflex action on its bloodvessels excited by* those nerves), and secondly, on the persistent irritation of the peripheral nerves, by which the exalted excitability of the cord is aroused—the same cause thus first inducing the morbid susceptibility of the cord to reflex action, and subsequently furnish- ing the irritation by which reflex action is excited. Dr. Dickinson's observations tend to confirm those of Mr. Clarke, and add the interesting fact that the situations of the various lesions correspond anatomically with the side on which the injury exists. '•' The irritation from the left hand, conveyed, as we must suppose, by certain of the left posterior roots, occasioned especial congestion of the left posterior horn, and further changes in the white matter in contact with it—that is, in the left posterior and lateral columns. The central and anterior jiarts 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 seg- ment 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 appearances that are described by Lockhart Clarke, but believe them to be due to exudation from the blood- vessels, and not to degenerative changes. It is in the posterior commis- 570 SURGICAL DISEASES OF THE NERVOUS SYSTEM. sure of the gray* matter of the cord, and esjiecially in the lumbar region, that they have found what they regard as the " essential alteration" of tetanus; this consists in the development of a large number of nuclei which are variously- disjiosed, and many of which are flattened from mu- tual compression; the changes are in fact the same as, though jierhaps 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 Murrell controvert the ordinary* view that tetanus is due to increased ex- citability of the spinal cord, and believe that it is due to a diminished " resist- ance" of the cord, which allows impressions conveyed by the afferent nerves to spread through the reflex portion of the central nervous system. Accord- ing to Ross, very much the same changes are found in tetanus as in hydro- phobia, 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. Motti has observed lesions of the sympathetic nerve, on the side opposite to that of the injury. Aniidon has ingeniously tried to connect the various symptoms met with in tetanus with the several lesions discovered after death. Diagnosis.—Tetanus may be distinguished from spinal meningitis by the early fixation of the jaw, and by the occurrence of paroxysmal spasms with permanent muscular rigidity in the intervals—the rigidity of sjiinal meningitis being, in a great degree, voluntarily assumed in order to j>revent pain of motion. From Hydrophobia, the diagnosis may be made by ob- serving that, in the latter disease, the spasmodic movements are clonic, not tonic, that the face is convulsed and restless (no risus sardonicus), and that delirium is as common as it is rare in tetanus.1 From poisoning by strychnia, the diagnosis is sometimes very difficult, jiarticularly if com- paratively small quantities of that drug have been repeatedly administered. It is to be observed, however, that in strychnia-poisoning there may be complete intermissions between the paroxysms, and that (according to Poland) there is spasm of the muscles of respiration, with early and marked laryngismus, but no fixation of the jaw—the patient being able to open the mouth and swallow. Tetanus has been mistaken for rheumatism, and on the other hand, hysteria has not unfrequently been mistaken for tetanus ; the diagnosis, could however, scarcely be very difficult, unless (as in a case mentioned by Copeland) tetanus and hysteria actually coex- isted in the same patient. Prognosis.—The prognosis of acute tetanus is invariably unfavorable. It is doubtful whether there be any authentic case of recovery under such circumstances. In the subacute or chronic cases, the disease being de- veloped at a comparatively late period, and running a less violent course, there is more hope of a successful issue, and by* promjit treatment life may occasionally 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 Treatment should consist in the administration of such remedies as may diminish the morbid excitability of the spinal cord, and at the same time lessen the irritation of the peripheral nerves—it being probably to a com- bination of these two elements that the production of the tetanic sjiasm 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, 1 Bernhard and Hadlich describe under the name of Tetanus Hydrophobicus a form of the disease in which there are convulsions of the muscles of deglutition. TREATMENT OF TETANUS. 571 from pure exhaustion. The modes of treatment which have been proposed for tetanus are almost countless, including such diverse remedies as vene- section, active stimulation, profuse purgation, and the induction of nar- cotism with opium. All means fail in acute cases—each has been occa- sionally successful in those of the chronic variety. The drugs which have obtained most reputation of late years have been opium, conium,1 bella- donna, cannabis Indica, woorara,2 bromide of potassium, salicin, antipv- rine, gelsemium,3 hydrate of chloral, and the Calabar bean. Of these the first and last two are those upon which I am disposed to place most reliance, and of which I would therefore recommend the employment. Eighteen cases collected by* Dr. Eben Watson, in which the Calabar bean was used, gave ten recoveries and eight deaths; upon the whole, a favora- ble record. The bean may be given in large doses (Holthouse gave 4^ grains of the extract at once, the patient recovering), the only limit to its administration being the effect produced in controlling the spasms. It ap- pears to act as a direct sedative to the spinal cord, and it has the addi- tional advantage that it enables the patient while under its influence to take food with facility*. It may be given by the mouth or rectum, or by hypodermic injection, a third of a grain of the extract being probably a large enough dose for the latter mode of administration. 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 with the Calabar bean, as suggested by Holthouse, on account of its well-known sedative effect upon the peripheral nerves. Demarquay recommends the hypodermic injection of morphia into the masseter, or whatever 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 combination having furnished but 59 deaths— a mortality* of less than 38 per cent. TTrethran has been successfully* em- ployed by* AY. T. Jackman, and cocaine, hypodermically injected, by Dr. Lopez. A cathartic may sometimes be required at the beginning of the treatment, to remove any irritating matters from the bowels, and concen- trated food and stimulus must be given, throughout the case, in as large quantities as the jiatient can be induced to take. The inhalation of ether or chloroform may be occasionally resorted to with temporary benefit, and the apjilication of an ice-bag to the spine might be tried, though its use should be watched, lest it induce too great depression. Tracheotomy has occasionally been resorted to, and, according to Richet, may be expected to be of service when sjiasm 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 wound should be explored, and any foreign bodies carefully removed. The afferent nerve or nerves (if any can be recognized) should be divided or partially excised, or, if the operation be otherwise indicated, amjiutation may be performed, if a limb be the seat of injury. Nerve-stretching, as suggested by Nuss- baum and Callender, has been successfully* resorted to by Yerneuil, Yogt, Wheeler, W. J. Smith, Clark, Ratton, Ransohoff, D'Oilier, and Fenger, but 1 Hypodermic injections of conia have been used with some success by Prof. C. Johnston, of Baltimore. 2 Recoveries under the use of woorara have been reported by two Irish surgeons, Dr. Maturin and Mr. McArdle. The latter suggests that the woorara should be com- bined with pilocarpine. 3 Recoveries under the use of gelsemium have been reported by Dr. J. B. Read, of Alabama, and Dr. Spratly, of the Birkenhead Hospital, England. 572 SURGICAL DISEASES OF THE VASCULAR SYSTEM. in my own hands, as in those of most who have tried it, has failed to give even temporary relief, 40 cases to which I have references having given but 10 recoveries.1 Though section of the nerve will promise best if re- sorted to at an early period, it should not be neglected even at a later stage of the case. If no special nerve-lesion can be detected, a /\ incision down to the bone may* be made, as advised by* Liston and Erichsen, so as to in- sulate the part. The wound itself should be dressed with narcotics—-jiar- ticularly opium, in the form of laudanum, or a solution of suljihate of morphia (gr. v-f^j), or, if the wound is sloughing, powdered opium with charcoal OJ-Jj)—and in cases of burn or scald, this will often be the only local treatment which can be emjiloy*ed. The application of atrojiia to the end of the divided nerve, or by hypodermic injection, has occasionally been found useful. If the wound were already healed, it would be projier 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 with 28 deaths. Letievant reports 16 neurotomies with 10 recoveries. But, as justly re- marked by E. Labile, the recoveries have usually been in chronic cases, in which equally good results may often be obtained by internal treatment alone. During the whole course of treatment, the patient should be kejit in a rather dark, warm, and dry room, and should be carefully guarded from currents of air. Verneuil even recommends that the whole body* should be immobilized in a gutter-splint, and covered with cotton-wool. Negretto records two cases in which, the disease having become chronic, a cure was finally effected by applying the actual cautery* on either side of the spinal column. CHAPTER XXIX. SURGICAL DISEASES OF THE VASCULAR SYSTEM. Diseases or Yeins. Phlebitis—Phlebitis, or Inflammation of a Vein, may result from injury, or from the absorption of septic material. It is probably (as men- tioned at page 182) by means of local inflammatory changes, in conjunc- tion with coagulation of the contained blood, that veins are repaired after division or rupture; and this clotting or thrombosis of the venous con- tents is the most important element in connection with inflammation of a vein. It may be either a primary or a secondary phenomenon, either the cause or the consequence of the changes in the venous coats, to which the term phlebitis is applied ; thus the phlebitis of pyaemia, and that seen after parturition (phlegmasia dolens), are the results of previous venous coagu- lation, while in many cases of lacerated wound, fractures, etc., the changes in the venous walls probably precede the formation of a clot. It is in the outer coats of a vein, according to H. Lee, who has particularly investi- gated the subject, that the changes of phlebitis are chiefly found. The 1 Of 45 cases tabulated by Ceccherelli, 14 were Huccessful, 2 doubtful, and 29 fatal. PHLEBITIS. 573 cellular coat becomes preternaturallv vascular and reddened, and is at the same time distended with serum, lymph, or pus, either separately or com- mingled. The circular fibrous coat is similarly affected, but in a less degree, becoming injected and thickened. The inner coat loses its normal transparency, becoming wrinkled or fissured, of a dull whitish color, and more or less stained by the venous contents, its hue varying with that of the contained coagulum. The inner and outer coats of an inflamed vein may* be 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 natu- ral pliability of the venous coats, so that, when divided, an inflamed vein remains jiatulous 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, which he calls fibrinogen and fibrinoplastin ; it is obviously* designed by nature to prevent the entrance of morbid materials into the general circulation, and hence, when the clot is well formed, and in a healthy* person, the disease is local, and unattended with any* jiarticular danger. Dr. Nancrede has in- geniously suggested that the extension of the clot depends upon the com- munication of lateral veins bringing fibrinogenetic material which results from the disintegration of tissue, and that hence when, 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 coagu- lation is arrested. The clot undergoes changes, becoming partially organ- ized, and converting the vessel into a fibro-cellular cord ; or may contract so as to allow the partial resumption of the circulation ; or may* perhaps undergo a slow jirocess of solution, and ultimately entirely disappear. Under other circumstances, the result is not so favorable: a large frag- ment of clot may become mechanically loosened and dislodged, and, being carried into the general circulation, may plug an important vessel (embo- lism), occasionally- even causing a fatal termination, as has happened in cases of phlegmasia dolens; or, if the blood be in an unhealthy condition (as in 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 jiage 451). Symptoms.—An inflamed vein becomes hard, somewhat swollen, pain- ful, and cord-like ; it has, besides, a peculiar knobby* feel and appearance, the knobs corresponding to the position of its valves. The course of the vein is marked by a distinct, duskv-red line, and the whole limb becomes somewhat stiff, and may* be the seat of intense pain, sometimes of an in- termittent or neuralgic character. There is always some oedema along the course of the vein and in the parts below, owing to the obstructed circula- tion and the consequent effusion of the fluid portion of the blood. This oedema may be soft, allowing pitting on jiressure, or may- be hard and tense. If the vein be deep-seated, the occurrence of tumefaction and pain may' be the only* evidences of phlebitis. The oedema usually subsides with the restoration of the circulation through the natural or collateral chan- nels, though it may jiersist for a considerable period. The constitutional disturbance attending phlebitis is rarely* of a grave character. The conditions described by many writers as suppurative and diffuse phlebitis appear to be really examples of diffuse inflammation of the areolar tissue,-or of cellular eiysipelas, which often extend rapidly in the course of the veins, and which are apt to terminate in pyaemia. (See pages 426, 442, 450, and 554.) 574 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Diagnosis.—The affection with which phlebitis is most likely to be con- founded is angeioleucitis, which, however, may be distinguished by observ- ing the brighter redness which it jiresents, 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 affec- tion is rather relieved than aggravated by pressure, and isnot acccoinjianied by oedema. The latter circumstance may also serve to distinguish inflam- mation of a vein from neuritis. Prognosis.—Phlebitis in itself is rarely* attended with risk to life ; when, however, inflammation of a vein is a mere concomitant of jiyaunia, or other grave constitutional condition, the question is very different; and even traumatic phlebitis, occurring in a person who is broken down in health, should be looked upon as a grave affection. Treatment.—In the treatment of phlebitis, all dejiressing measures should be avoided, the chief risk of the affection being from deterioration of the general health and consequent disintegration of the venous coagu- lum. If the tongue be heavily- coated, with fever and anorexia, half a grain of blue mass with two grains of quinia may be given every two or three hours, until about three grains of the mercurial have been taken, but beyond this the remedy should not, usually, be pushed. The quinia may be continued, eight or twelve grains being given in the course of twenty- four hours ; and the muriated tincture of iron may be added, in combination with the spirit of Mindererus if the use of a 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 withheld, 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 a mercury and belladonna ointment, of warm fomentations, or of evaporating lotions, as most agreeable to the patient; but if the inflammation appear disposed to extend upwards, with severe constitutional disturbance, an effort may be made to prevent its spread by the ojieration proposed by H. Lee, which consists in acupressing a healthy portion of the vein at two points about three-fourths of an inch apart, and then dividing the vessel subcutaneously between them. The oedema may be relieved by position, by gentle friction, and by the subsequent use of an elastic bandage. Varix, Varicose Vein, or Phlebectasis, consists in a morbid dilatation of a vein, usually accompanied by thickening of its walls. Any veins may become varicose, but those most commonly affected are the veins of the lower extremity, scrotum, and rectum. The varicose condition may be limited to the principal venous trunks of the part, or may affect the subcutaneous venous plexus, giving the appearance of a network of a purjile 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 con- ditions of varicose veins vary in different cases : thus, together with the dilatation, there is often elongation, rendering the vessel tortuous ; or the walls may be thinned instead of thickened ; or the dilatation may be sac- culated, forming pouches which generally correspond to the points of inter- communication with other veins. The causes of varicose veins are two- fold : (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 some- times to act as a predisposing cause, while in some cases the occurrence of VARICOSE VEINS. 575 varicosity* has been attributed to the effect of hereditary influence. Any occupation which requires the maintenance of the erect posture predisposes to varix. Varicose veins are rare in early life, and are rather more fre- quent in women 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 sensation of weight and ful- ness 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 cedematous. Deeji varix is more difficult of recognition, the subjective sy*mptoms commonly existing for some time before the implica- tion of the superficial veins renders the nature of the disease apparent. Muscular cramps are, according to Mr. Gay, quite significant of a vari- cose condition of the deeper veins. A'aricose veins are liable to be attacked by phlebitis and thrombosis, while inflammation of the surrounding tissues may lead to various troublesome conditions, such as the occurrence of eczema, or of ulceration (giving rise to the varicose ulcer), or to a sclere- matous condition of the part analogous to the Arabian elejihantiasis. A varicose vein occasionally* gives way by rupture or by ulceration, the acci- dent 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 stocking—the general health being maintained by* the use of laxatives to prevent constipation, with tonics, especially the muriated tincture of iron, if, as usually happens, the patient be in a feeble and relaxed condition Dr. J. H. Musser has found advantage from the internal administration of the Hamamelis Yirginica or witch-hazel. Hemorrhage from a varicose vein may lie 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 (partic- ularly if it be also painful), if its coats be so attenuated as to threaten hem- orrhage, or if it be connected with an ulcer which cannot be induced to heal. This mode of treatment consists in the obliteration of a portion of the vein, and it is radical as far as that portion is concerned, though it by no means insures a cure of the general disease, which, indeed, in most Fia 306.—Application of pins to varicose veins. (Miller.) instances, must be looked upon as incurable. Yarious means have been proposed for the obliteration of varicose veins, such as (1) the application 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 injec- 570 SURGICAL DISEASES OF THE VASCULAR SYSTEM. tion of ergotin or alcohol; (4) the jiassage of an electric current through the vessel ; (5) the subcutaneous section of the vein; (6) its compression at various jioints by means of a pin jiassed beneath the vessel, with a com- press or piece of bougie above, the two being fastened together with a thread, or wire, in the form of a figure-of-8 (Fig. 306) j1 (7) the apjilication of a metallic ligature ; (8) simply denuding and isolating the vein, as recom- mended by Rigaud, Cazin, and Bergeron ; and (!>) excision of a part of the vein, a Celsian mode of treatment revived by Marshall, Steele, House, Davies-Colley, and Dunn, and which I have myself practised with advan- tage. Probably the safest plan is that recommended by II. Lee, which consists in (10) securing the vein at two points, about an inch ajiart, In- passing acujiressure-needles beneath, but not through, the vessel; ajijily- ing, over the ends of the needles elastic bands or figure-of-8 ligatures ; and then subcutaneously* dividing the vein at an intermediate jioint. 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 week. Vascular Tumors or Angeiomata.2 (Arterial Varix, Aneurism by Anastomosis, Nasvus.) 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 dis- ease receives the name of Aneu- rism by Anastomosis or Racemose Aneurism, but the two affections are, in every essen- tial resjiect, the same. The vessels become tortuous, and in parts sac- culated, their coats (especially the middle) being thin, and causing the artery to resemble a vein. This affection is most common about the scalp and face, but may occur in other parts, as the tongue, extremi- ties, internal viscera, and bones; it is chiefly met with in early adult life, and its development is often attributed to a blow or other injury. Aneurism by anastomosis forms a tumor or outgrowth, of variable size and shape, usually of a bluish hue, compressible, and communi- Fig. 307.—Aneurism by anastomosis. (Ferohjsson.) eating to the touch a SJlODgV Or doughy* sensation, accomjianied by a whizz or thrill, sometimes amounting to pulsation, and synchronous with the cardiac impulse. This thrill disappears when the arteries leading to the tumor (which are themselves usually dilated and tortuous) areconqiressed, and returns with an expansive pulsation when the pressure is removed. Atis- 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. 2 £ee page 524. NJEVUS. 577 cultation gives usually a loud, superficial, cooing bruit, though occasionally a softer blowing sound. The temperature of the part is somewhat elevated. The diagnosis from ordinary aneurism may be made by noting the position of the growth (probably at a distance from any large artery), its doughy and compressible character, and the thrill, rather than distinct pulsation, which accompanies the re-entrance of the blood, when, after compression of the neighboring arteries, the pressure is removed. The bruit is more superficial than that of aneurism, and compression of the arterial trunks does not so completely* mask the physical signs of the disease as in that affection, blood still entering the part from other sources. When occurring in bone, aneurism by anastomosis may be mistaken for encephaloid, with which, indeed, it may coexist. The treatment should vary with the size and position of the growth. Excision or Ligation, in the way which will be described when we come to speak of naevus, is the mode of treatment to be preferred when the affec- tion is not very extensive, and suitably situated, as on the lip, scalp, or extremities. If excision be employed, the knife must be carried wide of the disease, in order to avoid profuse or possibly fatal hemorrhage. If the tumor be too large for ligation or excision, it will usually* be 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 coagu- lating fluids, and deligation of the main artery of the part. The use of coagulating injections is generally jireferred by French surgeons: Broca has reported a case in which, after the failure of acupressure to the nutri- tive arteries, he effected a cure by injections of perchloride of iron, the passage of the styptic being limited by surrounding the points of injec- tion with 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, particularly when the affection has involved the orbit. In such a case the primitive carotid is the vessel to be tied ; but if the disease were limited to the scalp, it might be better to adojit Bruns's suggestion, and tie one or both external 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 treat- ment to be recommended for aneurism by anastomosis occurring in the long bones is amputation. Naevus is an affection very analogous to the preceding, but differs from it in involving chiefly the capillaries or veins. When congenital, naevus constitutes the so-called mother's mark. 1. Capillary Nasvi, which are commonly, if not always, congenital, occur as flattened elevations, of a red or purple hue. usually* upon the face or upper jiart of the trunk, but occasionally in other situations. They may involve a considerable extent of surface, but rarely give any annoy- ance except from the attendant deformity. Sometimes, however, they ulcerate and bleed. They consist of a congeries of capillary vessels, and 578 SURGICAL DISEASES OF THE VASCULAR SYSTEM. may* accompany* the aneurism by anastomosis on the one hand, or the venous naevus on the other. (2) Venous Nasvi occur as prominent tumors or outgrowths, of a reddish- purple hue, smooth or lobated in outline, and somewhat comjiressible, doughy, and inelastic to the touch ; they are less exclusively confined to the upjier part of the body than the capillary- naevi, and, in their structure, consist of thin, tortuous, and sacculated veins, often interspersed with cysts. Yenous naevi may occur subcutaneously, when they form tumors which may be partially emptied by pressure, slowly filling again when the pressure is removed, and becoming distended by violent exertion or struggling on the part of the patient. Treatment.—Cutaneous naevi which are small and not disjiosed to spread, may often be left without treatment—when they may disapjiear spontaneously; and, on the other hand, a naevus may involve such a large extent of surface as to forbid any attempt at its removal. The shrivelling of small cutaneous naevi 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 purjiose has been de- vised by Sherwell, of Brooklyn, who supplements the operation by com- pressing the part by the application of collodion. For the treatment of the diffused form of naevus known as "port-wine stain," B. W. Richardson advises the application of the ethylate of sodium, while Squire recommends linear scarification with 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, consist- ing 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 naevi, 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 with com- pression. Owen recommends punctures with Paquelin's thermo-cautery as applicable to the largest naevi. The best modes of treatment, however, are commonly the application of caustics, the use of coagulating injec- tions, excision^ and ligation. (1) When the naevus 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 re- peated if there be any tendency to a recurrence of the affection. Sodium ethylate is recommended by B. W. Richardson and J. Brunton in prefer- ence to nitric acid, as causing less destruction of the epidermis. (2) Injection of a solution of the perchloride or persulphate of iron, by means of an ordinary hypodermic syringe, may be employed for small naevi in certain situations, as the eyelid or orbit, where other modes of treatment would be inapplicable ; the quantity injected should be very small (not more than two or three drops at a time), and compression should be made upon the returning veins, lest some of the injected fluid should enter the general circulation, and perhaps cause death, as has actually- occurred in cases recorded by Kesteven, Bryant, West, Gunn, and others. (3) Excision may be practised when the naevus is of large size, and in the form of a distinct tumor, the incisions being carried wide of the dis- ease, except when, as occasionally happens, the growth is surrounded by a capsule, and when therefore, as advised by Teale, enucleation may be N.EVUS. 579 safely practised. This condition is, according to Erichsen, most common in cases of naevus associated with fatty or cystic growths. (4) Ligation is in most instances the best mode of treatment, and may be applied in several ways. If the naevus 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 naevus 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. 308). The needles may be passed unarmed, the ligatures—which may be of strong silk or whipcord—being introduced as they are withdrawn. The nooses are then cut, and an assistant holds six ends firmly, while the surgeon knots the other two, this Fio. 308.—Nsevus ; application of the quad- subcutaneously around half of the naevus, ruple ligature. (Liston.) and thea tied. (Holmes.) process being repeated until the whole naevus is strangulated in four sec- tions. Another method is to apply the ligature subcutaneously, as shown in Fig. 309, taken from Holmes. When the naevus is elongated, a better plan is that described by Erichsen, which consists in passing a double ligature of whipcord, three yards long and stained black for half its length, in such a way as to have a series of double loops, about nine inches in length, on each side of the tumor (Fig. 310). The black loops being then cut on one side, and the white on the other, the ends are secured as in Fig. 311, so as to strangulate the growth 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 dealing with a naevus over the fontanelle, there might be some risk, if the ordinary needles were 580 SURGICAL DISEASES OF THE VASCULAR SYSTEM. used, of puncturing the membranes of the brain ; and hence in this situa- tion, after incising the skin with a lancet, the ligature should be carried beneath the growth by means of an eyed probe. The scalji is so adherent to a naevus in the cranial region that no attempt should usually be made gated nsevus. (Erichsen.) gated naevus. (Erichse.n.) to preserve the skin in this locality. For naevus 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 a*gent serving to divide the tissues without hemorrhage, and thus effecting rapid and painless removal of the morbid growth. Barwell suggests subcutaneous strangulation with a wire tight- ened every* three or four days, so as to cut through the base of the naevus without loss of any* skin. Strangulation with acupressure pins has been successfully emjiloyed by Bontflower, of Manchester. Though ligation is the safest mode of treating naevus, I once met with 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 naevus, and is usually covered with hair. Excision may be practised, if the dis- ease 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. Hemorrhage during and after the operation, may be controlled by pressure. Disease of Arteries. Arteritis and Arterial Occlusion.—Arteritis, or Inflammation of the Arterial Tunics, may occur as a primary affection, the result of injury or exposure to cold, but in the immense majority of cases is secondary to Arterial Occlusion, the result of thrombosis, or more frequently of embolism, the plug being derived from a fibrinous heart-clot. The repair of arteries after division is, as has already been mentioned (p. 188), due to the forma- tion of a clot, together with 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 is contracted, thickened, and softened; while the inner loses its CHRONIC STRUCTURAL CHANGES IN ARTERIES. 581 smooth and polished appearance, and becomes pulpy and stained from con- tact with the coloring matter of the blood. The clot which forms in cases of arteritis, and which indeed, as has been said, is commonly the cause of the arterial inflammation, may consist merely of masses of a fibrinous sub- stance, which do not completely occlude the vessel—or may form a com- plete plug, usually of a conical form, the lower part of which consists apparently of white blood-corpuscles and fibrin, and often adheres to the sides of the artery, while the upper part is of the color of ordinary clotted blood, and projects tail-like into the upper part of the vessel. The symptoms of arterial occlusion consist of acute pain in the course of the affected artery, and in the parts which it supplies, with a feeling of tension, great hyperaesthesia, and loss of muscular power. If the artery be superficial, it can be felt as a cord, and is either pulseless, or the seat of a sharp and jerking pulsation, according to the degree of its obstruction. If the artery be one of importance, gangrene may result, though, in y*oung 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 frag- ment may be detached and plug the artery at a lower point (this double occlusion almost invariably producing gangrene) ; or the clot may become completely disintegrated, and capillary embolism (arterialpyaemia) result. The treatment consists in the administration of opium to relieve pain, and of tonics, stimulants, and concentrated food, to maintain the patient's strength, with application of external warmth to the affected part in order to avert mortification. The subject of gangrene as the result of arterial occlusion, and the question of amputation under such circumstances, have been sufficiently* considered in previous chapters (pages 94, 206). 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 place in the connective- tissue corpuscles of the part, and at a later period, the intermediate sub- stance softening the masses of fat- granules fall apart, and, the current of blood carrying away the fat-par- ticles, velvety-looking depressions are produced, which constitute a form of what Yirchow calls fatty usure. 2. Atheroma, which is usually accompanied by the fatty change of the internal coat above described, appears to occur primarily in the external layer of the inner coat, at the junction of the latter with the middle coat, and forms a pultaceous (or atheromatous) mass, consisting of granular matter, fat-globules, plates and crystals of cholestearine, and half-softened fragments of tissue which have not yet undergone degeneration. During the early stage of atheroma, the appearance presented is that of a whitish, somewhat elevated spot, pro- jecting into the vessel, but still covered by a portion of the inner coat of the latter1 (Fig. 313). As the process continues, the inner coat becomes Fig. 3!2.—Fatty degeneration in inner coat of aorta. (Green.) 1 Mr. Moore, in his essay in Holmes's System of Surgery, 2d edit., vol. iii., adopted the view formerly held by Rokitansky, that atheroma was a deposit on the lining mem- brane of the artery, derived from the blood. 582 SURGICAL DISEASES OF THE VASCULAR SYSTEM. perforated, the atheromatous mass is evacuated into the vessel, and the so-called atheromatous ulcer results (Fig. 314), just as in the affection pp'SS^- jsMJlm Fig. 313.—Atheroma of the aorta, showing the new growth in the deeper layers of the iDner coat, and the consequent iutornal bulging of the vessel. The new tissue has undergone more or less faity degeneration. There is also some cellular infiltration of the middle coat. t. internal, m. middle, e. external coat of vessel. (Green.) known as ulcerative endocarditis. While this change is occurring be- tween the inner and middle coats of the artery, its outer coat becomes thickened and indurated, thus tending to maintain the strength of the vessel, which at the same time becomes comparatively rigid and inelastic. Athe- roma is usually spoken of as a degenerative change, but, according to Yirchow, Billroth, Niemeyer, W. Moxon. and others, should be considered a result of inflammation. Atheroma is often supposed 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 495). 3. Ossification is a rare, but, according to Yir- chow, an occasional change met with in the inner arterial coat. It may coexist with or may take the jilace of the atheromatous change (atheromasia), and, like that, results, according to Yirchow, from inflammatory proliferation. 4. Calcification is frequently met with, and, unlike atheroma, often in the peripheral arteries; it occurs chiefly in the middle coat of the ves- sel, and has no necessary connection with the atheromatous change. It consists in the deposit of earthy matters, principally phosphate, with a lit- tle carbonate, of lime, and occurs in the form of plates, rings, or tubes, constituting the several varieties of the affection known as laminar, annu- lar, and tubular calcification. When in the superficial arteries, it is readily recognized by the touch. These various structural changes may exist independently, or, as is more common, may coexist in the same person. They may occur at any age, but are by far most frequently seen in those who have passed the period of middle life. They* are more frequent in men than in women, and are said to be predisposed to by intemperate habits and by syphilis ; when occurring in the limbs, they are usually symmetrical. The effect of these Fio. 314.—Atheromatous ulcer of aorta. (Liston.) ANEURISM. 583 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 ir- regular dilatation and elongation ; hence, an atheromatous or calcified artery may become tortuous, and is peculiarly apt to become the seat of aneu- rism. Rupture may* take place through an atheromatous ulcer, and lead to fatal hemorrhage, as has been occasionally seen in the aorta -1 while both atheroma and calcification render an artery more apt to be rujitured by external violence, and interfere with the success of haemostatic mea- sures—a ligature perhaps cutting through at once, or becoming prema- turely* detached and leading to secondary hemorrhage. Finally, the loss of smoothness in the lining surface of an atheromatous or calcined artery, hinders the circulation, and offers a nidus 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, jiarticles de- tached from an atheromatous ulcer may* produce capillary* embolism, and give rise to one form of arterial pyaunia. Little can be done in the way of treatment for these structural changes, beyond attention to the general health of the patient; if wide-spread, they* would of course render the sur- geon cautious in recommending any cutting ojieration that was not impera- tively required. Should occlusion and gangrene occur, the case should be treated on the principles laid down in previous portions of the work. Aneurtsm. 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 207), as well as the general dilatation of an artery which constitutes the disease known as arterial varix or cir- soid aneurism; there remain for discussion three varieties of aneurism, which may be called respectively* : 1, the tubular or fusiform; 2, the sac- culated ; and 3, the dissecting aneurism. 1. Tubular or Fusiform Aneurism.—This is a circumscribed dilatation of all the coats of an artery, in its whole circumference. It is accompanied by* elongation of the vessel, with thickening and structural change of its coats. It is most common in the aorta, but also occurs in the iliac and femoral arteries, and has been seen in the basilar artery. Several fusiform aneurisms may coexist in the course of the same vessel, the in- tervening 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 com- pressing other parts, as the oesophagus or bronchi; or, when occurring in the intra-pericardial portion of the aorta, by bursting into the pericardial sac (Fig. 315). More commonly, however, a sacculated aneurism (Fig. 316) 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 the artery, or of a previously* existing fusiform aneurism, and which communicates with the interior of the vessel by means of a com- paratively small orifice, called the mouth of the sac. Sacculated aneurisms are divided into true and false ; the true sacculated aneurism being one 1 Similarly, fatty degeneration of the cerebral arteries is a very common antecedent to the occurrence of apoplexy. (See Paget, Lectures on Surgical Pathology, 3d edit., p. 106.) 58-t SURGICAL DISEASES OF THE VASCULAR SYSTEM. in which all the arterial coats enter into the formation of the sac-wall, and the false sacculated aneurism (which is by far the more common) being one in which, the inner and part of the middle coat having given way, the sac-wall is formed by the thickened outer coat of the artery, with jierhajis Fig.315.—Large fusiform aneurism of as- Fig. 316.—Sacculated aneurism of ascend. cending aorta bursting into pericardium. ing aorta. (Erichsen.) (Erichsen.) the external layers of the middle coat. A true sacculated aneurism must be of small size, and with a large mouth to its sac ; for it is scarcely con- ceivable that a large sac could be formed from the portion of arterial wall corresponding to the area of a small sac-mouth. It is very probable, how- ever, that a considerable number of sacculated aneurisms are at first' true, and subsequently, as they increase in size, become false by rupture of the inner coats of the sac-wall. False sacculated aneurisms are further classi- fied by surgical writers as circumscribed and diffused, the aneurism being circumscribed as long as its sac remains entire, and becoming diffused when its sac gives way—the contained blood being then either widely spread among the adjoining structures, 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 distinguish one from the other ; while a diffused aneurism is in reality nothing more than an aneurism the sac of which has given away. 3. Dissecting Aneurism is almost exclusively met with in the aorta, and is a rare form of the disease, in which the blood makes its way between the coats of the artery itself. A sac may thus be formed in the arterial wall; or the blood may dissect up the coats of the vessel for some dis- tance, at last bursting through the external tunic, and probably causing death by syncope; or, finally, the blood may re-enter the artery through a softened patch of the inner coat, thus giving the appearance of a double aorta. The only contingency in which a dissecting aneurism would be likely to demand the especial 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. NUMBER, SIZE, AND STRUCTURE OF ANEURISMS. 585 Causes of Aneurism__The chief Predisposing Cause is unquestion- ably the existence of structural changes (particularly* fatty degeneration and atheroma) in the arterial walls. Calcification does not directly* tend to cause aneurism, but rather lessens the dilatability of the artery which it affects ; it has, however, an indirect influence, the wrant of elasticity which it produces tending to increase the strain upon other portions of the vessel, and thus jiredisposing them to aneurismal disease. Age has been looked upon as a predisjiosing cause, aneurism usually occurring during the middle period of life ; the explanation is, that at this age, while atheromatous changes have begun, the laborious occupations of youth are commonly still con- tinued. Similarly, 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 struc- tural arterial changes, and from their being more commonly engaged in occupations which themselves predispose to aneurismal disease. Any occu- pation which requires intermittent violent muscular exertion, predisposes to aneurism, by inducing occasional violent action of the heart, and conse- quent over-distention of the arteries ; thus hotel-porters, soldiers, and sailors, or those who, usually leading sedentary lives, indulge occasionally in athletic sports, are said to be more liable to aneurism than those whose occupation is uniformly laborious. Climate appears to exercise some pre- disposing 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 circulation may predispose to aneurism by increasing the tension of the arterial walls; it is thus, as we have seen, that calcifica- tion 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 predis- pose the vessel to aneurism ; thus the exposed situation of the popliteal artery renders it jieculiarly liable to the development of aneurismal disease. The Exciting Causes of aneurism are wounds, blows, and sudden strains. The effect of wounds has already been considered (see pp. 207, 208); blows and strains, which may* cause rupture of a healthy artery, may still more readily induce partial dilatation of one which is weakened by disease, thus giving rise to a tubular or to a true sacculated aneurism; or (which is commoner) may cause the giving way of the portion of the inner coat which covers an atheromatous patch, leading to the evacuation of the latter, and the consequent formation of a false sacculated or of a 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 with one of the subclavian or carotid artery, or with one of the aorta. Popli- teal aneurism is frequently symmetrical. When a large number of aneu- risms coexist, as in cases recorded by Pelletan and Cloquet, the patient is sometimes said to suffer from the aneurismal diathesis. 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). 2 According to Church, embolism is the most frequent cause of intra-cranial aneu- rism in young persons (St. Bartholomew's Hosp. Reports, vol. vi. p. 99). 586 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Aneurismal tumors vary in size, from that of a jiea,1 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 inwards, is found to be as follows: (1) An investment of condensed areolar tissue, forming an adventitious sac ; (2) the true aneurismal sac, ('(insisting 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 calcareous patches which they contain; (3) concentric layers or laminae of decolorized fibrinous clot, which appear to have been successively sejia- rated from the blood, as if by whipjiing,2 and of which the inner layers are softer and redder3 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. 583, 584); 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 formation of an aneurism—experiencing a distinct sensation of something having given way, or a sharp pain, as if from the stroke of a whiji—or (as in the ease of intra-orbital aneurism) hearing a sudden sound, as of the exjilosion of a jiercussion-cap—a small, pulsating tumor being, perhaps immediately, or soon after, discovered upon examining the part. In other cases, the development of an aneurism is very gradual, the patient perhaps not becoming aware of its existence until it has attained a 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 position—its pressure-effects—and which might equally be due to any other tumor of the same bulk, and in the same locality. The peculiar symptoms of aneurism are made apparent by auscultation and manual examination, and depend ujion 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 between the sac and the artery upon which it is developed; in certain internal aneurisms, the auscultatory signs alone are available for diagnosis. 1 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 -fe of an inch. 2 This is denied by W. Colles, who believes that the laminated coagulum is formed by the walls of the sac itself. 3 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. 587 General Characters.—An external aneurism presents the appearance of a rounded or oval tumor, situated in the course of a large artery, some- what 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 com- pressible, but if, on the other hand, the sac contain a large amount of fibrinous clot, it will be comparatively hard and inelastic; the skin over an aneurism is usually* healthy*, though stretched; as the tumor grows it may, however, become discolored, thinned, or even ulcerated, and suppuration may occur in the subcutaneous areolar tissue. Muscular weakness of the part, stiffness, and a tired feeling, are frequent accompaniments of aneurism. Pulsation.—The pulsation of an aneurism is peculiar, being of an eccen- tric, expansive character, separating the hands when placed on either side of the tumor—the fluid pressure of the blood entering the sac being, accord- ing to a well-known law of hydraulics, exerted equally* in all directions. This pulsation is most marked when the mouth of the sac is large, and when the sac contains but a small quantity of laminated clot—the pulsation of a partially consolidated aneurism, if at all perceptible, being compara- tively obscure, and sometimes scarcely distinguishable from that trans- mitted to a solid tumor by a subjacent artery. The characters of the pulsation are rendered less distinct by pressure above, and more distinct by pressure below, the aneurism, or by elevating the part in which the tumor is seated. By firmly* compressing the artery above the sac, the pul- sation 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 which 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 intra- thoracic aneurism, in which the radial pulse of the affected side may be much weaker than on the sound side, or altogether absent. This, in par- ticular instances, may be due to arterial occlusion from arteritis, to the rigidity produced by calcification, or to external pressure, but, in the majority of cases, is probably owing to the mechanical action of the sac- walls in equalizing the blood current and thus lessening pulsation, just as the air-chamber does in the ordinary "hydraulic ram." Bruit.—This is the name given to the intermittent sound which is heard by applying the ear to an aueurismal tumor, and which is due to the rush of blood from a narrow into a dilated cavity: the bruit varies a great deal in different cases, being usually of a rasping or sawing character, and most distinct in tubular aneurism, and in those with large sac-mouths. It may be scarcely perceptible, or entirely absent, in an aneurism with a very small mouth, or which is nearly filled with laminated coagulum ; in cases of femoral or popliteal aneurism, the bruit may often be rendered more distinct by causing the patient to lie down, and by elevating the limb. The bruit, which is often accompanied with a peculiar thrill, is synchronous with the aneurismal pulsation, and ceases with the latter if the artery be com- pressed above the tumor—returning immediately when the pressure is removed. According to Savory, the thrill is most marked when the aneu- rism projects from the distal 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 aneu- rism are venous congestion and oedema, from compression of the deep-seated veins. In some cases a varicose condition of the superficial veins may result from the same cause, and gangrene may even follow from the obstruc- 588 SURGICAL DISEASES OF THE VASCULAR SYSTEM. tion 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 sujijily to more distant parts. Pressure upon nerves gives rise to intense pain, usually of a lanci- nating character, and, in certain situations, may lead to serious conse- quences by* interfering with the functions of important jiarts : thus hoarse- ness and spasmodic dyspnoea may result from compression of the recurrent laryngeal nerve (Fig. 318), dyspnoea, or (as in a case recorded by AV. F. Atlee) uncontrollable eructation, from pressure on the pneumogastric, and, in cases of intra-cranial aneurism, facial paralysis, deafness, ptosis, strabis- mus, or blindness, from compression of various cerebral nerves. Pressure upon secreting glands, or their ducts, may cause trouble by interfering with the functions of the part. Pressure upon bones and joints often leads to serious consequences, the flat bones (as the sternum or ribs) becoming eroded and perforated (Fig. 317), or caries and disorganization of articula- tions 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 jiain, as in the vertebra] column in cases of aneurism of the aorta. Finally, serious consequences Fio. 317.—Kibs perforated by an aortic an- Fig. 318.—Aneurism of the innominate artery, com- eurism. (Pirrie.) pressing and stretching the recurrent laryngeal nerve, and pushing the trachea to the left side. (Erichsen.) may result from pressure on important viscera : thus dyspnoea maybe due to compression of the trachea (Fig. 318), bronchi, or lungs; dysphagia to compression of the oesophagus; and progressive emaciation to pressure on the thoracic duct—while hemiplegia may result from the compression ex- ercised by an intra-cranial aneurism on the brain. Symptoms of diffused Aneurism.—When the aneurism becomes dif- fused 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* disapjiear ; the part becomes cedematous, and often cold and livid, from venous conges- tion ; the pain is suddenly increased, and syncope may occur; the swell- ing 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 sponta- DIAGNOSIS OF ANEURISM. 589 neous cure. Usually, however, the swelling continues to increase, with or without pulsation, or evidence of inflammation, and the case ends in gan- grene, from conjoined arterial and venous obstruction; or, the clot becom- ing disintegrated, with suppuration and ultimate giving way of the skin, death follows from external hemorrhage. In some cases rupture of the aneurismal sac leads to wide extravasation of blood among the tissues of the part, the accident being accompanied with much shock and pain, faint- ness perhaps resulting from loss of blood from the general circulation, and gangrene ensuing at no distant period. Diagnosis.—The affections with which aneurism is most likely to be confounded are various forms of tumor, abscess, and simple arterial dilata- tion. 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 want of care in the examination of the case. From Pulsating Tumors of a vascular or encephaloid nature, aneurism may usually be distinguished by its more circumscribed form, its more for- cible 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 growth occur in a locality in which 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 communicated from the latter, and may thus simulate aneurism ; the diag- nosis may usually be made by observing that the growth can be lifted from, or pushed to one side of, the vessel, when the pulsation will diminish or disappear ; that the pulsation itself is not of an eccentric or expansive char- acter ; that there is no bruit, or at least merely a dull, beating sound, such as may be produced by compressing an artery with a stethoscope; and that the degree of tension of the tumor is not affected by compressing the artery at a point nearer the heart. In some cases, however, a tumor may* be con- nected with several arteries which surround or penetrate its substance, and the diagnosis in such a case might be impossible. Non-Pulsating Tumors, of a glandular or cancerous nature, may be mis- taken for aneurisms in which 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 some- times be made by* observing the mobility of the tumor; thus, by its mov- ing with 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 sup- puration in the surrounding tissues, or from the formation of an actual communication between an aneurism and the cavity of an abscess. Errors of diagnosis, under these circumstances, have been made by no less emi- nent surgeons than Desault, Dupuytren, Liston, and Pirogoff. It is prob- able that, in some of these cases, careful auscultation might reveal a bruit, even if all the other signs of aneurism were absent. General Dilatation of an Artery may simulate aneurism, especially one of the tubular variety ; the diagnosis is made by observing the absence of the characteristic symptoms of the latter disease. Under the name of mimic or phantom aneurism, Sir J. Paget and Dr. S. West have described localized pulsations of arteries which simulate aneurisms, but are not persistent. 590 SURGICAL DISEASES OF THE VASCULAR SYSTEM. For illustrations of the difficulty* of diagnosis in cases of aneurism, the student may advantageously consult several papers by Dr. Stejihen Smith, of New York, in the American Journal of the Medical Sciences for Ajiril and October, 1873, and January, 1874. Terminations of Aneurism.—An untreated aneurism may termi- nate in a sjiontaneous cure, or may cause death by jiressure (in imjiortant parts, by inducing syncojie, by rupture and consequent hemorrhage, or by- causing gangrene. 1. Spontaneous Cure__This, which is unfortunately a rare termina- tion, may be effected in several ways; and it is to be observed that the modes of treatment which 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 sjiontaneous cure, and is seen almost exclu- sively in sacculated aneurisms and those occurring in arteries of the second or less magnitude. A case, however, occurred to Stanley, in which an aortic aneurism was spontaneously cured in this way. The sac of the aneu- rism, acting as a diverticulum, allows contraction of the artery below, which, together with the enlargement of the collateral branches given off above, tends to lessen the force of the current through the aneurism, and thus to encourage the separation of fibrin and consequent formation of the laminated clot. This mode of cure is imitated in the medical treatment of aneurism, as well as in the surgical treatment by comjiression on the car- diac side of the sac, by flexion, by the Hunterian mode of ligation, and to a certain extent by AVardrop's operation. A modification of this mode of spontaneous cure is that which is said to occur from the compression of the artery by the aneurism itself, or by another aneurism or solid tumor. (2) Occlusion of the Artery below or above the Sac by Means of a Fibri- nous 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 lami- nated clot; or, jiossibly, 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 possi- bly cause coagulation, and consequent cure of the aneurism, though the soft clot formed in this way is more ajit to become subse- quently disintegrated, leading to suppura- tion and rupture of the sac. This mode of cure is imitated by the use of direct pres- sure, galvano-puncture, the injection of Fig. 319.-Stellate rupture of an aor- Coagulating fluids, etc. tic aneurism into the pericardium. (4) Finally, a spontaneous cure may, (Erichsen.) perhaps, occasionally result from Suppura- tion and Gangrene, leading to the extru- sion of the aneurismal sac as a slough, while hemorrhage is prevented by the occlusion of the artery* by inflammation. This method of cure is imitated in what is called the "old operation," or that of Antylhis, which is practically equivalent to an excision of the sac. The evidence of the occurrence of a spontaneous cure consists in the more or le?s gradual disappearance of the aneurismal pulsation and bruit, TREATMENT OF ANEURISM. 591 the sac at the same time becoming firm and contracted, and the circulation being carried on by means of collateral branches. 2. Modes of Death—An aneurism may prove fatal by (1) pressure on important parts, as the phrenic or pneumogastric nerve, the trachea, heart, or lungs; (2) syncope, which may occur from a large aneurism be- coming suddenly diffused, and is sometimes the immediate cause of death in cases of aortic aneurism ; (3) rupture of the sac and hemorrhage— which may be internal, into the brain or spinal canal, pleura, pericardium (Fig. 319), 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 wheu an external aneu- rism becomes diffused, and which is usually complicated with hemorrhage. The rupture of an aneurism on the cutaneous surface is commonly effected by the occurrence of suppuration and pointing, with the formation of a small slough, as in an abscess ; on a mucous surface, by the occur- rence of a small circular ulcer ; and on a serous surface, by the formation of a fissured or star-like opening. (Fig. 319.) 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 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, stimu- lants, and large quantities of liquid. The treatment by position and re- stricted 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 and Broadbent for the relief of dyspnoea, in cases in which this has been a troublesome symptom. Holmes has suggested the withdrawal of blood directly from the aneurism by means of an aspirator ; but the plan seems to me a very unsafe substi- tute for venesection, and I have heard of one case in which it was the im- mediate cause of death. Various drugs have acquired a certain reputation in the treatment of aneurism, especially the acetate of lead and the iodide of potassium, the former of which is very highly spoken of by Mr. Hutch- inson, and the latter by Dr. Balfour, of Edinburgh. Speir, of Brooklyn, recommends the employment of gallic acid and the subsulphate of iron, and F. Flint the administration of chloride of barium. Digitalis, vera- trum viride, and aconite, have also been used with advantage, while Langenbeck, Dutoit, Plagge, and others, have employed with success hypodermic injections of ergotine. The local application of ice has been of use in some cases, but is a dangerous remedy, having, according to Broca, induced gangrene of the skin. The pain of a growing aneurism may sometimes be relieved by the use of anodyne plasters or embrocations, while hemlock or lead plaster may be used to give external support in a case in which rupture of an aneurism is impending. 592 SURGICAL DISEASES OF THE VASCULAR SYSTEM. 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 aneuris- mal sac, constituting what is known as the " Old Operation;" on tin; Cardiac Side, as in Hunter's and Anol's methods; and on the Distal Side, as in the plans of Brasdor and AVardrop. 1. The "Old Operation."—This, which until the early part of the last century, was, with the excejition of amjiutation, the only ojieration employed in the treatment of aneurism, is also spoken of as the Antyllian method, from Antyllus, who was one of the first, if not the first, to enqiloy it. It consists in opening the sac, and applying ligatures above and below, as was directed in speaking of traumatic aneurism (see page 207), though it would appear that by the older surgeons the ligatures were sometimes applied first, and the sac subsequently laid open, or even totally excised. The operation is often a very- severe one, and is more liable to be followed bv hemorrhage than the Hunterian operation, on account of the artery being tied in immediate proximity to the sac, and where, therefore, it may probably be diseased. In certain situations, however, as in the axilla, root of the neck, or gluteal region, this operation may sometimes be projierly employed, and it was, under such circumstances, several times resorted to by- the late Prof. Syme, with the most brilliant and gratifying success; it may also be practised in cases of diffused femoral aneurism, as a substitute for amputation ; and in any locality, if an aneurism have burst or have been accidentally laid open, it may often be the most eligible mode of treatment. A modification of this method, attributed to Guattani, and since revived by Watson, of Jersey City, eonsists in plugging the sac, and, if possible, the opening of the artery from which it arises. 2. Ligation on the Cardiac Side of the Tumor__The method of ligating an artery for aneurism which, when practicable, is now emjiloyed in preference to any other, is that known as the Hunterian Method (Fig. 321), from the illus- trious John Hunter, by whom it was first re- sorted 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 jiass through the sac by7 means of the collateral circu- lation ; the cure is thus effected by the deposition of laminated coagulum, and not by the sudden clotting of the whole contents of the tumor. //\\ /A\ Ariel'8 Method (Fig. 320), which is spoken of '/ \\ // \\ by most French writers as identical with Hun- ter's, consists in the application of a proximal ligature immediately above the sac; it was em- ployed by Anel in 1710, in a case of traumatic aneurism of the brachial artery*, and apparently as a mere experimental variation upon the old method.1 It does not seem to have been repeated, except once by Desault, and fell into oblivion until after the promulgation of Hunter's plan of operation. Anel's method is defective in not allowing any current through the sac, except from the Fig. 320. Fio. 321. Auel's Hunter's operation. operation 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 ANEURISM. 593 distal end—imperfect coagulation and suppuration being therefore apt to follow—and in requiring the ligature to be applied to a part of the vessel which is very* liable to be diseased, thus exposing the patient to a consider- able risk of hemorrhage; the operation is, moreover, difficult, on account of the disjilacement of the artery by the tumor, and not free from danger. In performing the Hunterian operation, those precautions are to be observed which were mentioned when speaking of ligation in the continuity of arteries (page 197); before tightening the ligature, it is well to make distal compression for a few 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 becoming painful and hy*peraesthetic; loss of muscular power is also occa- sionally* met with. 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 estab- lishment of the collateral circulation, after the Hunterian operation, usually requires the enlargement of two sets of anastomosing vessels—one around the seat of ligation, and another around the aneurism itself—unless in the rare cases in which the sac becomes obliterated, still leaving a channel for the normal flow of blood. If, however, the artery be tied near the sac, as in aneurism of the primitive carotid or external iliac—or in any case by Anel's method—but one set of collateral vessels is needed. If the collateral circulation above the sac be too rapidly established, the operation may fail, the pulsation of the aneurism being renewed as forcibly as at first; in most cases, however, enough coagulation takes place while the circulation is temporarily arrested to insure the continuance of the clotting process, and the attainment of ultimate success. AAThen two sets of collateral branches are enlarged, the lower arch of anastomosis is commonly first developed, owing to the aneurismal swelling itself having led to previous dilatation of the neighboring vessels. If the lower anastomosis be defective, consolida- tion of the tumor may not take place, and suppuration of the sac, or even gangrene, may follow. Causes of Failure after the Hunterian Operation.—There are several circumstances which may* lead to failure after the Hunterian method of ligation; these are, (1) hemorrhage from the point of ligature, (2) return of pulsation from too free development of the upper collateral circulation— that above the sac, (3) suppuration and sloughing of the sac, often accom- panied by hemorrhage, 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 (which, according to Crisp, usually occurs from the seventh to the fifteenth day*) is more frequent in the upper than in the lower extremity, on account of tbe greater freedom of arterial anastomosis in the former situation, but is apt to occur in any locality in which large branches are given off in close proximity to the point of ligation—the clots, upon which arterial occlusion 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. 38 594 SURGICAL DISEASES OF THE VASCULAR SYSTEM. after the use of the ligature depends, being, under such circumstances, insufficient to resist the force of the circulation. With regard to the material \ to be employed as a ligature, strong, well-prepared, carbolized or chromi- cized catgut is, I think, upon the whole, the best. Its use is less likely to be followed by secondary hemorrhage than that of silk, and, if it be projierly prepared, and applied with sufficient force to divide the inner and middle coats of the vessel and thus secure jiermanent obliteration, is not likely to permit failure, which may otherwise occur from the artery remaining per- vious and thus permitting a return of the blood-current. The treatment of hemorrhage from the point of ligation, in a case of aneurism, is the same as for bleeding after ligation in the continuity of an artery in any* other case, and is to be conducted as directed at page 2(H). (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 AA'illis allows the collateral circulation to be very quickly established. In many cases the recurrent pulsation consists of a mere thrill, without any bruit; but it is occasionally as distinct as before the ojieration. It usually occurs within twenty-four hours after the tightening of the ligature, though sometimes not for four or six weeks, and more rarely at an intermediate period. The prognosis of these eases 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 jioint of the artery than the seat of original disease. Enlargement of the sac after ligation, without pulsation, is due to the reflux of blood from the artery on the distal side. If excessive, it may lead to serious consequences—in- ducing gangrene, by obstructing 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 aneu- rism, the surgeon should ascertain, by pressure with the finger, that doing so will entirely arrest the pulsation in the sac. By neglect of this precau- tion, 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 consequence prevented. The treatment of recurrent pulsation may usually be satisfactorily conducted by elevating the limb, making moderate compression upon the sac, and perhaps cautiously applying cold. If the pulsation persist, a ligature may be applied lower down, as in Anel's method; but if sloughing of the sac be imminent, the surgeon's only re- sources will be amputation and the " old operation"—the former being indicated in cases of popliteal or axillary, and the latter in those of cervical or inguinal, aneurism. (3) Suppuration and Sloughing of the Sac.—This may occur as a con- sequence of recurrent pulsation—or may result from imperfect develop- ment 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 circulation through the sac being completely arrested (leading to coag- ulation en masse, instead of to the deposit of laminated clot), or from external violence, or even careless handling of the tumor before or after operation. The symptoms are those which characterize the occurrence of suppuration in general, the sac finally giving way, and (in about twenty- LIGATION ON CARDIAC SIDE OF ANEURISM. 595 five per cent, of the cases in which this accident happens) death resulting from hemorrhage. Bleeding is particularly apt to occur in those cases which have been marked by recurrent pulsation, and then follows immedi- ately upon the giving way* of the sac; in other cases it may not occur for several days; while if suppuration takes place at a late period, the arteries communicating with the sac may be sufficiently occluded not to allow any hemorrhage at all. Suppuration of the sac is most common in cases of axillary and inguinal aneurism, though it may occur in other situations. The treatment consists in laying open the sac, evacuating its contents, and promoting healing by granulation, a provisional tourniquet being applied as a matter of precaution ; should hemorrhage occur, an attempt must be made to secure the bleeding orifice with a ligature, or by the appli- cation of the actual cautery—and, if these fail, amputation should be prac- tised, provided that the situation of the aneurism admits of such a course. (4) Gangrene of the Limb usually results, as has been mentioned, from the combined effects of arterial occlusion and venous congestion ; it is 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 invariably* of the nature of moist gangrene from implication of the veins. In order to prevent the occurrence of gangrene, those measures should be adopted which were advised in speaking of gangrene from arterial occlu- sion (page 206) ; in some cases it may be jiroper (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 ojieration, over that of Hunter, that it is less apt to be followed by mortification. If gan- grene have actually- occurred, amputation must be performed, usually at the shoulder-joint, in the case of the upper limb, and at the junction of the upper and middle thirds of the thigh, in that of the lower extremity. Beside the above, which are the common causes of death after ligation for aneurism, there are certain special risks in particular 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, accord- ing to Pilz), and Intra-thoracic Inflammation about two-fifths of the deaths after ligation of third part of the subclavian (ten out of twenty- five, according to Erichsen). Indications and Contra-indications for Ligation.—The application of the ligature, in the treatment of aneurism, is indicated (1) in cases in which the disease is active and advancing, and so situated that, while pressure, flexion, etc., are not applicable, the use of the ligature is not attended with unusual risk ; (2) in any* case in which less dangerous modes of treatment have been tried and failed ; (3) in case an aneurism has burst into an articu- lation ; (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 impera- tively required to prevent death from hemorrhage. The use of the ligature is, on the other hand, contra-indicated (1) by the presence of any compli- cation—such as extensive arterial or cardiac disease, the existence of inter- nal aneurism, old age, or the prevalence of erysipelas—which would pro- bably render the operation peculiarly dangerous; (2) by the locality of the aneurism being such that pressure or flexion would probably be sufficient to effect a cure, as in many aneurisms of the brachial, femoral, and pop- liteal arteries ; and (3) by the locality of the aneurism being such, that, from the proximity of anastomosing branches, or from any other cause, the 596 SURGICAL DISEASES OF THE VASCULAR SYSTEM. operation would almost certainly terminate unsuccessfully—the imminence of rupture being in such a case the only circumstance that could justify operative interference. Multiple aneurism is usually, though not always, a contra-indication ; thus, if two aneurisms exist on the same limb, they mav both lie cured by the same operation ;' or double pojiliteal aneurism by ligation of both femoral arteries; in most cases, however, the existence of more than one aneurismal tumor contra-indicates, though it may not positively forbid, ligation. Though I have said that ligation is contra-indicated in many cases of popliteal aneurism, yet I believe that in other instances it is the best mode of treatment. The operation, however—which, though delicate, is not in itself very dangerous—should not, of course, be indiscriminately resorted to. If the aneurism be quite small, pressure will 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, however, an intermediate set of cases, in which pressure would not be likely to succeed, and in which, if persisted in, it would certainly increase the" obstruction to the venous circulation, and thus lessen the chances from subsequent ligation. In such cases, 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 re- putation and the interests of his patients, rather by adapting his remedies to the ex- igencies of each particular case, than by advocating and invariably employing any exclusive mode of treatment. 3. Ligation on the Distal Side of the Tumor.—This operation is attrib- uted to Brasdor, whose name it bears. It was recommended by Desault, but first practised by Descbamps, and subsequently by AVardrop—being indeed often sjioken of as AArardrop's method. Though this sur- geon, however, successfully employed Bras- dor's operation, the plan which he himself suggested, and which properly bears his name, is somewhat different. In Brasdor's operation, the whole circulation on the dis- tal side of the sac is arrested—in Ward- rop's only a jiart of the distal circulation, by the application of a ligature to a branch of the main trunk, or to one of several arteries jiroceeding 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 through the sac. The risks, besides those incident to the Hunterian mode of ligation, are that the sac, being still distended Fig. 322. Fig. 323. Brasdor's Wardrop's operation. operation. 1 Pemberton has recorded a case in which three aneurisms on the same limb were cured by ligation of the external iliac artery. COMPRESSION IN ANEURISxM. 597 by the cardiac impulse, may continue to increase in size, the operation thus failing, even if suppuration and sloughing do not lead to a fatal termina- tion. Hence, except in particular cases, as of aneurism of the root of the carotid, or of the innominate, the distal ligature is not to be recommended. II. Acupressure has been successfully employed in a few cases of aneurism, but does not appear to present any particular advantages over the use of the ligature. Various modifications of this method, under the name of temporary ligature, filopressure, etc., have also been employed by Stokes, Dix, and others, but not often enough to enable us to say whether they will ultimately be found any better than the methods of treatment which have been longer before the profession. (See page 201.) 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 in- struments (instrumental compression). Direct Pressure upon the aneu- rismal sac was introduced by Bourdelot, in the seventeenth century, and has since been successfully employed from time to time, by various sur- geons, but is so uncertain, and occasionally* so dangerous a method, that it is now generally abandoned as an exclusive mode of treatment1—while Distal Compression, which was proposed by* Yernet, in the last century, failed in its author's own hands, and is rarely emjiloyed at the present day, though Varick reports a case of inguinal aneurism in which it effected a cure in connection with rest in bed and the administration of iodide of potassium. Both direct and distal compression may, however, prove valuable adjuvants to pressure on the proximal side of the sac, as in the plan adopted by Reid, Wagstaffe, Tyrrell, Sydney Jones, F. A. Heath, AV right, T. Smith, AAreir, Freeman, AVheeler, Boutelle, Nash, 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 suc- cessful result having been obtained in 35, while only 2 proved fatal. The treatment of aneurism by Compression on the Cardiac Side of the Tumor was employed by Hunter, Blizard, and particularly Freer, in England, and by Pelletan. Dupuytren, and others in France, but did not attain the posi- tion which it now occupies in the estimation of the profession until it was, about forty years ago, revived and systematized by the Irish school of surgeons, particularly by Hutton- Bellingham, Tufnell, and Carte. It is not necessary, as was formerly sujiposed, 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 laminae of fibrinous clot, it is sufficient to exer- cise enough compression to simply arrest the pulsation of the sac, with- out preventing the flow of blood through it. This mode of treatment is particularly apjilicable to sacculated aneurisms, though it may also succeed in cases of the tubular variety, in which, however, the cure is effected rather by the gradual contraction of the aneurismal dilatation, than by* the dejiosit of fibrin. The chances of success by compression are great- est when the sac contains only fluid blood, coagulation in an already* par- tially* consolidated aneurism being apt to occur suddenly, and in an imper- fect manner. After recovery, the sac is commonly entirely filled up, but 1 Laplace reports several cures effected by direct pressure applied through a hol- lowed-out ball of cork by a figure-of-8 bandage. 598 SURGICAL DISEASES OF THE VASCULAR SYSTEM. in some cases a channel remains, through which the normal circulation is carried on. During the treatment by compression, the patient should of course be confined to bed,1 and the hygienic and other means sjioken of under the head of Medical Treatment put in force. Nervous irritability and jiain 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 may be effected by the use of various forms of apparatus, such as a Signoroni's or a Skey's tourniquet Fio. 32").—Gibhons's modification of Charrieie's compressor. (Figs. 31, 32), Lister's .com- pressor (Fig. 33), Bcade's or Carte's ajiparatus (in the latter of which (Fig. 324) elastic force is applied by means of vulcan- ized India-rubber bands), or a simple conical weight, held in position by means of a leather socket, or, as successfully em- ployed in Bellevue Hospital, New York, a bag of shot sus- pended from the ceiling.2 In situations in which a considerable extent of artery can be dealt with (as in the thigh), alternate pressure upon several points may be practised, by means of an instrument such as that repre- sented in Fig. 325, which was modified from one of Charriere's by Dr. Gibbons, and which has been still further improved by Dr. Hopkins, by increasing the number of points of pressure. Special care must be taken in the apjilication of instrumental comjiression, 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 deeji-seated veins, and to guard against excoriation of the skin by carefully shaving and powdering the part, and by frequently changing the point of pressure. In situations, in which very* deep pressure is necessary to control the circu- lation, and in which, therefore, the treatment becomes very painful (as in comjiressing 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, Majiother, Levis, Agnew, and other surgeons, have succeeded in curing aneurisms of 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 with an India-rubber bandage; a shot bag, held in place with elastic bands, is employed by Madruzza, of Perugia. Fiq. 324.—Carte's compressor for the groin. COMPRESSION IN ANEURISM. 599 the iliac and femoral arteries, and even of the abdominal aorta, by com- pletely arresting the flow of blood through the sac by means of instru- mental compression, 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 anaesthetic. 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 ojierations. AVhile "the rapid pressure treatment" is un- questionably a valuable addition to the surgeon's means of dealing with aortic and inguinal aneurisms, it cannot, in my judgment, replace, in the treatment of aneurisms in other situations, the ordinary mode of making instrumental comjiression—which aims to effect a cure by inducing a gradual formation of laminated coagulum, and which I believe to be safer, if less brilliant, than the rapid method, which has already* led to at least six fatal results in the hands of British surgeons. 2. Digital Compression, which was first proposed by Vanzetti, of Padua, and which has been successfully resorted to by Knight, of New Haven, Parker and Wood, of Xew York, S. W. Gross, Agnew and many others, myself included, may be emjiloyed as an exclusive measure of treat- ment, or as an adjuvant to compression by* means of instruments. For its use in the former mode, constant relays of skilled assistants are usually required, and these frequently cannot be obtained ; hence, though its statis- tical results are very favorable (the average duration of treatment in suc- cessful 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 without fatigue. The statistics of digital compression have been par- ticularly 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 twice after ojiening 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 treat- ment except flexion, which he thinks should be preferred in any case in which it is applicable. AVhen 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, com- pression should be steadily maintained, if possible, until consolidation is complete, or at least measurably advanced. This may usually be accom- plished by using an instrument such as that of Dr. Gibbons, or by employ- ing digital compression during the intervals, in which the pressure of the instrument is relaxed. A cure has, indeed, been obtained in cases in which pressure has occasionally been intermitted for several hours at a time, but it seems more probable that, when 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 on 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 600 SURGICAL DISEASES OF THE VASCULAR SYSTEM. making gentle direct pressure upon the tumor, during the whole course of treatment, by means of a carefully-applied bandage, the action of which may* be aided by Corradi's plan of interjiosing an air-ball between this and the aneurism. Advantages and Disadvantages of Compression.—The advantages of this mode of treatment are very obvious; it is certainly, though not en- tirely free from risk, far safer (in most cases) than ligation of the artery, and, in cases in which it proves successful, is not materially more tedious. In manv instances, a cure has been effected in from a few hours to three or four days, and the average duration of treatment, in successful cases, is, according to Hutchinson's statistics (for popliteal aneurism), about nine- teen days, or about the same time as is commonly required for recovery after ligation of the femoral artery. The 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 would have been had the latter ojie- ration been primarily employed. This fact is, indeed, denied by many sur- geons, 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 conges- tion than from arterial deficiency*; and that comjiression tends rather to increase than to diminish venous congestion, will probably not be doubted. Nor is it fair to assert that the long list of failures after compression is entirely* due to want of care in its application; for the advocates of the ligature might as justly respond, with the late Mr. Syme, that most of the untoward results of that operation were due to the ojierator's want of skill —Svme 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 preference (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 which the aneurism, being detected at an early* stage, would be in the most favorable condition for thause of com- pression, and in which the pressure treatment, if even it failed, would not seriously lessen the jirospect 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 probably- be amenable to the ligature, and in which, there- fore, pressure should be at least tried before resorting to such formidable measures as amputation or the " old operation." Finally compression may be tentatively emjiloyed in almost every case —even in popliteal aneurisms of moderate size, which are those specially adajited to the use of the ligature. If, however, decided benefit be not obtained 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. IY. Flexion—This mode of treatment was introduced by Mr. Ernest Hart, in 1858,2 and has since been successfully emjiloyed by Shaw, Pem- 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. GALVANO-PUNCTURE IN ANEURISM. 601 berton, and several other surgeons. Its efficacy* depends chiefly upon the interference with the arterial circulation caused by bending the vessel to an acute angle, but is assisted by the direct compression exercised upon the sac by the contiguous surfaces between which it is thus placed. Flex- ion is applicable in cases of popliteal aneurism, and of aneurism at the bend of the elbow or in the axilla. Its application is very simple, consisting merely in the retention of the limb in the flexed position by means of a double collar or figure-of-8 bandage. If flexion is to be employed by itself, the limb should be bent so as to completely* check the aneurismal pulsation. In most cases, however, it is preferable to employ moderate flexion, using it as an 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 writer finds that 49 cases gave 26 successes and 23 failures, 11 of the successes having been due to flexion alone, and 15 to this in combination with other methods; while Fischer finds that 57 cases gave 28 successes (20 by flexion alone) and 29 failures. It is probable that a combination of flexion with alternate instrumental and digital comjiression, would be found in many cases as satisfactory* as it would be certainly a less irksome mode of treatment than either plan by itself. Y. Manipulation.—This method consists in squeezing or kneading the aneurismal sac in such a way as to break up the contained laminated coagulum—a fragment of which it is hoped may plug the artery at the distal side, and thus lead to the consolidation of the tumor. This plan was introduced by Fergusson, and has been successfully- employed by* Little, Teale, and Blackman, of Cincinnati, having been combined by the last- mentioned surgeons with proximal compression. According to Yan Buren, this is the true exjilanation 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 conse- quent diffusion of the aneurism, or inflammation and gangrene, may be •caused by* the ajiplication of too much force; and that (in cases of subclavian or carotid aneurism, for the former of which Fergusson employed it) a fragment of clot may* occlude the carotid or vertebral artery, and thus lead to grave, if not fatal, cerebral disturbance. Cases are mentioned by Es- march and Teale in which 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. YI. Galvano-puncture was first employed by B. Phillips, in 1838, and has since been resorted to in a number of cases of aneurism by Petre- quin, Ciniselli, Duncan, Althaus, and others. Needles from both poles of the battery, should, as a rule, be introduced into the sac, and Macewen carries them to such a depth as slightly* to scratch the opposite wall. The great risks of the operation are that coagulation en masse will probably occur, and that sloughing of the aneurismal wall may take jilace at the points of puncture—an accident which would be apt to be followed by* hemorrhage. Embolism of the carotid proved fatal in a case referred to by AVheelhouse. The statistics of this mode of treatment are not very favorable; 89 cases collected by Duncan gave 12 deaths and only 31 re- coveries, 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 comjiression or ligation, and yet require active treatment. 602 SURGICAL DISEASES OF THE VASCULAR SYSTEM. (Jiiimaraez has reported a case of carotid aneurism cured by the external apjilication of electricity. YII. Injections of Coagulating Liquids, and esjiecially of the perchloride of iron, have been practised upon several occasions, and some- times with success. This is, however, a very- dangerous method of treat- ment (the principal risk 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 com- plete—in localities, in fact, in which either comjiression or ligation would be equally- applicable, and certainly preferable. VIII. Acupuncture, and the Introduction of Foreign Bodies, such as fine wire (Moore, Domville, Murray*, Buck, Loreta, Gerster, Ran- sohoff, Lepine (three cases), Lange, Morse, Pringle, Hulke (two cases), Rubio, Morris, and Gould); watch spring (Montenovesi, Bacelli (three cases), and Saboja); pins (Richardson); horsehair (Levis, Maury, Stim- son, and Paul) ; catgut (Bryant, Van der Meulen, Abbe, and Richardson) ; and silk threads (Schrotter), have been tried—each aiming to effect a cure by furnishing a starting point for coagulation. Acupuncture, in conjunc- tion with proximal compression, proved successful in a case of ilio-femoral aneurism reported by Macewen ; but the introduction of foreign bodies has proved useless in every case but one (Morse's) in which it has thus far been employed.1 Barwell introduced a steel wire and then passed a gal- vanic current through it, but his patient died within a week, and two cases' similarly treated by Roosevelt and Abbe were likewise unsuccessful. Dr. Kerr, of San Francisco, is said to have operated in this way on three pa- tients, of whom two died and one passed from observation. IX. Strangulation has been successfully emjiloyed for very small aneurisms, two needles or harelip pins being passed beneath the tumor, and a ligature thrown around their extremities^ as in cases of naevus. X. Caustic has likewise been used with success as an apjilication to very* small aneurisms. XI. Amputation__Finally, amputation would be required, if an aneurism in a limb should become diffused and threaten gangrene, if the pressure of the tumor should cause extensive caries of the neighboring bone, or if hemorrhage should occur from external rupture. Amputation may also be required in the event of the failure of ligation. Arterio-Venous Aneurism.—As the result of ulcerative action, a preternatural communication may occasionally- be formed between an artery and a contiguous vein, constituting a non-traumatic variety* of aneurismal varix. The symptoms and treatment do not differ from those of the trau- matic form of the disease, which has been already described (see page 208). Treatment of Particular Aneurisms. From a consideration of the principles laid down in the preceding pages, and from an examination of the statistical results, as far as they can be ascertained, of various modes of treatment, we may arrive at the following conclusions as to the best course to be adopted in dealing with aneurismal disease in various parts of the body. Thoracic Aorta—Permanent benefit can seldom be hoped for from operative 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 Dr. Dobell recommends the injection of melted spermaceti. ANEURISM OF THORACIC AORTA. 603 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 jilan has been adopted in seventeen cases, and the latter in eighteen, relief having been afforded in several of each cate- gory- ; the most successful operations have been those of Heath, one of whose jiatients 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 jiart of the subclavian.1 In a case of sujiposed aortic aneurism in which Mr. Holmes tied the left carotid, the patient survived twelve years, dying eventually of phthisis. An autojisy showed that there had been no aneurism, and that the symptoms had been due to stenosis of the valves of the pulmonary* artery*, with dilatation of its left branch. 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, Murray, Hulke, Gould, Sabojo, Barwell, and in three cases each by* Kerr and Bacelli; no benefit resulted to the patient in Domville's case, one of Kerr's was lost sight of, and the others all termi- nated fatally, as did the cases in which the introduction of silk threads was tried by Schrotter, and that of horsehair by Maury, of this city. Distal jiressure proved of benefit in cases recorded by* Dr. Ly*on and Mr. Edwards, 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 591. Cases of Aortic Aneurism treated by Ligation of the Carotid Artery. No. Operator. Result. Remarks. 1 Tilanus, Relieved. Died suddenly, five months subsequently. 2 Rigen, it Died in three months, from strangulated hernia. 3 Montgomery, O'^haughnessy, Died in four months ; sac suppurated. Died in seven days ; galvano-puncture also used. 4 Died. 5 Knowles, 11 Died of apoplexy. 6 Heath, Relieved. Died four and a half years afterwards, from ex-ternal rupture. 7 Annandale,2 <( Tumor still pulsated. 8 Pirogoff, " 9 Id. Died. Died in third week. 10 Holmes,2 U Died in two days ; internal carotid and internal jugular vein tied. 11 Callender, Bryant,2 Died in twelve months. 12 Died. Died in ten days ; pyaemia ; no clot in sac. 13 Barwell, Relieved. Died in four months ; wound healed. 14 Pick, No benefit. 15 Ashhurst, Relieved. Died in seven weeks, from suffocation. 16 Kuester,2 Died. Died in forty hours. 17 Morris,2 Died in fourteen days ; carotid not found ; in-ternal jugular vein wounded and tied. 1 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. 2 Right carotid ; in the other cases the left carotid was tied. 604 URGICAL DISEASES OF THE VASCULAR SYSTEM. Cases of Aortic Aneurism treated by Ligation of both Carotid and Suhcla rian Arteries. No. Operator. Result. 1 Hobart, Died. 2 3 4 Heath, Maunder, Sands, Relieved. Died. Relieved 5 Maury, Died. 6 Speir, <( 7 8 Barwell, Kuester, Relieved. 9 10 11 12 13 14 Lediard, Pollock, Wyeth, Marsh, Alexander, Cameron, u Died. Relieved. Died. Slightly relieved. Relieved. 15 16 17 is Pepper, Meriwether, Lawrie, Wells, f < u k Recovered. Remarks. Subclavian tied in frst portion; hemorrhage from carotid on sixteenth day. Life prolonged for four years. Died on sixth day, from occlusion of aorta. Hemorrhage from carotid on forty-third and forty-eighth days, checked by pressure : not much benefit from operation. Death thirteen months afterwards. Ligatures came away without bleeding ; aneurism grew with increased rapidity. Introduction of horsehair tried. Death from external rupture of aneurism. Carotid constricted with artery constrictor ; two days afterwards, subclavian tied ; no hemorrhage from either wound, but death on thirty-fourth day from external rupture. Died fifteen months afterwards. Carotid tied first, and subclavian some months after- wards. Patient living seven months after operation. Died in ten days. Died a year after operation, from diarrhoea. Hemorrhage from sac fifty-one days after operation. Died six months afterwards, from recurrence. Doing well twenty months after operation. Innomi- nate artery also involved. Discharged as "cured" in three weeks. Innominate Artery.—The chief operative treatment applicable to innominate aneurism is the distal ligature, applied to the carotid, to the subclavian or axillary, or to both vessels, consecutively, or at the same time. The carotid alone appears to have been tied for innominate aneurism twenty-five times, with six more or less permanent recoveries, and nine- teen deaths. The subclavian or axillary alone has been tied five times, with at least temporary benefit in three instances The double ligature has been emjiloyed in fifty-one cases, the arteries having been tied consecu- tively in seven, and simultaneously in forty-four, only two of the former category* and fourteen of the latter proving permanently successful In four cases which have been already referred to (Hobarth's, Heath's, Maun- der's, and Sands's), the aneurism was eventually* found to have been aortic, while in Cuvillier's case (which was likewise supposed to be one of innomi- nate aneurism) the affected artery was found after death to have been the subclavian. Hodges, of Boston, employed the double simultaneous ligature in a case of supposed innominate 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 were dilated; and in a similar case referred to by Stimson as having been operated upon by Doughty and A. B. Mott, by consecutive ligation, when the patient died three years afterwards, the aorta alone was found to be dilated.1 On the other hand, Cheever, of 1 Wyeth, however, believes that there was an aneurism of the innominate in this case, and that it was cured by the operation. ANEURISM OF INNOMINATE ARTERY. 605 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 subclavian artery, the ac- companying vein was ruptured, death following in two hours. From the above figures it may be seen that, as far as statistics bear upon the question, the advantage, as regards permanent benefit, is, upon the whole, with simultaneous ligation of both vessels, which, moreover, is the operation which has commended itself to the majority of surgeons; 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 emjiloying antiseptic methods, the risk of hemorrhage would be so much lessened that the question of tying the first portion of the artery might jiroperly Fig. 326.—Result of simultaneous ligation of carotid and subclavian arteries for innominate aneurism. (From a patient in the University Hospital). be entertained. But as the operative treatment by any jilan is attended with great risk, a fair trial should always be first given to the effect of rest and medical treatment, aided, perhaps, 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 enforcement of rest and the application of ice. Fig. 326 shows the result in a case in which I tied both arteries for innomi- nate aneurism at the University Hospital. The symptoms of aneurism gradually disappeared after the operation, and the patient is known to have remained well for two years afterwards. 606 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Cases of Innominate Aneurism treated by Ligation of Carotid Artery. No. Operator. Result. 1 Evans, Recovered. 2 Mott, Relieved. 3 Id. Died. 4 5 Key, Morrison, Recovered. 6 7 Fergusson, Hutton, Died. a 8 9 Campbell, Wright, (t 10 Broad bent, " 11 Hewson, " 12 Neumeister, " 13 Scott, " 14 Dohlhoff, " 15 Porta, " 16 Villardebo,1 " 17 Ordile, (< 18 19 Pirogoff, Id. Relieved. << 20 Id. Died. 21 Nussbaum, " 22 Id. a 23 Heath, " 24 Desgranges, Relieved. 25 Ashhurst, Died. Remarks. Lived twenty-eight years subsequently. Died seven months subsequently, from asphyxia. Death from hemorrhage in three weeks. Died in a few hours. Lived twenty months subsequently. Died on seventh day, from pneumonia. Died on sixty-sixth day; suppuration of sac. Died on nineteenth day, from pneumonia. Died on sixtieth day ; hemiplegia. Died in fourth month, from hemorrhage. Died on eleventh day. Died on fifth day; hemiplegia. Died from rupture of sac. Died on sixth day ; paralysis. Died in forty hours from erysipelas. Died on twenty-first day, from hemorrhage. Hemiplegia. Died from rupture of sac. Died from rupture of sac. Mistaken for aortic aneurism, and left carotid tied. Death almost immediately, from anaemia of brain. Died twelve months subsequently, from indepen- dent causes. Death not hastened by operation. Cases of Innominate Aneurism treated by Ligation of Subclavian or Axillary Artery? No. Operator. Result. Remarks. 1 2 3 4 5 Wardrop, Laugier, Broca, Blackman, Bryant, Relieved. Died. Relieved. Died. Relieved. 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 Fearn, Recovered. Died from causes unconnected with operation. 2 Wickham, Died. Died in two and a half months ; rupture of sac. 3 Malgaigne, " Died on twenty-first day, from erysipelas. 4 Bickersteth, a Died in three months. 5 J. Adams and F. Treves, Relieved. Died in three months. 6 Beaney, Recovered. 7 Gay, Relieved. Died in eleven months. 1 This appears to be identical with the case attributed to Rompani. Erichsen mentions other unsuccessful cases, attributed to Knowles and O'Shaughnessy, which I have placed among those of aortic aneurism (page 603). 2 Dupuytren's case, usually placed in this category, was one of subclavian aneurism. CAROTID ANEURISM. 607 Cases of Innominate Aneurism treated by Simultaneous Ligation of Carotid and Subclavian or Axillary Arteries. No. Operator. Result. Remarks. 1 Rossi, Died. Died in six days. 2 Hutchison, a Died in forty-one days ; some doubt as to whether subclavian was really tied. 3 J. Lane, (( Rupture of sac. 4 McCarthy, " 5 Durham, " Died on sixth day, from shock. 6 Green, >< Died in three months ; rupture of sac. 7 Holmes, a Died in eight weeks ; galvano-puncture also used. 8 Ensor, " Died in nine weeks. 9 Weir, t< Died in fifteen days ; rupture into trachea. 10 Barwell, Recovered. Died subsequently from bronchitis; aorta also 11 Id. " [involved. 12 Id. Died. Died in thirty hours from effects of anaesthetic. 13 Id. Recovered. 14 Id. " [orrhage ; aorta also involved. 15 Kelburne King Relieved. Died in one hundred and eleven days, from hem- 16 Eliot, Died. Died on twenty-fifth day, from hemorrhage. 17 Stimson, Recovered. Died in twenty-one months, from phthisis. 18 Palmer, Relieved. Died after four months. 19 Denuce, No benefit. Wounds healed ; no change in tumor. 20 Ransohoff, Died. Died on seventh day. 21 King (of Hull) Relieved. Doing well two months after operation. 22 Marsh, Pollock, 23 Died. Died in eight days. 24 Browne, Recovered. 25 J. L. Little, a Died three years and four months after operation, 26 Bergman n, n [from pleurisy. 27 Rosenstern, " 28 Banks, Died. 29 Hartley, Relieved. Alive after 3£ years. 30 Jessop, Died. Secondary hemorrhage on forty-ninth day. 31 Id. No benefit. Patient lost sight of. 32 Id. Secondary hemorrhage. All signs of aneurism disappeared ; patient known 33 Ashhurst, Recovered. to be well two years after operation. 34 Praeger, Packard, Left hemiplegia followed ; died in less than a year. 35 Died. 36 Dunlop, Recovered. 37 Percival, Relieved. 38 Mynter, Recovered. 39 McBurney, " 40 Dunlop, Agnew, May, 41 42 Died. Carotid and axillary tied. 43 Morton, Recovered. Ibid. 44 Warren, No benefit. Ibid. 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 consider- able risk, the mortality being, according to Norris's statistics, over thirty- six per cent., and according to those of Pilz, over forty-three percent.1 Of 82 cases in which the common carotid was tied during our late war, no less than 63 (16.8 per cent.) terminated fatally, and 101 cases collected by 1 Both carotids have been tied in at least twenty-eight cases—once simultaneously (fatal in twenty-four hours), and twenty-seven times with a greater or less interval between the operations ; only five of the latter cases proved fatal. 608 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Mr. Maunder, of ligation for wound or traumatic aneurism, gave but 34 recoveries. I have myself tied the common carotid in five 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 interference with the circulation 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 ; eighty-three cases of the former operation referred to by J. D. Bryant, gave only three deaths. If, however, as is usually the case, the aneurism involves the common trunk itself, and jiressure proves unavailing, ligation of the primitive carotid must be resorted to. Ligation by the Hunterian method has, according to Pilz, been done in eighty-seven cases, with fifty-five known recoveries and thirty-one deaths, the result of one case not having been ascertained. For traumatic aneurism at the root of the carotid, the surgeon may choose between Brasdor's and the "old operation," which has been successfully employed by Syme and Frothing- ham. For non-traumatic aneurism the " old operation" would be unsuit- able, 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 Wardrop) is the plan of treatment most to be recommended. Of nine patients on whom this operation has Fio. 327.—Carotid aneurism. (From a patient In the University Hospital.) been performed, six recovered (Wardrop, Bush, Colson, Wood, Delens, De Mello Ferrari) and three died (Lambert, Demme, Lane)—a sufficiently favorable record to encourage a resort to the operation under suitable cir- cumstances.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 with 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 Xoyes, 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. 1 I have omitted Wardrop's second case, in which it is somewhat doubtful whether the artery was really tied. A case is also attributed to Barbosa. 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 unac- counted for. SUBCLAVIAN ANEURISM. 609 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 Bvrd's cases, in which the common carotid was tied with both its branches, have already been referred to (page 211). Vertebral Artery__Including Fenger's case, this vessel seems to have been tied on six occasions, and five times successfully; but it does not apjiear that the operation has ever been attempted for non-traumatic 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, and compression alone in cases reported by Weir and Simes. Mobres cured his patient by the apjilication of cold. Ligation of one or both vertebrals for epilepsy was recommended and practised a few years ago by W. Alexander, but his later reports of the operation are unfavorable. A case in the hands of W. D. Spanton termi- nated fatally from secondary hemorrhage on the twenty-second day. Bernays adopted this method in three crises, but in no instance with any permanent benefit to the patient. Three successful cases are, however, recorded by J. L. Gray. Subclavian Aneurism.—The statistics of this serious affection have been particularly investigated by Sabine, of New York, Koch, and Poland. The table on the next page shows the results of various modes of treat- ment in 122 cases collected by* the last named writer. From these 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 ojieration is justifiable in cases in which the aneu- rism is situated in the third portion of the vessel, so that a ligature can be applied outside of the scaleni muscles, or even between them—the case under such circumstances ajiproximating 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 prac- tised 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 27 cases, of which at least 23 have proved fatal. The only instance of recovery is that in which Dr. Smyth, of New Orleans, tied also the carotid and vertebral, the patient surviving ten years and then dying from hemorrhage from the sac, into which the blood had found its way through the sub-scapular artery. The first portion of the subclavian has, including McGill's case of tem- porary occlusion, been tied twenty times, and in every instance with a fatal result. Eighteen of these operations were upon the right side, and two (Rodgers's and McGill's) upon the left. We thus have 47 cases of ligation of either the innominate or the first part of the subclavian.or, considering cases of subclavian aneurism only*. 36 instances of the proximal operation, with only two ascertained survivals, and only one of these a recovery—surely not enough to justify a repeti- tion of the proceeding unless in very exceptional circumstances. If the operation is to be done at all, Dr. Smyth's example should be followed, and the vertebral and carotid secured, as well as the innominate. 39 610 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Table Showing Results of Various .IFodes of Treatment in Subclavian Aneurism. Mode of treatment. Cases. 49 Recovered, or in process of recovery. Died. Uncer-tain. 1. None, or medical treatment only 13 31 5 2. Moxa and hypodermic injection of ergot1 1 1 3. Direct compression2 ..... 3 3 4. Compression on cardiac side3 .... 1 1 5. Injection of coagulating fluids4 2 2 6. Acupressure of axillary and innominate 1 1 7. Manipulation ....... 4 "2 2 8. Galvano-puncture5 ...... 1 1 9. Operation for ligation of innominate or subcla- vian begun, but not completed . 7 1 6 10. Ligature of subclavian (3d portion), embracing cases of subclavio-axillary aneurism6 . 21 9 12 11. Ligature of subclavian (1st portion), subclavio- axillary in one case ..... 11 11 12. Ligature of innominate ..... 12 12 13. Ligature of innominate, carotid, and vertebral7 1 1 ... 14. Ligature of subclavian and carotid8 1 • •• 1 15. Ligature of subclavian, carotid, and vertebral 1 1 16. Ligature of axillary 1 fB d ^9 17. Ligature of carotid 1 v ' {. ... 4 1 18. Amputation at shoulder joint10 l 1 122 33 84 5 1 Dutoit has reported a case successfully treated by hypodermic injections of ergotine, supplemented by digital pressure on the cardiac side of the sac; Gay has also recorded a case in which compression was employed with marked advantage. 2 Direct compression has proved successful in a fourth case reported by Mr. Holmes. 3 Annandale tried instrumental compression applied immediately to the innominate artery, but his patient died from hemorrhage on the 12th day. A case cured by distal compression has been recorded by Warren Stone. 4 Levis tried the introduction of horsehair, and Hulke that of wire, both with fatal results. s A second success by galvano-puncture has been recorded by Saboja, a Brazilian surgeon. 6 Another (fatal) case occurred in the practice of the late Sir W. Fergusson. " A case of simultaneous ligation of the innominate and carotid has been recorded by Mr. Banks. 8 A successful case has been since recorded by Dr. Little, of New York. Dr. Gerster has successfully tied the carotid and axillary. 9 Successful cases have since been reported by Prof. Toland, of San Francisco, and Dr. Forbes Moir, of Aberdeen. 10 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. Rose, 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. 611 Cases of Ligation of the Innominate Artery. No. Reporter. Result. No. Reporter. Result. 1 Mott, Died. 15 Bickersteth, Died. 2 Graefe, u 16 O'Grady,1 11 3 Norman, a 17 Smyth,2 Recovered. 4 Arendt, it 18 Porter,3 Died. 5 Hall, a 19 Hutin,4 11 6 Bland, " 20 Lynch,5 a 7 Lizars, it 21 Buchanan,6 " 8 Dupuytren, a 22 Partridge7 tt 9 Cooper, u (of Calcutta), 10 Id. << 23 Thomson,8 a 11 Gore, (< 24 Banks,9 No benefit. 12 Pirogoff, " 25 May, Died. 13 Bujalski, ti 26 Durante,10 Undetermin- 14 Id. tt 27 Langton,11 " [ed. 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, tt 12 Liston,13 3 Hayden, a 13 Parker,14 4 O'Reilly, tt 14 Hobart,15 5 Partridge, a 15 Cuvillier,16 6 Liston, n 16 Kuhl,17 7 Rodgers, it 17 Ay res,18 8 Auvert, it 18 Bullen,'8 9 Id.12 tt 19 McGill,19 10 Arendt, it 20 Banks,20 The distal operation has been somewhat more successful, but is still unpromising. What course then is to be pursued for an aneurism which involves the first or second portion of the subclavian, and which resists bloodless treatment? Amputation at the shoulder-joint (which would act as a modified distal operation) would under such circumstances jirobably be the best procedure. It would, as pointed out by Fergusson, who sug- gested the plan, have the advantage over the ordinary distal method of diverting the force of the circulation by removing the part which had pre- 1 In this case the carotid also was tied. 2 Carotid and vertebral also tied. 3 Modified acupressure employed in this case. 4 Operation for secondary hemorrhage. 5 Operation for hemorrhage after gunshot wound. 6 After opening sac ; patient died in a few minutes. 7 Barwell's ox-aorta ligature used ; death from hemorrhage on 42d day. 8 Operation for hemorrhage ; patient died in an hour and a half. 9 Girdlestone's kangaroo-tendon ligature used; aneurism returned, and first part of subclavian tied ; died from hemorrhage. 10 Vertebral also tied. ll Carotid also tied. 12 Case of axillary aneurism. 13 Carotid also tied. 14 Carotid and vertebral also tied. 15 Distal operation for aortic aneurism ; carotid also tied. 16 Traumatic aneurism for bayonet wound ; carotid also tied. 17 Operation for malignant tumor of head. 18 For secondary hemorrhage following gunshot wound. 19 First part of left subclavian temporarily compressed with torsion forceps ; pleura wounded ; death on sixth day. 20 Same case as No. 24 in preceding table. 612 SURGICAL DISEASES OF THE VASCULAR SYSTEM. viously demanded an arterial supply. This method has been put in prac- tice by Prof. Spence, and by Messrs. Holden, II. Smith, Heath, and W. Hose, and in the first and last named surgeon's 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 operation) in addition to amputation, and this was done in Rose's case above mentioned. Axillary Aneurism.—This, which is a less frequent affection than subclavian aneurism, admits of several modes of treatment. Compression upon the third portion of the subclavian, either by the finger, or instru- mentally (the jiatient being anesthetized), should be tried, and may some- times prove successful, as in two cases referred to by Bennett May; ad- vantage 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 opera- tion, and amputation at the shoulder-joint. Ligation of the axillary below the clavicle has been done for aneurism (as a Hunterian operation) in 22 cases,1 with 8 deaths, giving a mortality of 36 per cent. The statistics of ligation of the third part of the subclavian, for axillary aneurism, are slightly more favorable, 81 cases, according to Koch and May, giving but 25 deaths—a mortality of only 30 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 ojieration,2 and it is, therefore, worth while to inquire, with Mr. Syme, whether the old opera- tion might not in some eases be preferable. Statistics are as yet wanting to decide this question, but the operation, which was twice successfully resorted to by* Syme himself, is at least worthy of further trial; it was twice performed in May's series of cases, with one recovery and one death. Amputation at the shoulder-joint for axillary aneurism was successfully performed by Syme, and likewise by Morton, of this city, for hemorrhage and gangrene after ligation of the second portion of the subclavian. Three cases embraced in May's series gave two recoveries and one death. Either this or the "old operation" would be necessarily indicated in any case of axillary aneurism 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 sac- rificing the upper extremity. Hemorrhage during either ojieration might be prevented by compressing the subclavian over the first rib, through a preliminary incision 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 com- pression or by flexion, and, if these fail, by the "old operation" or by am- putation, either of which would probably be safer than ligation of 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. Another case has been added by May. 2 The mortality for all causes is, according to Norris's statistics, 43^ per cent. (Am. Jour, of Med. Sciences, July, 1845), and according to Koch's no less than 51 per cent. Of 52 cases recorded during our late war, 41 terminated fatally, a mortality of over 78 per cent. ABDOMINAL AND INGUINAL ANEURISMS. 613 axillary, whether in the armpit or below the clavicle. For aneurism of the brachial at a lower point, or of either of its branches, if compression fail, the Hunterian operation should be employed. The traumatic and arterio-venous aneurisms met with at the bend of the elbow, as the result of venesection, are best treated by the "old operation" (see pp. 208, 209). Abdominal and Inguinal Aneurisms.—Dr. Murray, of New- castle-on-Tyne, cured an aneurism of the abdominal aorta by instrumental comjiression above the sac, in five hours (the patient being under the effect of chloroform); and Dr. Heath, of Sunderland, is said to have been equally successful by using pressure, without anaesthesia, continued for twenty minutes—irregular 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. Phillipson. This mode of treatment is, however, not entirely free from danger: a patient of Bryant's died eleven hours after the removal of the clamp (which in this instance was applied over the aorta on the distal side of an aneu- rism of the cceliac 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) terminated fatally from gangrene of the intestine, under the care of Mr. Simon ; a fifth, also from intestinal gangrene, in a case of distal compression recorded by Messrs. Lunn and Benham, and a sixth, from rupture of the sac, in a patient treated by dis- tal compression by Dr. Skerritt, 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. 32, 33), 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. Loreta reports a case of abdominal aneurism treated by the introduction of silver wire after exposing the sac by abdominal section. The sac of the aneurism became consolidated, but the patient died from rupture of the adjoining aorta on the 22d day. Morris's case, in which a similar operation was performed, terminated fatally on the fifth day, and Pringle's and Lange's cases were also unsuccessful. In Morse's case the patient recovered from the opera- tion, and was reported as doing well seven weeks subsequently. Aneurism of the common iliac artery may be treated by compression on the cardiac side of the sac, the patient being in a state of anaesthesia. Cases are recorded by Mapother, Heath, Eck, and others, in which satis- factory cures have been in this way obtained. If possible, the compress- ing pad should be applied over the iliac artery itself, but if the size of the tumor will not permit this, over the aorta. 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 since been repeated by James, 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 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. 614 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Murray, Monteiro, South, McGuire, of Bichmond,1 Va., Stokes, of Dublin (by Porter's method of modified acupressure), and Watson, of Edinburgh.- Czerny, of Vienna, has also tied the aorta for hemorrhage following a gun- shot wound, after previous ligation of the external and common iliacs, and Czernv, of Heidelberg, for hemorrhage during an operation for extirpation of the kidney. All of the ten cases proved fatal, though Monteiro's patient survived until the tenth day. In Cooper's, James's, and Watson's cases, the incision was made through the linea alba, and in the others on the left side, as in ligating the common iliac. The uniformly fatal result of this operation should forbid its employment, unless under very exceptional circumstances. 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. Cases of Ligation of the Common Iliac Artery. No. Reporter. Result. No. Reporter. Result. 1 Gibson, Died. 42 Brainard, Recovered. 2 Liston, it 43 Biinger, Died. 3 Garviso, ti 44 Busch, it 4 Pirogoff, it 45 Caldas, Recovered. 5 Deguise, Recovered. 46 Carr, Died. 6 Post, Died. 47 Chiappini, Recovered. 7 Uhde, " 48 Cock, " 8 Edwards, ii 49 Cutter, Died. 9 Holt, u 50 Czerny, 11 10 Parker, it 51 D'Almeida, " 11 Buck, it 52 Delisle, u 12 Mott, Recovered. 53 Fenger, " 13 Crampton, Died. 54 Gouley, " 14 Stevens, tt 55 Id. u 15 Salomon, Recovered. 56 Gurlt, it 16 Syme, Died. 57 Hamilton, u 17 Peace, Recovered. 58 Hammond, u 18 Hey, " 59 Hargrave, ii 19 Garviso, ii 60 Hunter, ii 20 Lyon, Died. 61 Ingram, ii 21 Jones, " 62 Isham, ii 22 Wedderburn, " 63 Kummel, Recovered. 23 Van Buren, it 64 Ladureau, Died. 24 Stephen Smith, ii 65 Lange, Recovered. 25 Stone, tt 66 Langenbeck, 11 26 Goldsmith, ti 67 Luzenberg, ii 27 Guthrie, Recovered. 68 McKee, Died. 28 Stanley, Died. 69 Mc.Kinlay, Recovered. 29 Moore, " 70 Maunder, Died. 30 Meier, it 71 A. B. Mott, Recovered. 31 Bushe, tt 72 Id. Died. 32 Chassaignac, it 73 Mouret, Recovered. 33 Baudelocque, ii 74 Nicoladini, Died. 34 Blandin, tt 75 Packard, Recovered. 35 Mayo, tt 76 Pitta, Died. 36 Baker, " 77 Richter, Recovered. 37 Id. ti 78 Sands, ti 38 Barbosa, tt 79 Sch on born, ii 39 Barral, it 80 Watson, Died. 40 Baxter, ti 81 T. Smith, n 41 Bickersteth, Recovered. 82 Fluhrer, u 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. 2 For secondary hemorrhage, after previous ligation of the common iliac. ANEURISMS OF INTERNAL ILIAC AND BRANCHES. 615 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. Stejihen Smith, of Xew York, I have been able to add 50 others; of the whole 82, but 23 terminated successfully, showing a mortality* for the operation, as employed for all causes, of over 71 per cent. (See Table, page 614.) It is probable that the old ojieration would, in some cases of aneurism of the common iliac, be preferable to ligation of that vessel, as it certainly would be to. ligation of the aorta. This procedure has, however, not yet been employed ; it was attempted by Coojier in the case in which that surgeon tied the aorta, and was 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 prevented by the use of Lister's aorta compressor, and the patient recovered from the operation, but died about three months afterwards from pleurisy—when autopsy* showed the aneurism to have been of the external iliac, the ligatures having been really applied below the bifurcation of the common trunk. Aneurisms of Internal 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 isehiatic arteries are more common, and may be treated in a variety* of ways. Fischer, of Hanover, has particularly- investigated the statistics of these affections, and from an analysis of 35 cases (14 of trau- matic and 21 of spontaneous aneurism) concludes that the injection of the perchloride of iron is the best mode of treatment. If this method fail, or if it be not thought proper to employ it, it would further appear that for traumatic aneurisms the "old operation," as practised by Bell, Syme, Bickersteth, Hussey, and Darby, and for those of a non-traumatic nature ligation of the internal iliac, are the measures to be preferred. The follow- ing table is compiled from Fischer's paper:— Mode of Treatment. None, or medical only Compression .... Galvano-puncture . Old operation1 Ligature of gluteal2 " " internal iliac " " common iliac Injection of perchloride of iron Summary Mr. Holmes, who rejects one of Fischer's cases as an example of aneu- rism by anastomosis, recommends, after a careful examination of recorded cases, compression, either rapid or gradual, applied to the aorta or common iliac, and aided if need be by galvano-puncture or the use of coagulating 1 Another (unsuccessful) case of the old operation has been since recorded by Mr* G. R. Turner. 2 Other cases of ligation of the gluteal artery have been recorded by T. A. McGraw, Thorndike, Trepper, and Lindner. T RAUMATIC. Spontaneous. A GGREi.ATB a ■a S "3 o E* 6 ■6 ijss. M. Great advantage may often be derived from the use of an oakum seton drawn through the carious bone, as recommended by* Sayre, of New York. When the carious bone can be reached from the surface, it may be fiu. 334—Gouge- fig. 335.—Burr- scraped or cut away with a gouge or forceps. head di-ui. gouge-forceps, or with a burr-head drill or osteotrite. The process should be continued until all the diseased bone has been removed, which may usually be known by the hardness and density of the surrounding healthy part; if the latter be softened by inflammation, the surgeon may know that he has gone far enough when the detritus retains its red color in spite of washing—carious bone when washed becoming white, gray, or black. When the disease is very extensive, as where it involves the whole or greater part of one of the tarsal bones, or the articulating extremity of a long bone, very free gouging (which Sedillot has recommended under the name of evidement) may be employed, though in many cases excision will be preferable. Finally, amputation may be necessary to prevent fatal exhaustion. Before, how- ever, resorting to so grave an operation—and this remark applies in a less degree to any cutting operation for caries—the surgeon must consider that the affection with which he has to deal is essentially of a chronic nature, and may persist for many years, ending perhaps, eventually, in sponta- neous recovery; hence, in many cases, particularly with patients who, from their social condition, can afford to be invalids, it will be more prudent, as long as life is not endangered, to avoid modes of treatment which are in themselves necessarily attended with considerable risk. Necrosis.—Necrosis is the name given to mortification of bone; like gangrene of the soft parts, it may be acute or chronic, dry or moist, inflam- matory, senile, etc. Causes.—The most frequent immediate cause of necrosis is osteitis, occurring as a complication of periostitis, of osteo-myelitis, or of both. Necrosis may, however, result (just as gangrene of the soft tissues) from external violence depriving the part of vitality, without the intervention of inflammation. Under these circumstances, or in any case in which the bone is suddenly killed, if the cancellated structure be involved (the blood and other fluids remaining in the part), the necrosis is of the moist variety; this form of necrosis corresponds to the mephitic gangrene of bone of Dr. Lidell. In the large majority of cases, however, necrosis is slowly devel- oped by the affected bone being deprived of its normal supply of blood; the compact structure is then chiefly involved, and the phenomena of dry or ordinary necrosis are presented. Thus in osteitis, the capillaries of the Haversian canals become strangulated, as it were, against the surrounding bony walls, and death of the part results as a consequence of arrested cir- 628 DISEASES OF BONE. vf?% culation. Among the more remote causes of necrosis may be particularly mentioned scrofula and syphilis, exposure to heat or cold, the ajijilication of caustics, exposure to the fumes of phosphorus, etc. The bones most often affected are the tibia, femur, humerus, jihalanges, skull, lower jaw, clavicle, and ulna; unlike caries, necrosis attacks the shafts, in j>reference to the articulating extremities, of the long bones. Necrosis is not very- common in young children (though it may occur among the sequelae of the eruptive fevers), being most frequent in early adult life; it is sometimes seen, like ordinary* senile gangrene, as a consequence simply of the dimin- ished vitality of old age. Bone deprived of its periosteum usually, though not necessarily, becomes necrosed; if both periosteum and medulla jterish, necrosis is almost certain to follow. Dry Necrosis.—Bone affected with dry or ordinary* necrosis is hard, and of an opaque, yellowish-white hue, though it may become blackened from exposure; it is insensible, sonorous when struck with a probe, and does not bleed. It may be, according to the part affected, peripheral, central, or total (see p. 623). The dead bone is at first connected with the surrounding parts, but becomes gradually* loosened, and is finally separated and thrown off as an exfoliation. While the process of loosening is going on, the periosteum, if not destroyed, furnishes new bone, which often forms a sheath around the dead portion, which is then said to be invagi- nated, and when separated constitutes a sequestrum. The separation is effected, not, as was formerly supposed, at the expense of the dead part, by absorption, but at the expense of the surrounding living bone, which under- goes meduUization, and is converted into a layer of granulations. The free surface of an exfoliation, or of a sequestrum, is pretty smooth, but the edges and deejier surfaces present a ragged or worm-eaten appearance, with depressions corresponding to the granulations by which they have been surrounded. The sheath of bone which envelops a sequestrum is called the iuvolucrum; this ' usually presents numerous round or oval openings which are called cloacae, and through which the extrusion of the sequestrum is eventually accomplished. It occasionally happens, in cases of total necrosis, that, while the original bone is perishing, and the periosteum furnishing a new osseous sheath, the medulla likewise, by a process of retrograde metamorphosis, becomes partially ossified,1 and the sequestrum is thus surrounded on both sides by living bone. < ■ Moist Necrosis.—This, which is a comparatively rare form of necrosis, is well described by Lidell under the name of Mephitie, Gangrene of Bone. This form of the disease manifests its peculiarities chiefly in the cancellated structure of bone, which, when thus attacked, is . moist, more or less softened, and of a dirty gray or greenish-brown hue, with an extremely offensive odor. This form of necrosis may occasionally be seen in compound fractures, in what Dupuytren called primary splinters (see pp. 174, 245), if these be not promptly removed; it may also result from violent contusion of bone, being thus more frequent, probably, in Fid. 336.— Central necrosis; new bone with cloacse. (Erich- sen ) 1 This fact was long since observed by Copland Hutchison, and has more recently been noticed by Packard, Markoe, Demarquay, and other writers : but the true ex- planation appears to have been first given by Oilier, of Lyons (see pp. 236 et sen.). NECROSIS. 629 military than in civil practice. Moist necrosis is always total—involving, that is, the whole thickness of the affected bone; there is little or no effort at repair on the part of nature in these cases, the periosteum either itself sloughing, or at best furnishing but a few imperfect nodules of bone. Symptoms of Necrosis.—The symptoms of necrosis may* be described as belonging to two periods, that in which the bone is dying, and that in which its separation as an exfoliation or sequestrum is effected; in moist necrosis, as the bone is at once deprived of vitality, the first stage is absent. The symptoms of the first stage of necrosis are those of osteitis, it being impossible to decide, before the occurrence of suppuration, whether necrosis is or is not about to occur. The death of any portion of the osseous skeleton is usually, though not invariably, attended by extensive suppuration of the soft parts,1 the abscesses thus formed gradually* contracting to sinuses through which, if a probe be jiassed, the necrosed bone can be readily re- cognized by the hard and rough sensation which it communicates. In cases of central necrosis, the diagnosis can only be certainly made if cloacae exist, through which the dead bone can be felt: if there be no cloacae, the affection may be indistinguishable from chronic osteitis, or (as already mentioned) from circumscribed abscess of bone. The first stage of necrosis is attended with a good deal of constitutional disturbance, which measur- ably subsides upon the occurrence of suppuration, though occasional ex- acerbations may be observed during the whole process of exfoliation. During the second stage, the dead bone acts as a foreign body*, keeping up the discharge, and furnishing the necessary irritation to effect its own separation, and to excite the osteogenetic function of the periosteum, by which the jirocess of repair is chiefly accomplished. The time required for the separation "of a necrosed portion of bone varies from a few weeks to many years; it is usually less for the upper than for the lower extremity, and, other things being equal, is proportionally shorter, as the necrosis is more circumscribed and sujierficial. Prognosis.—The prognosis of necrosis, in the large majority of cases, is favorable. It is very seldom that the disease, attacking the shaft of a bone, extends beyond the epiphyseal lines, and, after the removal of the dead part, the repair will usually be found so complete as to preserve the utility of the limb. In some very acute cases, as in necrosis resulting from sub- periosteal abscess, life may be endangered during the first stage of the affection, and at a later period death may* occasionally occur from exhaust- ion or from pyaemia. The latter disease not unfrequently causes a fatal result in cases of moist necrosis. Special risks attend necrosis in certain situations: thus in. the skull, there is danger of secondary* meningitis or cerebral abscess; in the ribs, of empyema ; and in the patella, of destruc- tive inflammation of the knee-joint—while an exfoliation from the posterior surface of the femur may penetrate the popliteal artery* and lead to fatal hemorrhage. Treatment.—The treatment of the first stage of necrosis consists in en- deavoring to moderate the inflammation upon which the affection depends, and in freely* opening any abscesses which may form. During the time occupied by the loosening of the dead bone, no ojierative treatment is, as a rule, admissible, and the surgeon should content himself with such measures as may serve to maintain the patient's health. As soon as the necrosed portion has become detached (not before, unless in very exceptional cases), it should be removed, nature being rarely able to effect its extrusion— 1 Necrosis without suppuration has been observed by Stanley, Paget, and Morrant Baker. 630 DISEASES OF BONE. though occasionally (especially in children) a piece of dead bone will be found protruding from the soft parts, when it may be readily pulled away. In case of an exfoliation (if there is no invaginating sheath), it will be sufficient, when the bone is found by the probe to be loose, to divide the soft parts, and tilt up the detached fragment or scale from the subjacent granulations, by means of a director or elevator introduced beneath its edge—when the loose bone may be readily drawn away with forcejis. If the necrosed bone be in the form of a sequestrum, the operation is more complicated: an incision should, in this case, be made down to the bone, in the line of the principal cloacae, joining two or more of them, if there be several, in such a manner as to avoid the chief vessels and nerves. In some cases, if a cloaca be large, it may be possible to withdraw the sequestrum through it/dividing the dead bone, if necessary, into two portions by means of cutting-pliers previously introduced. The cloacae may be enlarged with trephines, gouges, or chisels, or the portions of new bone between them may be divided with Hey's saw, gouge-forceps, or strong cutting pliers, Fig. 337.—Sequestrum forceps. Fig. 338.—Necrosis of femur, following |?unshot fracture. (From a specimen in the museum of the Episcopal Hospital.) the sequestrum being then drawn out with suitable forceps, whole or piece- meal, as the exigencies of the case may require. It is usually possible to determine beforehand that a sequestrum is loose by introducing a probe through a cloaca, or by introducing two probes through different ojienings, when a see-saw motion may often be detected. It sometimes happens, NON-INFLAMMATORY STRUCTURAL DISEASES OF BONE. 631 however, that at the operation the sequestrum is found to be only partially detached, bringing with it, when wrenched away, a portion of living and vascular bony tissue. The cavity* left by the removal of a sequestrum is commonly lined by a layer of granulations—though in scrofulous cases a sequestrum may* be surrounded with carious bone, which must then be re- moved with the gouge. It is important that the cavity should be thor- oughly exposed, and any overhanging edges of bone cut away, so that the soft tissues may be drawn in from the neighborhood of the wound, and that this may heal firmly from below. Neuber, Lange, and Gerster assist the closure of the cavity by depressing the soft parts and fixing them to its base w*ith strong, straight needles. The after-treatment consists in apply- ing a light dressing, and in placing the limb, if the involucrum be thin, on a suitable splint, so as to prevent deformity from bending. In acute necrosis resulting from subperiosteal abscess, when the whole diaphysis of a long bone has perished, Holmes and GHraldes recommend that the part should be removed as soon as the patient has rallied from the first shock of the affection. The operation, which has been suc- cessfully resorted to by Holmes, Letenneur, McDougall, Spence, Heath, Duplay, Weinlechner, Bockenheimer, Pve, Shrady and myself, requires a very free incision, dividing the periosteum w*hich will be found entirely separated, the bone being then bisected with a chain-saw, and wrenched from its epiphyseal lines by means of the lion-jawed forceps (Fig. 364). The bone most commonly affected is the tibia, but Bockenheimer's opera- tion was on the femur, and Shrady's on the humerus. Even if the limb be left jierfectly flail-like at the time, it probably will become consolidated, and ultimately useful. My own experience in this procedure is limited to two cases, in one of which I removed the whole humerus (at two opera- tions), and in the other the upper half of the tibia. In the latter case, the bone was completely reproduced, and in the former, though the arm was much shortened, a very useful limb resulted. Poncet hastened the cure, in a case of necrosis in which the periosteum was partially destroyed, by in- serting grafts from the bones of a dead infant and from those of a kid. The rule which has been given, not to operate in cases of necrosis until nature has effected the separation of the dead fragment, applies particularly to cases of ordinary dry necrosis. In the moist variety of the disease, should it be recognized during life, it would be, I think, right to attempt the removal of the dead bone at an earlier period. The risk of pyaemia would probably be thus lessened, while the condition of the patient could not be seriously* aggravated. Necrosis, affecting one of the spongy bones, as of the tarsus, or the articular extremity of a long bone, may require excision or possibly ampu- tation. The latter operation may also become necessary if the disease be so situated that the sequestrum cannot be safely removed, as in the femur represented in the accompanying illustration (Fig. 338), from a case in which my former colleague, Prof. Forbes, amputated at the hip-joint; or amputation may likewise be required in any case, if life be endangered from exhaustion and long-continued suppuration. NON-INFLAMMATORY STRUCTURAL DISEASES OF BONE. Under this head may be enumerated Hypertrophy and Atrophy, Rickets, Osteomalacia, Tubercle, Scrofula, Syphilis, and various forms of Tumor. Hypertrophy, when not the result of inflammation, appears as a form of exostosis, constituting the variety known as Osteoma (see page 632 DISEASES OF BONE. Fio. 339—Senile atrophy of neck of femur. (Liston.) 522): when resulting from inflammation, it receives the name of Perios- tosis. In neither case does the affection admit of treatment. Atrophy of bone often occurs simply- as a senile change, but may also result from injuries, as contusions or fractures, or from mere disuse. It is not unfrequently met with as the result of a fall, in the neck of the thigh-bone in old jiorsons, where it gives rise to shortening, and may be mistaken for fracture of the part (Fig. 339). The only admissi- ble treatment consists in the application of a high- soled shoe. Rickets is described by many writers as a dis- ease of the bones, but is in this work considered to be a general affection, and as such has already re- ceived attention (see page 462). Osteomalacia, Mollities Ossium or Fra- gilitas Ossium__Two affections, according to Paget, appear to be included under these names; one, which is more common, consists in fatty degeneration, and the other, to which the name osteomalacia should be strictly confined, consists in an absorption of the earthy* constituents of bone, the part affected being more or less reduced to a carti- laginous state. The latter form of the disease at- tacks particularly the bones of the trunk, especially the pelvis (where in the female it may impede parturition), while the for- mer is more common in the bones of the extremities. Several bones are usually affected. The softening process begins at the centre -and spreads outw*ards; the cancellous structure is dilated, its cells being filled with a red jelly-like mat- ter, consisting of fat, oil, blood, and nucleated corpuscles. If the compact structure be not involved, the bone is rendered brittle and liable to fracture, as in remarkable cases reported by Tyrrell, Arnott, R. W. Smith, Joseph Jones, and Blanchard, of Chicago. If the whole thickness of the bone, on the other hand, be involved, it becomes pliable and easily bent, the most curious distortions resulting, as in the oft-quoted case of Madame Supiot. The disease seldom occurs in childhood, but usually in early adult or mid- dle life ; it is more common in women than in men, and often ajijtears to have been induced by pregnancy or parturition.. It is sometimes heredi- tary, and, according to Heitzmann, may like rickets be artifically produced by long administration of lactic acid. It is not uncommon among the insane. Symjitoms.—The early symptoms are generally obscure, consisting chiefly in vague pains, which are probably considered rheumatic. Some- times the giving way of the limbs, the bones being either fractured or bent, is the first circumstance which attracts attention. The urine, and some- times the other secretions, contain an abnormal quantity of phosphates; and in a case recorded by Dr. Maclntvre, the urine contained also a large amount of animal matter of an albuminous nature. As the disease pro- gresses, the patient becomes bed-ridden, and may remain in this state for many years, eventually dying from simple exhaustion, or from some inde- pendent affection ; in other cases, the viscera may become fatally deranged by the pressure of the distorted bony parietes. Diagnosis.—In its early stages, osteomalacia is liable to be confounded with Rheumatism, and the diagnosis may not be possible until the appear- ance of phosphates in the urine, and the morbid condition of the bones, SCROFULA IN BONE. 633 reveal the nature of the affection. From Rickets it may be distinguished by observing that osteomalacia1 is a disease of adult life, and rachitis of infancy. The tendency to fracture, which gives to the disease the name of fragilitas ossium, may likewise arise from simple Atrophy, or from malig- nant disease. The former affection may be distinguished by investigating the history of the case, and the latter by observing the presence of sarco- matous or carcinomatous disease in other parts of the body. Treatment.—The treatment of this affection is as unsatisfactory as its pathology is obscure. The surgeon can usually do little beyond endeavor- ing to maintain the general health of the patient, to prevent the formation of bed-sores, and to relieve pain by the use of opium. The internal admin- istration of alum, however, appeared to produce temporary benefit in a case reported by Maclntyre. and Busch records two cases in which marked improvement followed the use of phosphorus. Tubercle of bone, at one time thought very common, has in recent years, until lately, been considered a rare affection, many cases of what the older surgeons would have called tuberculous deposit being looked upon as instances of chronic inflammation, attended by the formation of pus which had become inspissated, and had undergone cheesy degeneration (see jiage 459). The tendency of modern opinion is now, how- ever, in the ojiposite direction, and pathologists are now agreed that true tubercle does occur in bone, where it may be either circumscribed (encysted), or dif- fused (infiltrated). The cir- cumscribed variety is the rarer, and occurs chiefly in the skull and the articular extremities of the long bones, especially the tibia ; it jiroduces no disturbance until softening occurs, when it leads to an intractable form of caries, and, if in the neighborhood of a joint, often involves the latter in a destructive form of inflammation. The diffused tubercle affects particularly the shafts of the bones, and is, accord- ing to Holmes, less apt to run into softening than the circumscribed variety. Scrofula manifests its influence on the osseous system by predisposing to destructive inflammation and caries. Scrofulous differs from Simple Osteitis in its greater tendency to spread and to induce disorganizing changes, and in the absence or feebleness of the natural efforts at repair. The affected bone is soft, light, and oily, the proportion of fat and of solu- ble salts being increased, and that of calcareous matter and of the organic matrix markedly diminished. The symptoms of scrofulous osteitis are those of scrofula in general, superadded to a chronic and indolent form of bone inflammation. The treatment consists in the administration of reme- dies adapted to the scrofulous diathesis, with such local measures as may, if possible, prevent the occurrence of suppuration. After the subsidence of the acute symptoms, advantage may often be derived from pressure, Fig. 3-10.—Scrofulous osteitis ; magnified 2o0 diameters. (Erichsen.) 1 Osteomalacia is sometimes called Rachitis Adultorum. 634 DISEASES OF BONE. applied by strapping the part with compound galbanum plaster or soap plaster. Should sujipuration occur, the resulting caries must be treated as directed in the preceding pages, it being remembered, however, that the prognosis of operations, both in scrofulous and tuberculous eases, is less favorable than when there is no constitutional taint (see pages 460 and 462). Syphilitic Affections of Bone have already been referred to at page 496. Changes of Bone due to Affections of the Nervous System— Blanchard has noted bone-changes in cases of locomotor ataxia; these con- sist essentially in a rarefaction, preceded by decalcification, of the osseous substance around the Haversian canals, and lead to the occurrence of spontaneous fractures. The change is identical with that observed in the epiphyses in cases of tabetic arthropathy. Tumors in Bone.1—1. Cystic Growths in bone may occur as inde- pendent formations, or may be secondarily developed in solid tumors. Serous and Mucous Cysts are met with in the jaws, and possibly in other bones. They form smooth, indolent tumors, and, when large, give a sensation of semi-fluctuation, with a peculiar crackling sound, from the thinning of their bony investment; the superficial veins are often enlarged and tortuous. The treatment consists in removing a portion of the wall with a trephine or otherwise, the cavity being then stuffed with lint, so as to induce contraction and healing by granulation. Hydatids occurring in bone would closely simulate the simple cystic formations above referred to ; the treatment should consist in excision or amputation, according to the part affected. Sanguineous Cysts.—Travers excised the greater part of a clavicle on account of a cystic tumor containing blood. In most instances, sanguine- ous cysts apjiear in connection with solid growths, of a fibro-cellular, fibro- cartilaginous, myeloid, or malignant character. The treatment consists in excision or amputation, according to the situation and extent of the growth. Dr. Pierson, of Orange, N. J., has reported a remarkable case of sanguine- ous cyst of the sacrum. 2. Non-Malignant Solid Tumors.—The non-malignant solid growths met with in bone belong ordinarily to the fibrous, cartilaginous, and osseous varieties of tumor. The symptoms and treatment of these various affections have been sufficiently considered in Chap. XXVI. A caution may, however, be here given as to the removal of a bony tumor from the neighborhood of a joint: in this situation, exostoses frequently induce repeated attacks of synovitis, which may leave the synovial sac so thickened and dilated, that it is exposed to injury in any attempt to remove the growth. Hence, it is better, as a rule, not to interfere with these tumors, unless in a locality in which no special risk can attend the opera- tion. If an exostosis interfere with the usefulness of a part, an attempt may* be made to break it off with strong pliers (the skin being protected with chamois leather), without making any external wound ; such a plan was twice successfully adopted by the late Mr. Maunder. Should this fail, subcutaneous section with a saw or chisel would be the next best resort. In dealing with any non-malignant tumor of bone, enucleation may (as pointed out by Paget) be occasionally preferable to excision or ampu- tation. 1 Percussion is recommended by Lucke as a means of recognizing the presence of a tumor in bone, the morbid growth causing a lower resonance than in the normal condition. MALIGNANT TUMORS OF BONE. 635 3. Malignant Tumors.—Any form of malignant tumor may occur in bone, by far the most frequent, however, being one or other variety of Fro. 342.—Enchondroma of fe- mur. (From a patient in the Uni- versity Hospital.) Fig. 341.—Osteo-sarcoma of bones of forearm. (From a patient in the University Hospital.) sarcoma, an affection which in this situation runs a course fully justifying the name of malig- nant. Sarcoma may originate in the interior of a bone, when it is said to be central or in- terstitial, or may be primarily developed in and beneath the periosteum, when it is called periosteal or peripheral. In other instances it is said to be infiltrated, when the whole bone is softened and filled with sarcomatous material—a condition which, as already re- marked, has been confounded with osteomala- cia The central or interstitial sarcoma occurs chiefly in the cancellated structure of the flat bones and of the articular extremities of the long bones, producing long-continued pain, and (if in a long bone) often predisposing to frac- ture. As the tumor increases in size, the bone wall undergoes expansion, becoming thinned, and crackling on pressure (whence the old name "spina ventosa"), until finally the morbid growth makes its escape, when it grows with renewed rapidity. The peripheral or periosteal sarcoma occurs principally in or beneath the periosteal covering of the shafts of the long bones, the bony tissue itself remaining comparatively free from disease, though it occasion- ally becomes softened, when fracture may occur. In this form of tumor, partial ossification not unfrequently takes place. The myeloid tumor, or giant-celled sarcoma, is much less malignant than the other varieties. Symptoms.—The symptoms of malignant disease in bone are the presence of a rapidly growing lobulated tumor, elastic and semi-fluctuating to the touch, with sharp lancinating pains, and great distention of the subcuta- neous veins. A thrilling pulsation, sometimes accompanied with a blowing sound, is occasionally perceptible. As the disease advances, the neighbor- ing soft tissues and lymphatic glands become involved, while the " cancer- ous cachexia" is often rapidly developed. Diagnosis.—Malignant disease occurring in bone is to be distinguished from Abscess by the history of the case, the lobulated character of the tumor, the absence of inflammatory symptoms, and, if necessary, by the employment of the exjiloring-needle. From partially consolidated Aneu- rism, and from Aneurism by Anastomosis, it may usually be distinguished by attention to the early history of the case, when this can be ascertained. 636' DISEASES OF BONE. From Non-malignant Tumors, especially the fibrous or enchondromatous, the diagnosis is often difficult, and may be occasionally impossible, except by the aid of a microscopic examination. According to Thiersch, Wal- deyer, ahd Billroth, true carcinoma never occurs in bone as a primary affection ; either a preceding growth in some of the epithelial tissues has been overlooked, or the tumor on microscopic examination will be found to be a sarcoma. Maguire, of Manchester, has, however, collected 22 cases (including one of his own) in which the diagnosis of jirimary carcinoma of the femur seems to have been well established. Treatment.—This consists in excision or amputation : excision is to be emjiloyed in the case of the flat bones (as the scapula), or those of the face (as the upper jaw), but is rarely justifiable if the disease have jiassed the limits of the bone itself, involving the soft structures or lymphatic glands. Amputation is commonly* to be preferred in the case of the long bones, and should be performed at as early* a period as jxissible. It is usually advised to remove the limb at or above the nearest joint, but it would appear from cases recorded by Oollis, Pemberton, and others, that amputation in the continuity, or through the epiphyseal line, is sufficient; probably a safe rule would be, in the case of the forearm or leg, to remove the limb just above the elbow or knee, in that of the humerus at the shoulder-joint, and in that of the femur (unfortunately the most common of all), at as low a point as would insure the removal of the whole disease. 4. Pulsating Tumors of Bone—Most of the pulsating tumors met with in bone are in reality of a sarcomatous character; some, however, are probably of the nature of aneurism by anastomosis, and still others, pos- sibly, true aneurisms of the osseous arteries. The latter alone should receive the name of Osteoid Aneurism. The disease originates in the can- cellated structure (usually the head of the tibia1), and gradually distends the compact wall, which becomes thin and yielding, crackles on pressure, and finally gives way. When fully developed, the affection is attended with a marked pulsation, usually accompanied with thrill: by compressing the main trunk, the jmlsation stops, and the tumor may thsn be emptied by pressure, a cavity surrounded by a bony wall being perceptible. The pulsation may disappear when the resistance of the periosteum is overcome. The bruit,2 which is commonly distinct in pulsating sarcoma of bone, is often absent in osteoid aneurism. In the treatment of this affection the surgeon may (if the tumor be small and situated in one of the long bones) attempt extirpation of the growth with the knife, or, which is probably better, with caustics or the hot iron; if excision be practised, the surface of the bone from which the disease sjirings should be likewise removed. Ligation, of the main artery has been occa- sionally employed, but usually with only temporary if any benefit. If the disease be far advanced, or, if other measures have failed", amputation, as in malignant disease, is the only resource. Pulsating Tumors of the Cranial or Trunk Bones are almost invaria- bly of a malignant character, and rarely admit of successful treatment. 1 Dr. Peugnet, of New York, has recorded a remarkable case of osteoid aneurism of the lower jaw. 2 Strictly speaking, the sound in pulsating sarcoma of bone is rather a rustling or susurrus than a well-marked bruit, such as is found in ordinary aneurism. SYNOVITIS. 637 CHAPTER XXXI. DISEASES OF JOINTS. The older surgeons confounded together all diseases of the joints under the common names of arthritis and while, swelling, and it is within a com- paratively recent jieriod only, and in a great measure through the labors of Sir Benjamin C. Brodie, that a more accurate classification has become possible. The tendency at the present day, as justly remarked by Holmes, is to run to excess in the other direction; and the student is apt to be con- fused by the minute divisions of systematic writers, and to be disappointed, on entering practice, to find that he is unable to discriminate between affections which are actually indistinguishable, and which in the large majority* of instances really coexist in the same cases. The various constituents of a joint, synovial membrane, cartilages, bony articulations, etc., are so intimately- connected with each other, that a mor- bid condition of one is almost sure to involve the others secondarily. An exception should, perhaps, be made in the case of the synovial membrane, and I shall, therefore, in the following pages, first describe the affections which are limited to that tissue; considering, subsequently, those which involve the joint as a whole. Synovitis. Inflammation of the synovial membrane may arise from traumatic causes, or from exposure to cold; it may be uncomplicated, may be modified by the patient's being of a scrofulous, rheumatic, or gouty* diathesis, or may be a mere secondary occurrence in the course of puerperal fever, pyaemia, gonorrhoea, or syjihilis. Simple or uncomplicated synovitis may be acute or chronic, the difference being comparative, and referring to the intensity of the affection, rather than to any specific diversity. Pathology__The first effect of inflammation on a sy-novial membrane is to produce increased vascularity, with a diminution of the natural shin- ing appearance of the part. The amount of synovia is abnormally in- creased, being at first thin and serous, but subsequently cloudy, from the admixture of shreds of epithelium, inflammatory lymph, the coloring mat- ter of the blood, and (if the disease be not checked) pus. In many cases, the disease terminates in resolution, the parts gradually resuming their natural state, or perhaps remaining somewhat thickened, when there is a liability to relapse; occasionally the joint is left distended by serous effusion constituting the condition known as Hydrarthrosis, or Hydrops Articuli. In other instances, further morbid changes are observed: the synovial membrane assumes in parts an appearance of granulation, and while the intra-articular effusion becomes purulent in character, the cartilages become involved and perforated by ulceration, until finally the articulating ex- tremities of the bones themselves may become inflamed and carious. At the same time, the surrounding tissues, which at first were inflamed and infiltrated with lymph, undergo disorganization; abscesses form and make their way into the joint, or toward the surface, upon which they open by 638 DISEASES OF JOINTS. sinuous tracks; the ligamentous structures become elongated, thickened, and softened, and partial or complete dislocation may occur. Symptoms.—The symptoms are usually well marked. There \s pain, often accompanied by a feeling of distention, and usually referred to the affected joint, but occasionally* to others: thus j>ain in the knee attends inflammation of the hip. The pain is increased by motion or pressure, is often worse at night, and in some cases (as in the synovitis of pyaemia) is attended by marked cutaneous hypersesthesia. Swelling, varying with the amount of intra-articular effusion, is a characteristic symptom—the shape of the joint being altered by the distention of the synovial capsule. In the shoulder and hip, this alteration consists in a general enlargement of the part, while in the elbow the swelling is most marked on either side of the olecranon and beneath the tendon of the triceps, and in the knee on either side of the patella (which floats on the effusion) and beneath the tendon of the quadriceps femoris. Fluctuation, which is distinct in the early stages, when the effusion is of a serous character, becomes less so as the disease advances, from the production of inflammatory lymph, and the infiltration of surrounding structures. Heat and redness vary according to the superficial or deep character of the joint, and the degree to which the sujierincumbent tissues are involved. The position in which the patient involuntarily places the joint is characteristic: in the early stages, this position is such as to allow the greatest mechanical distention of the synovial capsule, while at a later period it is determined by the weight of the limb, by the necessity of maintaining the joint in a fixed position and of preserving it from the pressure of external objects, and lastly by the neighboring muscles becoming fixed in the positions which they have been permitted to assume. When synovitis ends in resolution, or subsides into a chronic state, the symptoms which have been described gradually pass away, the inflamma- tory fever (which runs high in the acute stage") diminishing, and the part gradually* returning, more or less completely, to its normal condition. The swelling may, however, as already mentioned, persist in chronic synovitis, constituting hydrarthrosis; while in some cases a peculiar crepitation or crackling may be developed by moving the part, due apparently to the rubbing together of bands and adhesions which have resulted from the organization of inflammatory lymph. The occurrence of suppuration in a joint (pyarthrosis) is marked by an increase of all the symptoms, and by the occurrence of rigors—while the accompanying inflammatory fever assumes a somewhat typhoid type. Abscesses form in the surrounding soft parts, the articular capsule gives way, and the contents of the joint are evacuated; recovery, if obtained at all, is effected by the obliteration of the articular cavity by a process of granulation and cicatrization, partial or complete stiffness or anchylosis resulting. When the disease invades the articular cartilages and bones, passing in fact into what will be presently described as Arthritis, the pain becomes much aggravated, assuming a peculiar "jumping" or "starting" character (usually worst at night), and often accompanied by a distinct grating on rubbing the articulating surfaces together. Treatment.—The Constitutional Treatment of synovitis presents no peculiarities requiring special comment, being essentially that directed in Chapter II. for any case of severe inflammation. Rheumatic, gonorrhoeal, or syphilitic complications require various modifications, according to the circumstances of the case. In the Local Treatment of synovitis (during the acute stage), great benefit will often be derived from the application PYARTHROSIS OR ABSCESS OF A JOINT. 639 of dry cold, in the form of Esmarch's ice-bag, or by the method of mediate irrigation (p. 56). In other cases, it may be better to surround the joint with a warm poultice, medicated with laudanum or hojis; that application should be preferred which is most agreeable to the patient. In every case, the joint should be placed at complete rest, and in such a position as will secure the greatest usefulness should anchylosis occur. For this purpose the limb should be fixed upon a well-padded splint, or in a suitable fracture- box, the mechanical support being so arranged as to prevent even the slightest motion of the affected joint. Continuous extension may be em- ployed, as recommended in the treatment of arthritis (p. 643), though its beneficial effects are, I think, less marked when the synovial membrane is alone involved than when all the tissues of the joint are implicated. When the acute symptoms have subsided, absorption of effusion and restoration of function may* be promoted by the repeated application of blisters or tincture of iodine, together with douches, frictions with stimu- lating embrocations, moderate pressure by means of a soap plaster and bandage, and the cautious employment of passive motion, if any tendency to stiffness be observed. Bergeret speaks highly* of the use of dry heat applied by means of bags filled with hot sand. If the joint be left in a relaxed condition, the patient should continue to wear an elastic support for some time after recovery*. Hydrarthrosis or Hydrops Articuli (Dropsy of a Joint) is almost invariably a result of chronic synovitis; it would appear, however, from the observations of Richet and others, that it may occasionally occur as a primary affection. Hydrarthrosis is most common in the knee, and is occasionally seen in the elbow, but very rarely in any other joint. The effused fluid differs from ordinary synovia, resembling more the contents of a hydrocele, or the fluid met with in ascites. This affection is often associated with a gouty or rheumatic diathesis, and is apt to recur from very slight causes. The treatment (in the event of the failure of the ordi- nary remedies for chronic synovitis) consists in the injection of the tincture of iodine, either pure or diluted. A portion of the effused liquid should be first evacuated by means of an aspirator, or a small trocar and canula introduced through a valvular incision; the iodine is then injected (not more than a fluidrachm of the tincture being used at once), and after remaining for a few minutes is again withdrawn, precautions being taken against the admission of air, and the wound being immediately sealed with collodion. Any inflammation which may result should be treated in the way already described. This mode of treatment has been used with great success by several European surgeons, and is favorably* spoken of by Mr. Erichsen; as, however, the plan is necessarily attended with some risk, it should not be employed except in very chronic cases which have resisted other modes of treatment, and in which the distention of the joint is pro- ductive of great inconvenience. Even the simple use of the aspirator is in these cases attended with some danger, as shown by fatal results which have occurred in the hands of Dubreuil and McDonnell. Schede and Labbe recommended intra-articular irrigation with a three or five per cent. solution of carbolic acid, and Guerin advises punctate cauterization with a hot iron. Pyarthrosis or Abscess of a Joint may, as has been mentioned, result from acute synovitis—or may accompany a more serious condition, such as arthritis, subperiosteal abscess, or osteo-myelitis—or may be a mere incident in the course of pyaemia. If the diagnosis of intra-articular abscess be not clear, the surgeon may, in the case of the superficial joints, satisfy himself as to the nature of the case by the use of an exploring or 640 DISEASES OF JOINTS. suction trocar. The treatment consists in evacuating the pus by means of a free incision, drainage being secured by position or by the use of Chassaignae's tubes or Ellis's wire coil (see p. 424). In some cases, ad- vantage may be derived from washing out the joint by injecting diluted tincture of iodine, or a weak solution of carbolic acid. Antiseptic irriga- tion of the joint is employed by Treves and M. H. Richardson. In favor- able cases, especially in children, recovery by anchylosis may be obtained; but should the strength of the patient begin to flag, no time should be lost in resorting to excision or amputation—the former operation being, under these circumstances, as a rule, applicable to the upper, and the latter to the lower, extremity. Death after pyarthrosis may result from simple ex- haustion, or from the development of pyaemia. Arthritis. By Arthritis is meant inflammation of a joint as a, whole; whichever tissue may have been first attacked, the remainder are sooner or later impli- cated. Arthritis usually begins with inflammation of the synovial mem- brane, or of the articulating extremities of the bones; more rarely the ligaments and surrounding soft parts are first involved, but it is doubtful whether the articular cartilages are ever affected, except secondarily. Gelatinous Arthritis—The origin of arthritis in ordinary Synovitis has already been considered; there is, however, a form of chronic synovitis, called by Barwell strumous, and by Athol Johnson scrofulous—but which, as justly remarked by Swain, may exist without any evidences of a scrofulous diathesis—in which the syno- vial membrane is found in a pulpy or gelatinous condition, and which almost invariably ends in destructive disorgani- zation of the joint. This condition of the synovial membrane is described by Brodie and Swain as a peculiar form of degeneration, called by the former pulpy, and by the latter gelatiniform, degene- ration ; Barwell, on the other hand, regards it as essentially the same as the granulation change referred to in sjieak- Fio.343.-Geiatinousarthriti*of eibow. inS of the pathology of synovitis in general, the difference being that, in ordinary* synovitis, this granulation-tissue undergoes further development, while in the cases now under consideration it remains in a rudimentary state. Godlee has studied the granulation-tissue from these cases of " white swelling," and finds it to consist of cells and nuclei embedded in a trabecu- lar meshwork with which "giant-cells" are connected by jirocesses. In fact, the appearances closely resemble those of miliary tubercle, and tend to confirm the view that the disease is of tuberculous origin ; similar ob- servations have been made by Friedlander. As the disease jn-ogresscs, the articular cartilages undergo a somewhat analogous change, the disease finally reaching the bones, which become softened and carious. The symptoms of this jieculiar form of disease, which may be appropriately called Gelatinous Arthritis, and which is rarely seen except in the knee and elbow, and in adults, differ from those of ordinary synovitis in several particulars. Thus the swelling is more diffused, and apparently unattended with fluctuation, being of a doughy and somewhat elastic type—this elas- SYMPTOMS OF ARTHRITIS. 641 ticitv, as pointed out by Fergusson, causing the bones, if pressed together, to resume their former position when pressure is removed. The swelling is often accompanied, and partially masked, by general oedema of the limb. The pain is less marked than in synovitis, and of a dull, gnawing charac- ter, differing both from the acute pain of ordinary synovitis, and from the "jumping" pain which attends exposure of the bone by ulcerating carti- lage. There is little or no heat, and if the part be at first red, the surface soon loses its color, often becoming eventually positively blanched—an appearance so characteristic as almost to justify the name of white swelling formerly given to these cases. Another point to which Swain calls atten- tion, is that considerable mobility of the joint often remains, even when the disease has reached an advanced stage. Arthritis from Bone Disease, etc.—Arthritis begins, in many cases, with a morbid condition of the bones which enter into the formation of the joint—this condition consisting of diffuse periostitis (subperiosteal abscess), osteo-myelitis, necrosis, caries, tuberculous deposit, or (which is probably the most common) a low form of osteitis of the articulating extremities, which is often described as strumous, but which has no neces- sary connection with the scrofulous diathesis (see page 458). Volkmann, however, regards a tuberculous deposit in the articular extremities as the most common cause of arthritis. Arthritis may likewise begin with inflammation of the Ligaments and other peri-articular structures (as after sprains), and it may possibly, in some rare cases, originate in primary inflammation of the Articular Car- tilages, or in the case of the knee-joint, as pointed out by Kocher, of the semilunar cartilages. Causes of Arthritis___Among the causes of arthritis may be enu- merated wounds (see page 224), sprains, contusions, exposure to cold and moisture, pyaemia, the puerperal state, scarlet fever, the scrofulous diathesis, etc. Symptoms.—The sj'mptoms of arthritis are those of deep-seated in- flammation ; they often begin very insidiously, but when fully established are easily recognized. The swelling is more uniform than in synovitis, and doughy rather than fluctuating to the touch ; the pain, which is specially referred in the case of the knee to the inside of that joint, and in the case of the hip to a point above and behind the great trochanter, is excessive, worst at night, aggravated by the slightest touch, or by motion of the part, and accompanied (when the disease is fully developed) by spasmodic contractions of the adjoining muscles, giving it the peculiar "jumping" or "starting" character which has been already referred to. These spasms occur particularly at night, coming on when the muscular system is relaxed by sleep, and often causing the patient to wake with a scream. These "jumping" pains have long been associated with ulceration of the articular cartilages, and were formerly supposed to be due to the condition of those structures ; it is now, however, generally acknowledged that inflammation and ulceration of cartilage are not, in themselves, attended with pain (car- tilage containing^no nerves), and that the peculiar starting pains of arthritis are really due to the condition of the plate of bone immediately beneath the seat of ulceration. When the cartilaginous disintegration has gone so far as to lay bare opposing surfaces of bone, they will rub together when the joint is moved, and distinct grating may be thus produced. The position assumed by the patient, in a case of arthritis, is quite characteristic: the affected joint is so placed as to enable it to be kept fixed, and to be most thoroughly relaxed; thus, in the case of the knee, the patient lies on the affected side, with the outside of the joint resting on the bed, the leg flexed 642 DISEASES OF JOINTS. Fro. 344.—Arthritis of knee-joint in an advanced stage. (From a patient in the Children's Hospital.) on the thigh, and the thigh on the pelvis—the ojiposite knee drawn up so as to serve as a guard, and to keeji off the weight of the bedclothes—and the whole attention apparently- concentrated and directed to shield the dis- eased part from injury-. The inflammatory fever is severe, assuming a typhoid type if suppuration occurs, and perhajis yielding to hectic in the advanced stages of the disease. The symptoms which accompany the occurrence of suppuration incases of arthritis are very much the same as were described in speaking of jiyar- throsis from synovitis. Pointing sometimes takes place at a comparatively early jieriod, but in other cases the pus, after escaping from the cavity of the joint, dissects uji the muscular interspaces of the limb for some distance before making its appearance on the surface. Occasionally many of the symp- toms of suppuration may have been jiresent, including even absorption of the cartilages and relaxation of the articular ligaments (as shown by unnatural mobility, or the occur- rence of dislocation), and distinct grating on motion, and yet recovery* may ensue under judicious treatment, without any discharge of pus, though with more or less complete anchylosis. In these cases the pus, or at least its fluid portion, has probably been absorbed, the pus-corpuscles undergoing fatty or cal- careous degeneration. It is in such cases as these that residual abscesses are sometimes observed after considerable intervals of time (see page 425). When arthritis of a large joint, as the hip or knee, has advanced to the stage of abscess, the jirospects of spon- taneous recovery are usually very limited. In some cases, particularly among those whose social condition secures to them careful nursing, abundant nutriment, opportunity for change of air, and other favoring circumstances, a cure by anchylosis may be obtained, the opposing joint surfaces becoming united by granulations which are subsequently organ- ized into a fibrous or imjierfect bony* tissue ; but in most instances, and as a rule with hospital patients, unless rescued by operation, such cases eventually- terminate in death from exhaustion, diarrhoea, or pyaemia, from phthisis, or from other diseases of internal viscera. Arthritis of the smaller joints offers a much more favorable prognosis. Elongation of the affected limb is occasionally observed in arthritis as the result of irritation of the epiphyseal cartilages, but in most cases the disease ultimately leads to shortening and withering of the part. Acute Arthritis of Infants.—T. Smith has described under this name a very acute form of the disease met with during the first year of life. The .affection, which is not dependent upon the presence of a syphilitic taint, \* a very fatal one, thirteen out of twenty-one cases, recorded by Mr. Smith, having ended in death. When recovery occurs there is little risk of anchy- losis, but the joint may be weakened by the loss of portions of bone. Two cases of recovery are recorded by Morrant Baker. Amputation has been successfully employed by G. Brown. Treatment__The Constitutional Treatment of arthritis consists pretty* much in the administration of anodyne diaphoretics, with occasional mild laxatives, during the acute stage—followed by tonics, especially iron and cod-liver oil, at a later period. Mercurials, which may be TREATMENT OF ARTHRITIS. 643 proper in traumatic arthritis, should be used, if at all, with great caution in these cases—medicines of any form being, indeed, of less importance than nutriment, which should be given abundantly and in an easily assimilable form. The most important part of the Local Treatment is to place the joint in a state of complete and long-con- tinued rest, and in a favorable position. If the shoulder be allected, the arm should be kept to the side, and directed somewhat forwards, while the elbow, if dis- eased, should be maintained in a flexed, and the wrist, hip, or knee in a straight or extended, position. In all cases in which the lower extremity is involved, the foot should be properly supported, so that when recovery is obtained the patient may not be left with a pes equi- nus. It is recommended by many excellent authorities, that if the limb be found in a vicious position, it should be forcibly placed right, while the patient is under the influence of an anaesthetic, any resisting muscles or tendons being subcutaneously divided if necessary. I think, however, that the object may be, in many cases, quite as well and more safely accomplished by the use of continuous extension, applied by means of elastic bands, or, which is more convenient, by means of the ordinary weight-extension apparatus (see Fig. 148). When the limb has been brought into the proper posi- tion, it should be fixed with well-padded splints or fracture-boxes, or, if the surgeon prefer, with some form of immovable apparatus, an aperture being cut so as to allow of inspection and topical medication of the joint. In many* cases of arthritis, particularly if affect- ing the knee or hip, the greatest advantage may be de- rived from the use of continuous extension, which may be applied with Barwell's splint, in which the extension is effected by an India-rubber accumulator; with a spiral wire spring sur- rounding the limb, as suggested by Holthouse ; or (which I prefer) with the ordinary weight-extension apparatus—a mode of treatment which was used by Brodie, and which has since been successfully resorted to by numerous surgeons. The efficacy of this simple apparatus may be still further increased by the application of lateral long splints or sand-bags. An ingenious splint for making extension in cases of arthritis of the wrist has been devised by Fagan, of Belfast. The relief from pain afforded by continuous extension incases of joint-disease is very* marked. It apjiears to act by counteracting the tendency to muscular spasm, and thus pre- venting the inflamed ends of bone from being pressed together. With regard to topical medication in cases of arthritis, the best appli- cation during the acute stage is, I think, usually a warm poultice, though in some instances dry cold appears to afford more relief. Leeches may be required in some cases. When the first acute symptoms have subsided, benefit may often be derived from counter-irritation in the form of blisters, or the actual cautery. The cautery should be applied before the occur- rence of suppuration (the patient being anaesthetized), by drawing the iron, heated to a black heat only, rajiidly across the joint, in lines at least an inch apart; it is not necessary to produce a slough, and the surrounding parts may be protected (as recommended by Voillemier) by coating the whole with collodion, the cautery thus only affecting the part which it absolutely Fig. H45.—Barwell's splint for makiug con- tinuous extension. 614 DISEASES OF JOINTS. touches. Xelaton suggests the use of a metal rule as a guide to the lines in which the cautery is to be applied. The hob iron, though doubtless an efficient remedy*, is one to which all patients have a feeling of repulsion, and should therefore, I think, be reserved for very urgent cases. Blister- ing I have usually* found quite satisfactory ; the blister should be jilaccd over the seat of greatest pain, and it is better to use a small than a large blister, repeating it if necessary. The tincture of iodine may also be employed, painting it around but not over the joint, in the way recom- mended by Furneaux Jordan. In the chronic stages, great advantage may* also be derived from painting the part with iodine, and from the use of pressure applied by means of a soap plaster and firm bandage. Marshall speaks very favorably- of the application of a solution of the oleates of mercury and morphia in oleic acid, while Barwell employs, in the gelatinous form of the disease, injections of diluted tincture of iodine (one. part to fifteen), not into the joint, but into the thickened surrounding tissues. Injections of carbolic acid have been tried, and sometimes with benefit, by Knbrr, Hueter, Petersen, Schmidt, and other surgeons. Le Fort injects a ten-per-cent. solution of sulphate of zinc, with one-fourth jiart of alcohol. If suppuration occur, the case must be treated by free incisions, etc., as directed in sjieakingof pyarthrosis; if the bones be but slightly involved, recovery may still be sometimes obtained by perseverance in conservative treatment, but under opposite circumstances excision or amputation will usually be indicated, if the joint be so situated as to admit of operative in- terference. Fitzpatrick, of Dublin, speaks favorably of the application of the potassa-cum-calce to the affected tissues, but a case thus treated by Mr. Holmes ended fatally through the development of pyaemia. The local use of sulphuric acid has proved successful in cases reported by J. W. Haward and other surgeons. Erasion of Joints ; Arthrectomy.—Wright, of Manchester, has intro- duced a mode of treatment which consists in laying open the joint and clipping or scraping away the diseased structures. This operation, which is now generally known by the name of arthrectomy, is especially applica- ble to the knee-joint; I have adopted it in four cases, one patient making a good recovery, two being still under treatment, and the fourth— though his wound healed well—dying of malignant purpura in the course of the sixth week. It has the advantage over excision of not being followed by shortening, but, on the other hand, is very apt to be followed by sec- ondary contraction, to guard against which the patient should wear some mechanical support for a long time. Mandry, from an analysis of 63 cases operated on by Yolkmann, Kbnig, and other surgeons, finds that 10 per cent, proved fatal, though not directly from the operation, 27 per cent. ended in failure, and 63 per cent, in recovery. There was more or less contraction in 55 per cent., and only eight patients recovered with a mov- able joint. In cases of gelatinous arthritis, the chances of spontaneous recovery are so slight that arthrectomy or excision is indicated at a com- paratively early period. The account which has been given above of arthritis in general will suffice for a description of the affection as met with in most of the articula- tions, as the shoulder, elbow, wrist, knee, ankle, tarsal joints, etc. There are, however, two situations in which arthritis occurs, which impress certain peculiarities on the disease, requiring more detailed consideration ; these are the hip and the sacro-iliac articulation. Arthritis of the Hip-joint, Morbus Coxarius, Coxalgia, or Hip-Disease, is an affection of early life (more than two-thirds of all cases occurring in persons under fifteen years of age), and is much com- HIP-DISEASE. 645 moner in boys than in girls.1 Three varieties of the disease are recognized by Erichsen, according as it begins in the head of the femur, the acetabu- lum, or the proper structures of the joint (especially the synovial mem- brane) ; and this division being, in some respects, convenient, I shall fol- low that author in speaking of femoral, acetabular, and arthritic coxalgia. Nature.—The nature of hip-disease has been a matter of much dispute, many distinguished surgeons looking upon it as almost always, if not invariably, a constitutional affection, depending upon a tuberculous or scrofulous diathesis. The remarks made in a previous chapter upon struma are particularly* applicable here ; while it is certain that, in some cases at least, a deposit of tubercle does lead to hip-disease, and while there can be no doubt that the scrofulous diathesis does act as a predisposing cause of the affection, there can be as little doubt, I think, that many cases are simply of an inflammatory nature, and that, in a majority of instances, the disease is to be looked upon as having a local origin, and (which is of the highest importance, in a practical point of view) as specially demand- ing local treatment. Causes.—The exciting causes of hip-disease are usually of an apparently trivial character, such as slight blows or falls, sprains, over-exertion in walking, or sitting on cold steps, or in wet grass. Symptoms.—The symptoms of the affection vary in its different stages, three of which are commonly described by surgical writers. Hip-disease usually begins very insidiously, obscure pains, which are probably- con- sidered rheumatic, and a limping or shuffling gait, often existing for some time before any* deformity is discovered. (1) Pain is felt in the affected joint and in the corresponding knee, the latter symptom being most marked in the femoral form of the disease, and apparently due to irritation of branches of the anterior crural and obturator nerves. The pain in the hip is constant in the arthritic form, of a very acute type, and accompanied with a feeling of tension, and with tenderness above the great trochanter. It is increased by motion or exercise, and is, therefore, worse in the evening, but the "starting" pains caused by mus- cular spasm do not come on until a comparatively late period. In the femoral and acetabular varieties, the hip pain is of a dull, gnawing char- acter, worse at night, often intermittent, and specially elicited by striking on the knee or heel, and thus pressing the joint surfaces together ; starting of the limb is developed at an early period. Of course, as the disease advances, in whatever form it may have originated, the different symptoms become merged together, so that these distinctions are only available in the earlier stage of the affection. (2) Swelling is most marked in the arthritic variety, which may* be looked upon as the acute form of the disease. Redness and Heat are rarely observed in any case on account of the deeji situation of the joint. (3) Deformity.—In the first stage of hip-disease, the knee is slightly flexed, and the limb usually but not always abducted—this position being involuntarily assumed, as most easy to the patient. Slight limping accom- panies this stage of the disease. The second stage is marked by flattening of the buttock, the fold of the nates on the affected side becoming almost if not quite obliterated ; with this there are abduction and consequent elon- gation of the limb, the latter in the large majority of cases being apparent merely, and due to a twist of the pelvis, caused, as pointed out by Barwell, 1 Of 100 consecutive admissions for hip-disease into the Children's Hospital of this city, 61 were of boys and 39 of girls. Again, of 419 cases of excision for hip-disease collected by Culbertson, in which the sex of the patient was ascertained, 297 were in males, and 122 in females. 646 DISEASES OF JOINTS. by* the effort to preserve parallelism of the limbs, though in the arthritic form of the disease there may possibly be in some instances true elongation, from distention of the synovial capsule. When in this stage the patient stands, the whole weight is borne by the sound limb, that which is diseased being carried forward, flexed, and abducted. If now he be placed in the recumbent posture, the limbs may be brought to the same level, the deformity apparently disappearing; but by careful examination it will be found that the relative position of the thigh and pelvis is the same as in the standing posture, the lumbar spine being unduly- arched, and the pelvis distorted into an abnormally* vertical position. In this stage there is marked lameness, and it is to this stage also that the pain in the knee particularly belongs. In the acetabular variety of the disease there is comparatively little deformity, while in the femoral there may be, as long as the patient is going about, apparent shortening, which, however, yields to apparent lengthening after a few days' rest in bed. The deformity* of the third stage (between which and the second there may be an interval of comparative comfort) consists in adduction of the limb (Fig. 347), lead- ing to shortening, which is greater in appearance than in reality, with undue prominence of the buttock on the affected side, marked obliquity of the pelvis, and compensatory double lateral curvature of the spine. The rima natium, which in the second stage inclined towards the affected side ease in second stage ; Fio. 348.—Excised head and neck showing flattening of Fio. 347. — Hip - disease in of femur; showing change in shape buttock, with appar- third stage ; showing shorten- of bone in third stage of hip-disease enteiongation. (Krotn ing and adduction, with ob- (see Fig. 317). (The specimen is in a patient in the Chil- liquity of pelvis. (From k pa- the Mutter Museum of the College dren's Hospital ) tient in the Children's Hospital.) of Physicians of Philadelphia.) (Fig. 347), is now directed away from it. The shortening of the third stage of hip-disease is, at the beginning of that stage, merely apparent, depending on the effort to bring the adducted limb into parallelism with its fellow ; as the malady progresses, however, actual shortening occurs, from alteration in the shape of the bones which enter into the formation of the joint (Fig. 348), and in some cases, though in fewer than was formerly HIP-DISEASE. 647 supposed, from positive dislocation taking place. The deformity of the first and second stage is, according to Verneuil, due to inflammation of the muscles in proximity to the joint—the psoas and lesser gluteals; at a later period these undergo atrophy, and the deformity of the third stage is caused by inflammation of the abductors and sartorius. (4) Dislocation is chiefly confined to the femoral variety of the disease, and its occurrence is often attended with marked relief from pain; if, as sometimes happens, it takes place without the previous formation of ab- scess, a new socket may be developed upon the dorsum ilii, the acetabulum becoming gradually filled up and obliterated. In the acetabular form of the affection the cotyloid cavity may become perforated, the head of the femur jierhaps slipping through into the cavity of the pelvis. (5) Suppuration may or may not occur in the arthritic form of hip-dis- ease, but it is almost inevitable in the other varieties. It occurs earlier in the acetabular than in the femoral form of the affection. The spot at which pointing occurs is often significant; thus an abscess opening on the outer part of the thigh, below the trochanter, indicates disease of the caput femoris, while abscesses opening in the pubic region denote disease of the acetabulum—the abscess being intra-pelvic or extra-pelvic according as it opens above or below Poupart's ligament. Abscess opening in the gluteal region may indicate either form of the affection. Terminations of Hip-Disease.—The arthritic and occasionally the other forms of the disease, if submitted to judicious treatment at an early period, may terminate favorably, though in many cases the best that can be hoped for is a cure by anchylosis. Even if the joint be anchylosed, provided that the limb have been kept in a straight position, the result will be quite satisfactory*, the mobility of the pelvis compensating in a great degree for the stiffness of the joint; but unless precautions have been taken in regard to position, anchylosis with great deformity* will ensue, such distortion as is exhibited in the accompanying cut (Fig. 349) being by no means unfrequently met with. If suppuration have occurred, and therefore we may say as a rule in cases of acetabu- lar or femoral coxalgia (particularly if followed by consecutive dislocation), the utmost that can usually be attained by- conservative measures is recovery with a shortened, deformed, atrophied, and often useless limb. Death may occur from simple exhaustion, diarrhoea, tuberculo- sis, amyloid degeneration, or pyaemia, or from some intercurrent affection which would have been successfully resisted but for the constantly depressing influence of the joint-affection. Diagnosis.—Hip-disease may be distinguished from rheumatism by observing the limitation of the affection to one joint, and by noting the characteristic deformity*. This may be readily made apparent, as pointed out by Prof. Sayre, by placing the patient upon a perfectly hard plane sur- face, when, if the knee of the affected limb be brought down, the lumbar spine instantly becomes arched. From lateral curvature of the spine with Fio. 349.—Deformity resulting from double hip-disease. (From a patient under the care of Dr. Hodge in the Chil- dren's Hospital.) 648 DISEASES OF JOINTS. neuralgic tenderness, it may be distinguished by the pain being increased by pressing together the joint-surfaces, and by the existence of painful nocturnal spasms, while the diagnosis from antero-posterior curvature of the spine may be made by observing the mobility of the hip in that dis- ease, and the different seat of pain—though if the abscess in spinal disease point on the outer side of the thigh, pressing on filaments of the obturator nerve, there will be pain referred to the knee, just as in hip-disease. Mor- bus coxarius could only* be mistaken for abscess external to the joint, for disease of the knee, or for caries of the great trochanter, by* neglect of careful examination ; and I am disposed to say the same in relation to perinephric abscess, and to perityphlitis, which, according to Dr. (libnev, is not unfrequently mistaken for hip-disease. From sacro-iliac disease, the diagnosis may be made by observing that in that affection the seat of greatest tenderness is different, that there is no shortening, and no j>ain on moving the hip if the pelvis be fixed, and that the pelvic distortion is per- manent and absolute, not, as in hip-disease, temporary and relative. The diagnosis from separation of the upper epiphysis of the femur with abscess, is difficult, if not impossible—a matter which, fortunately, is of no practical moment, as excision would be equally indicated in either affection. Prognosis.—Statistics are wanting to show the mortality of hip-disease, it being but seldom, from the chronic nature of the affection, that the sur- geon has the opportunity of watching a case to its termination. My own impression is very decided, that, when suppuration has occurred, the bones being involved, recovery without operation is an extremely rare occur- Fiq. 350.—Sayre's short splint applied. Fio. 351.—Sayre's long splint applied. (Sayre.) (Sayre.) rence : this impression is confirmed by the results of 9 terminated cases observed by Gibert, which gave 8 deaths and but 1 pecovery. It is true that hip disease does not appear very frequently in our mortuary records, but this is owing to the fact that the patients are carried off by secondary complications or intercurrent affections, to which death is attributed—no reference being made to the chronic condition, without which those affec- HIP-DISEASE. 649 tions would not have occurred, or would not have proved fatal. Femoral, and still more acetabular, coxalgia may be therefore looked upon as ex- tremely grave diseases ; the arthritic form of the affection, how*ever, offers, as already mentioned, a much more favorable prognosis. Treatment.—It is very important that early treatment should be adopted in every case of hip-disease, and accordingly a rigid examination of the case should be instituted on the slightest suspicion of the existence of this serious affection. During theirs/ stage of the disease, the patient should be put to bed, and the joint kept in a state of complete rest by the use of extension, and, if needful, the adaptation of a suitable splint. I myself employ an ordinary long splint, well padded, or sand bags, as in the treat- ment of fractured thigh, but the surgeon may use with equally good results the carved splint of Dr. Physick, or one moulded from gutta-percha, leather, or pasteboard, or sjilints made from wire gauze, as recommended by Barwell and Bauer, or finally any of the forms of immovable apparatus which were described at page 84. The particular form of splint used is a matter of indifference, provided that the limb be kept in a proper position, and the joint in a state of absolute rest. To relieve pain, especially the starting pain which is one of the most distressing symptoms of the affection, continuous extension is the most valuable agent which we possess. The ordinary weight-extension apparatus may be used, as in cases of fractured thigh, or Barwell's elastic "accumulator" may be employed instead. The simple weight is the most convenient means, and is, according to my* ex- perience, very efficient. J. Wood employs double ex- tension, a weight being attached to each limb and counter-extension made by- raising the foot of the bed. I have not, myself, found it necessary to resort to sub- cutaneous division of the tendons or spasmodically con- tracted muscles, an operation which has, however, been successfully emjiloyed by Bonnet, Bauer, Sayre, and other surgeons. If the affection have run on to the second stage, the same treatment is to be employed, together with counter-irritation by blisters or the cau- tery, applied to the seat of the greatest pain, usually a little above and behind the great trochanter ; the general condition of the patient must at the same time receive attention, the state of the digestive organs being looked to, and the strength maintained by the administration of food and tonics, especially iron and cod-liver oil. In most cases of arthritic coxalgia, and in some at least of the femoral variety, if the treatment above described be early adopted and strictly* carried out, a marked improvement will soon be manifested, the pain and tenderness gradually disappearing, till at length motion of the joint is no longer productive of suffering, and the patient feels and considers himself well The time required for this favorable evolution of events is of course variable, six or eight weeks being probably a minimum period. If now all further treatment be neglected, the disease will in a short time almost in- evitably recur, and probably in an aggravated form ; and yet it is very important that the patient should be no longer confined to bed, but should be enabled to take exercise in the open air. It is in these circumstances, I think, that the ingenious forms of appa- Fig.352.—Agnew's mo- dification of Thomas's apparatus for coxalgia. The splint is applied to the affected limb, a high- soled shoe placed upon the opposite foot (sound limb), and the patient required to use crutches. 650 DISEASES OF JOINTS. ratus devised by Davis, Sayre. Andrews, Taylor, Thomas, of Liverpool, Agnew, and other surgeons, are particularly serviceable ; they act by keep- ing up extension and counter-extension, while the patient is enabled to walk about and lead a comparatively active life.1 In the third stage of the disease, the treatment already advised is still applicable, extension being more particularly indicated, in order to prevent or counteract the tendency- to shortening. If abscess form, the same plan may- still be continued, counter-irritation being, however, now abandoned as useless. If the abscess originate within the synovial capsule, distend- ing and threatening to rupture the latter, the pus may be evacuated by means of an aspirator, or simple trocar and canula, with precautions against the entrance of air, as advised by Dr. Bauer. Under other circumstances, the abscess should, I think, be treated on the general principles laid down at page 425. It is rarely* possible to effect the absorption of pus under these circumstances, but the attempt is worth making, and will occasion- ally succeed—as in a case mentioned by Barwell, and as in one under my own care in which absorption occurred under the influence of dry cold.11 After abscesses have opened in cases of hiji-disease, leaving sinuses which lead down to carious bone, it is still possible in some instances to obtain a cure by anchylosis, and, in cases not admitting of operation, this is the best termination that can be hoped for. Little can be done, under these circumstances, beyond keeping the limb straight, moderately extended, and with the foot well supported, while the strength of the patient is main- tained by appropriate constitutional and hygienic treatment. In many of the cases, however, which reach this condition (at least among the class of children that come into our city hospitals), excision, or possibly ampu- tation, may afford a better chance of life than perseverance in expectant treatment. Kirkpatrick, Stokes, and Stoker recommend early trephining of the trochanter and cervix femoris, followed by drainage, in hiji-disease of the femoral variety. The two first-named surgeons supplement the operation by apjilying potassa-cum-ealce to the track of the wound. Arthritis of the Sacro-Iliac Joint (Saero-Iliac Disease).— This affection, which is extremely fatal, is fortunately rare, though proba- bly not quite as rare as is commonly supposed—being sometimes not recognized by practitioners, as indeed it has, until comparatively recently, been commonly* ignored by systematic writers. It has been particularly studied by Xelaton and Erichsen. Sacro-iliac disease is an affection of early life, and usually begins with a condition analogous to, if not identi- cal with, that form of arthritis which has been called gelatinous, though, in other instances, the bones appear to be first affected. The disease can seldom be traced to any definite exciting cause. The Symptoms consist of pain and tenderness, with swelling over the line of the sacro-iliac junction, the pain being aggravated by motion, laughing, coughing, straining at stool, etc., and accompanied by a peculiar sensation, as if the body were falling apart. Pain is elicited also by press- ing the sides of the pelvis together. The patient is lame from the' begin- 1 Hutchison, of Brooklyn, simply applied a patten to the sound limb, and put the patient on crutches, believing that sufficient extension was produced by the weight of the affected member itself. The same method of producing extension is adopted by Thomas and Agnew, but, by their instruments, they secure immobility of the joint at the same time. Supplementing Dr. Hutchison's simple apparatus with'a pasteboard splint, moulded to the affected hip, I have often been able to dispense with more costly appliances. 2 Mr. A. Jackson, of Sheffield, advises that the joint should be freely opened at an early period, and the head of the femur turned out for a few days, to be afterwards replaced when the inflammation has somewhat subsided. RHEUMATOID ARTHRITIS. 651 ning; and as the disease advances, becomes completely bedridden, usually lying on the unaffected side. The limb on the diseased side is commonly extended, elongated, from downward displacement of the os innominatum, and toasted from atrophy of its muscles. It is sometimes markedly cedema- tous from obstruction of the iliac vein. The hip is deformed, from the side of the pelvis being tilted forwards and rotated down wards. Suppura- tion occurs at a rather late period of the disease, abscesses jiointing, ac- cording to Erichsen, over the joint, in the gluteal or lumbar regions, within the pelvis, or in connection with the rectum. In a case which was under my care at the Episcopal Hospital, abscesses pointed in the groin, in the gluteal region, and on the inside of the thigh. The Diagnosis of sacro-iliac disease can usually be made without much difficulty, the affection with which it is most likely to be confounded being hip-disease, the diagnostic marks of which have already been pointed out. Disease of the spine, may be distinguished, even if there be no posterior curvature, by* the presence of tenderness in the region of the affected ver- tebra', and of stiffness of the whole spinal column, with absence of any elongation of the limb, or sign of disease about the sacro-iliac joint. Neu- ralgia of the hip may be distinguished by the diffused and superficial char- acter of the jiain, and by the absence of any real displacement of the os innominatum; while sciatica may be recognized by the seat of pain being below the sacro-iliac joint and extending down the limb, and by the ab- sence of elongation or other signs of articular disease. The Prognosis of advanced sacro-iliac disease is always unfavorable ; Erichsen, who has devoted special attention to the subject, says that he has never seen recovery in any case in which the disease was fully devel- ojied, and in which suppuration had occurred. When seen at an early stage, however, there is more hope of successful treatment, and cases of recovery under these circumstances have been reported by McGuire and other surgeons. The Treatment consists of endeavoring to prevent suppuration, by plac- ing the joint at rest by means of the weight-extension apparatus, as ad- vised by Prof. Maguire,1 and at a later period by supporting the part with a leather or pasteboard splint, moulded to embrace the pelvis, hip, and thigh; counter-irritation may be of service in the early stage, and the general health should be sustained by the administration of cod-liver oil and other tonics. The patient should of course stay in bed, and preferably in the prone position. No operation is, under ordinary circumstances, ad- missible in this grave affection, though, if caries had occurred, it might be proper to make an incision and endeavor to remove the diseased bone with gouge and curette. Rheumatoid Arthritis. Rheumatoid Arthritis is the name proposed by Dr. Garrod for a peculiar form of inflammation of the joints, which was described by Adams, R. W. Smith, and Canton, as Chronic Rheumatic Arthritis, which Barwell calls Arthritis Deformans, and which, in the case of the hip, is sometimes known as Morbus Coxae Senilis. The pathology of this disease is involved in much obscurity ; rheumatoid arthritis resembles both gout and rheuma- tism, and yet does not appear to partake of the nature of either of those affections. It probably begins with hyperaemia of the synovial membrane and increased synovial secretion, followed by thickening, and sometimes J. Wood employs double extension, as in cases of hip-disease. 652 DISEASES OF JOINTS. elongation, of the ligaments, gradual absorption or ossification of the in- terarticular cartilages, and finally* porcelanous induration and eburna- tion of the bony extremities. Barwell, however, believes that osteitis is the pri- mary* condition, and that the synovial change is entirely secondary. In the case of the hip, which is the joint most com- monly* affected, the round ligament disaji- pears, and the head of the bone becomes irregularly enlarged, flattened, someliines elongated, and jilaced at a right angle with the shaft. The cervix femoris becomes shortened, apparently by interstitial ab- sorption, and is often surrounded by vas- cular fringe-like projections of the synovial membrane. The acetabulum becomes en- larged, and sometimes flattened, but in other cases deepened!, so as to surround the head of the femur as with a cup. E.Xten- Fia. 353—Appearanoe of the head of gjve gtalactitic bony Outgrowths Often ap- ftDeRuI?T,)Ur ^ rh*uma,°id anhritu- pearabout the base of the great trochanter, and especially along the inter-trochanteric line, while similar osteitic formations are developed in the ligamentous and other soft tissues. On section, the bone is found to be rarified, with an excess of oily matter—in a state, indeed, of osteoporosis with eburnation. All the joints of the skeleton may be involved, but those in which the dis- ease is most commonly observed, are the articulations of the hip, shoulder, and lower jaw. Rheumatoid arthritis of the shoulder is, according to Can- ton, the true pathological condition in those cases described by Soden and others as displacement of the long head of the biceps. The joints on either side are often symmetrically affected. Rheumatoid arthritis usually occurs in the male sex, and in persons who have passed the middle period of life; when met with at an earlier age, the jiatients are generally females -r the disease appears in most cases to result from the action of cold in persons of debilitated constitution, the development of the affection in any particular joint being sometimes hastened by traumatic causes.. Symptoms—The disease begins with pain of a rheumatic character, increased, in the case of the hip, by standing or walking, and followed by impaired power of motion, preventing the patient from either standing erect, stooping, or sitting in. the ordinary posture. The limb may at first appear lengthened, but subsequently becomes shortened from changes in the shape of the bones, the apparent shortening being still further increased by obliquity of the pelvis. The limb is somewhat flexed and everted, the buttock becoming flattened; while the trochanter is unduly prominent and thickened. Crackling, or grating may be elicited by rotating the limb, being evidently produced by the stalactitic formations already referred to, and by the rubbing together of the eburnated surfaces of bone. The mus- cles of the thigh waste, but those of the calf of the leg maintain their nutrition ; the loss of motion in the hip is in some degree compensated for by increased mobility of the lumbar vertebrae. Suppuration occasionally, but very rarely, occurs, nor, according to Barwell, is there any tendency to the production of anchylosis. Diagnosis___Rheumatoid arthritis is chiefly interesting to the surgeon in a diagnostic point of view, being frequently mistaken for fracture in the * PERIARTHRITIS AND ANCHYLOSIS. 653 neighborhood of the affected articulation. The diagnosis can usually be made by inquiring into the history of the case, and by observing that the affection is not limited to a single joint. The arthropathies, or articular affections which depend upon lesions of the nerves and nerve-centres, locomotor ataxia, etc., present many analogies to rheumatoid arthritis, and, according to Mitchell, are often clinically indistinguishable therefrom. The rapid wearing away of the articular extremities in tabetic arthropathy is the diagnostic feature chiefly relied upon by Charcot and Buzzard. Prognosis___The disease is very seldom fatal, but, on the other hand, is extremely chronic and intractable, and productive of a great deal of pain and discomfort. Treatment.—But little can be done in the way of treatment, beyond the emjiloy*ment of ordinary hygienic means and the administration of tonics, especially cod-liver oil, iron, and quinia, the affected joint being, during the acute stage, kept at rest, and occasionally blistered. Iodide of potassium may be sometimes used with advantage, as may be arsenic and guaiacum. R. W. Smith speaks highly of the latter drug, in combination with sulphur, rhubarb, alkalies, and aromatics. Change of air, and a re- sort to various mineral springs, may be properly advised in some cases. With regard to motion of the diseased joints (in the chronic stage), it may be said that the patient may take as much exercise as he can without inducing an aggravation of pain. Erichsen recommends, in the case of the hip, external support by means of lateral irons, jointed opposite the articulations, with a pelvic band and leather socket for the thigh and leg. Excision of the hip has been resorted to in this affection, but is not to be recommended ; the prospective benefits of the operation, under these cir- cumstances, are not sufficient to compensate for the risk which would necessarily* attend its performance. Periarthritis. This name is applied by Duplay and Gosselin to a condition simulating arthritis, but due to inflammatory changes in the neighboring bursae and other jieriarticular tissues. There is less swelling and constitutional dis- turbance than in inflammation of the joint itself, and the diagnosis from rheumatism may be made by* observing that but one joint is affected, and from neuralgia by noting a peculiar crackling which may be commonly detected by palpation of the affected bursae. The treatment in the acute stage consists in the enforcement of rest, with the use of cataplasms, or belladonna and mercurial ointment, and at a later period in friction with stimulating liniments, and the employment of passive motion to prevent the occurrence of false anchylosis. Anchylosis. Frequent reference has been made in the preceding pages to the cure of joint-diseases by anchylosis, a word which, as used by surgeons, is equiva- lent to stiff-joint. Anchylosis, or ankylosis (the latter is etymologically the more correct spelling), may be incomplete or complete. In incomplete or fibrous anchylosis, the stiffness is due to thickening of the joint capsule, with the development of bands of fibro-cellular material which cross from one articular surface to the other, and which result from the organization of in- flammatory lymph, or of the granulation structure which in joint-diseases replaces the synovial membrane and articular cartilages. The stiffness of the part is further promoted by contraction and adhesion of the neighboring 654 DISEASES OF JOINTS. muscles and tendons, the latter being almost exclusively- concerned in the production of the so-called false anchylosis, which results from mere disuse. In complete or bony anchylosis (Fig. 854) the joint may be entirely obliter- j ated, the articulating surfaces being united throughout by bone (synostosis), or (which is probably the more common condition) there may be fibrous anchy- losis, with the superaddition of osseous | arches or bands, which cross from side to side externally- to the joint, and I which may be new formations, of the 1 nature of exostoses, or may result from the deposit of ossific matter in j ligaments or other pre-existing soft | structures. Bony anchylosis is rarely jj met with except as the result of trau- matic arthritis, fibrous anchylosis being more common in the ordinary forms of the disease, particularly in patients of a strumous diathesis. It i not unfrequently hapjiens, indeed, under the latter circumstances, that, while more or less perfect anchylosis is taking place in one part of a joint, caries or necrosis is in existence at another. In bony anchylosis there is absolutely no motion of the joint, while fio. 354 -synostosis of hip-joint. (Pierie.) in the fibrous variety slight motion may always be elicited by careful ex- amination, particularly if the patient be in a state of anaesthesia. Some- times the surgeon endeavors to obtain anchylosis as the best termination of arthritis, or as a means of increasing the firmness of a limb, in cases of paralysis or recurring dislocation. The operation of suturing the relaxed' tissues for this purpose, with or without excision of the articulating surfaces, is called by Euringer arthrodesis. Treatment.—The treatment of anchylosis varies according as it is complete or incomplete, and according to the position in which the joint has become stiff. 1. Fibrous Anchylosis in a good Position.—No treatment should be adopted under these circumstances until all acute inflammatory symptoms have subsided ; when the disease has become chronic, passive motion may be cautiously emjiloyed, being aided by frictions, the salt douche, etc. In fibrous anchylosis of the elbow, the patient may himself practise passive motion by swinging a flat-iron or other weight, as advised at j>age 241. Advantage is occasionally derived from the use of well padded splints, the angle of which may be varied by means of a Stromeyer's screw or other similar contrivance, or from the use of continuous extension by elastic bands or by a weight. It may be, in some rare cases, justifiable to attempt subcutaneous division of the restraining intra-articular bands, but the opera- tion is not very promising, and is necessarily attended with some risk. Fibrous anchylosis of the shoulder is often followed by the development of a bursa beneath the scapula, the motions of which bone give rise to a crackling sound, described by Terillon under the name of subscapular friction. 2. Fibrous Anchylosis in a Bad Position.—If the elbow be anchylosed TREATMENT OF ANCHYLOSIS. 655 in an extended position, or the shoulder, knee, or hip at a right angle, it becomes important to adopt more active treatment, though no ojieration should be performed until acute symptoms have passed away*. In many cases, particularly* in those of rheumatic origin, it is possible at once to restore the limb to a position in which it will be useful, by forcibly flexing and extending the joint, and thus rupturing the intra-articular adhesions, while the patient is in a state of anaesthesia. If this be done, the force Fia 355.—Deformity (consecutive dislocation) following arthritis of knee-joint, the tibia displaced backwards and upwards. should invariably be first applied in the direction offlexion, and the adhe- sions should be broken by a series of quick, short jerks, rather than by slow pressure. In other instances, continuous extension, by means of elastic bands (Fig. 358), or a weight, will be safer and equally efficient; the humerus has been fractured in attempting forcibly to break up adhesions of the elbow-joint, and Louvrier and Homans have recorded ruptures of the popliteal artery in similar operations for anchylosis of the knee. If resistance be made by contracted tendons in the neighborhood of the joint, these should be subcutaneously divided, a few days being then allowed to elapse before the employment of extension. Any inflammation which fol- lows these manoeuvres must be treated upon general principles. In the case of the hip-joint, subcutaneous osteotomy, by Adams's or Gant's method, may often be resorted to. The deformity* met with in anchylosis following arthritis of the knee-joint usually consists in flexion, backward displacement of the tibia upon the condyles of the femur, and outward rotation .of the leg and foot (Fig. 355). In these cases, simple extension, even with division of the hamstring tendons, is not sufficient, the backward displace- ment persisting, and rendering the limb weak and comparatively* useless ; under such circumstances, the ingenious apparatus of Mr. Bigg (Fig. 359) may* be employed, which acts by* means of sjirings, drawing the head of the tibia downwards and forwards, while the condyles of the femur are at the same time pressed upwards and backwards. Subcutaneous division of the adhesions uniting the femur and patella is suggested by Mr. Willett, and has been advantageously resorted to by Mr. Maunder, as has subcu- taneous section of the crucial ligaments by Prof. Tiffany, of Baltimore. Anchylosis of the knee in a position of over-extension is extremely- rare ; it is well seen in the accompanying illustration (Fig. 356), from a patient under my care in the Episcopal Hospital. The displacement in these cases is an exaggeration of that which is commonly observed, the head of the tibia slipping entirely* behind the femur and projecting in the popliteal space. In cases of partial fibrous anchylosis, complicated by frequently recurring inflammation of the joint (Fig. 357), excision or amputation will not unfrequently be required. 656 DISEASES OF JOINTS. 3. Bony Anchylosis in a Good Position.—If a joint be affected with bony anchylosis, and in such a position as to retain the usefulness of the Fio. 356.—Anchylosis of knee-joint in position of Fia. 357.—Chronic arthritis of knee-joint, over-extension. (From a patient in the Episcopal with partial anchylosis in bad position. (From Hospital.) a patient in the Episcopal Hospital.) limb, prudent surgery would dictate that no operation should be resorted to ; an exception may occasionally be made in the case of the elbow, which may be in some instances advantageously excised under these circum- stances. P. H. Watson and Annandale prefer to an ordinary excision of the elbow, a partial operation in which the lower portion of the humerus only is removed. 4. Bony Anchylosis in a Bad Position.—Various operations have been employed to remedy bony anchylosis under these circumstances. Hip.—Dr. J. Rhea Barton, of this city, in the year 1826, treated a case of osseous anchylosis of the hip by sawing through the femur between the trochanters, thus allowing the limb to be brought into a straight position; the. patient recovered, as was anticipated, with an artificial joint, which remained movable for several years. This operation is often said to have consisted in the excision of a wedge-shaped piece of bone, but a reference to the original account of the case shows clearly that but one section was made with the saw. In 1830, Dr. J. Kearney Rodgers, of New York, improved upon Barton's operation by removing a disk of bone from be- tween the trochanters, the portion exsected being half an inch thick at its outer, and three-quarters of an inch thick at its inner, side; the operation proved successful, the mobility* of the new joint persisting after two and a half years. In 1»62, Dr. Sayre, of Xew York, still further improved upon Rodgers's procedure, by removing a segment of bone from between the trochanters, the upper section being semicircular, with itsconcavity downwards, andthe upper end of the lower fragment being rounded off, so as to imitate as closely as possible the natural form of a ball-and-socket joint. A somewhat similar TREATMENT OF ANCHYLOSIS. 657 operation has been employed by Volkmann. Dr. H. Leisrink has tabulated ten cases, in which one or other of these operations was resorted to, which, Fia. 359.—Bigg's apparatus for con- traction of the knee. Fin. 358.—Barwell's splint for making continuous extension in cases of anchylosis of the knee. with Barton's original case, one referred to by Mr. Holmes, and others in the hands of Textor, Post, Peters, Volkmann, and Walter, of Pittsburgh, who has operated on both hips of the same patient, give 23 operations (on 22 persons), of which seven are known to have proved fatal—a mortality which, though large, is less than has followed ordinary excision of the head of the femur for anchylosis, two out of four cases of the latter operation having terminated in death. Dr. Poore's statistics show a still better result, 35 cuneiform sections having given, according to this writer, 28 recoveries, 2 failures, and only 5 deaths. W. Adams has more recently suggested a return to Barton's method, the section, however, being through the neck of the bone, and the operation being subcutaneous, while no attempt is made to secure a movable joint; the operation thus modified has been performed, according to Dr. Poore, in sixty-eight cases, of which fifty-six ended in cure, six in death, and six in failure, showing a mortality of less than nine per cent. This procedure, therefore, though inferior to those of Sayre and Volkmann, as regards the ultimate result,1 when that is successful, seems to be less dangerous than any of the other methods which have been proposed, and should be preferred in most cases, particularly- as the mobility of the pelvis compensates in a great degree for the loss of a movable articulation. Tillaux reports a case suc- cessfully treated by fracturing the neck of the femur, and Gant, Maunder, and other surgeons, have successfully divided the thigh-bone below the lesser trochanter—Gant with a saw, and Maunder and his followers with chisels. Of 64 operations in this situation analyzed by* Dr. Poore, 54 1 In Sands's, Jessop's, and Lund's cases, however, movable joints were obtained. 42 658 DISEASES OF JOINTS. ended in recovery, 4 in failure, and 6 in death, a mortality of a little over 9 per cent. Barwell employs a chain-saw, and divides the bone between the trochanters, as in Barton's original method. 1 have myself emjiloyed Fig. 360.—Adams's saw for subcutaneous division of the neck of the femur. either Adams's or Gant's operation in twenty cases (in three cases ujion both sides, Figs. 361-364) and in every instance with a favorable result. The choice between the operations should depend upon the condition of the articulation; when the cervix femoris is not materially altered in form, Adams's plan may be preferred, but in other cases section below the tro- Figs. 361, 362.—Subcutaneous osteotomy of both thigh-bones for anchylosis following hip-disease" (From a patient in the Children's Hospital.) chanter is better, and may be safely employed even in cases of fibrous an- chylosis in strumous subjects. I make the incision, or rather puncture, on the outer side of the limb, pass the saw flatwise in front of the femur, and then, turning its edge backwards, divide the bone in an antero-pos- terior direction. Figs. 365 and 366, from electrotypes kindly given me by Dr. H. R. Wharton, show the occurrence of firm bony union after such an operation. Barton's operation has been, according to Chelius, successfully employed (by Van Wattman) in a case of bony anchylosis of the elbow, and a similar procedure, or, which would be better, subcutaneous section, as practised by Mears for old dislocation, might be properly resorted to if it should be necessary to interfere in a like condition of the shoulder. Knee.—Barwell recommends (in case of bony anchylosis of the knee) that, in persons under fourteen years of age, advantage should be taken of TREATMENT OF ANCHYLOSIS. 659 the fact that the upper epiphysis of the tibia is, at this time of life, not yet united to the shaft, to straighten the limb by producing an epiphyseal frac- Flus. 363, 364.—Anchylosis of both hips; subcutaneous osteotomy below the trochanters. (From a patient in the University Hospital.) ture—the upper truncated end of the diaphysis then resting against the angular edge of the epiphyseal end, and the limb being shortened by little more than an inch. This mode of treatment is, according to Barwell, quite satisfactory and entirely* free from risk. In a case of bony anchylosis of Figs. 865, 366.—Bony union after subcutaneous osteotomy of the femur. the knee, in a bent position, Dr. J. Rhea Barton, in 1835, removed a wedge- shaped piece of bone from the front of the femur, immediately above the condyles; the portion of bone did not involve the entire thickness of the shaft, the posterior shell of bone which was left, slowly yielding as the limb was, subsequently, gradually brought into an almost straight line. The result was entirely satisfactory, the thigh becoming firmly* united in its new position. In 1844, Dr. Gurdon Buck, of New York, modified this jirocedure by exsecting a wedge-shaped mass embracing the entire thickness of the bone, and containing the condyles of the femur, head of the tibia, and patella, performing, in fact, what has since been called " excision in a 660 DISEASES OF JOINTS. block." In 1853, the same surgeon, in a case of fibrous anchylosis, sub- stituted for the removal of a wedge-shaped mass, an ordinary excision of the knee-joint, the parts being subsequently held together with silver wire. Culbertson has collected fourteen cases of Barton's operation, to which should be added three others (successful) by Blackman, of Ohio, J. E. Adams, of London, and Kilgarriff, of Dublin, making in all seventeen cases with two deaths, while one or other of Buck's methods appears, according to the same author, to have been employed thirty-nine times with five deaths—the mortality of the former operation being thus 11.8, and that of the latter about 12.8 per cent.1 A safer method consists in subcutaneously perforating the anchylosed joint in various directions by means of a suitable drill (Fig. 128), the re- maining bony adhesions being then forcibly ruptured, and the limb being, after a few days, gradually brought into a straight position by an extending apparatus. This operation appears to have been first suggested by Mal- gaigne, who proposed to use a chisel and mallet (as has since been done by L. S. Little and Maunder), though Dieffenbach had previously suggestea separation of the united joints by means of a chisel and saw—not, however, used subcutaneously. Brainard, of Chicago, in 1854, proposed to apply the drill to the bone immediately above the joint, and the first operation upon this plan was performed by Pancoast, of this city, in 1859. Brainard subse- quently apjilied the drill to the knee-joint itself, and the operation has since been repeated upon several occasions by Prof. Gross and others. Nine cases, collected by S. W. Gross in 1868, had proved uniformly successful. Section of the femur above, and, if necessary, of the tibia and fibula, also, below the joint, with chisel and mallet, has been employed with great success by Mr. Barwell. These procedures are certainly preferable to the others that have been proposed, being not only attended with less risk of life, but having the great advantage of not shortening the limb by the removal of any portion of bone. In a case of great deformity of the knee from injury, without, however, complete anchylosis, I divided the femur just above the condyles with Adams's saw, and then, having straightened the limb, put it up in plaster of Paris. The result was satisfactory, though the patient still required the support of a leather splint when I last heard from him. Loose Cartilages in Joints. The name " loose cartilage" is given to certain bodies which are met with in joints, and which are very analogous to the rice-like bodies de- scribed as occurring in compound gan- glia, and in diseases of synovial bursal. These loose cartilages have, according to Rainey, as quoted by Barwell, a distinct investing membrane of a fibro-cellular character, and are found on section to consist of two layers, one fibro-cartilagi- nous, and the other resembling bone. They appear, in most instances, to origi- nate in a transformation of the villous or fringe-like processes of the synovial mem- brane, being thus at first attached by narrow pedicles to the parietes of the joint, but subsequently often becoming isolated. They are, according to R. Fig. 367.—Trochlea of humerus ; showing formation and connection of loose cartilag- inous bodies. (Miller.) 1 Other successful cases, operated on by Buck's first method, have since been re- corded by Morton, of this city, and by Vauce, of Louisville. LOOSE CARTILAGES IN JOINTS. 661 Adams, especially* met with in cases of rheumatoid arthritis, and are most common in the knee, though occasionally seen in other joints. Usually quite small and round, they* are sometimes found as large as a chestnut, and flattened or elongated. They may be single, or may coexist in large numbers. According to Teale and Paget, these bodies are in some cases actually fragments of articular cartilage, which are separated by a slow process of exfoliation following necrosis, the result of injury. This is, how- ever, denied by Prof. Humphry, with whose view upon this point my own observation leads me to agree. Fatty* and sarcomatous growths in the knee-joint have been observed by* various surgeons, including Barwell, Volkmann, Weir, and myself. Symptoms__If closely* attached, these bodies may give rise merely to weakness of the joint, with a tendency* to intra-articular effusion, but if floating or loose, they are apt to be caught between the opposing joint surfaces—this occurrence causing intense pain, sometimes accompanied with nausea or syncope, and the patient being unable to move the joint, and sometimes falling, while rajiid synovial effusion commonly supervenes. These symptoms, it will be seen, closely resemble those of dislocation of the semilunar cartilages (see page 313). Treatment__This may* be palliative or radical. The palliative treat- ment consists in supporting the joint by means of an elastic bandage, so as to restrain its motion and lessen the risk of the loose body becoming caught between the articulating surfaces. Hilton advises that the loose cartilage should be fixed in contact with the synovial membrane, by means of adhe- sive strips applied externally, when absorption of the foreign body may often be obtained. Richet employs a ring with sharp points which trans- fix the cartilage and hold it in position until it adheres. Hadden, of New York, uses a small truss for the same purpose. The radical treatment, which consists in removing the foreign body, either by direct or by sub- cutaneous incision, is attended with considerable risk to life, the mortality of the direct operation being, according to H. Larrey's and Barwell's sta- tistics, 18, and of the subcutaneous procedure 7.6 per cent. Hence neither should be emjiloyed, unless the disease be attended with so much suffering as to make interference absolutely necessary-. The direct operation con- sists in making a sufficiently free incision over the loose cartilage, which is firmly fixed between the surgeon's finger and thumb, the skin being drawn to one side so as to make a valvular opening, as recommended by B. Bell. The loose cartilage is then squeezed out through the cut, which is immediately closed, while the limb is kept at rest upon a splint. Any inflammation which may follow is to be treated upon the principles already laid down.1 The subcutaneous operation, which, though much safer, is more difficult and more likely to result in failure, consists in fixing the loose cartilage as before, and dividing the synovial membrane over it with a long tenotome passed subcutaneously beneath the skin; the foreign body is then squeezed into the periarticular areolar tissue, where it mav be left to be absorbed, or from whence it may be removed by direct incision, after some days' interval, as advised by Goyrand. Another plan, introduced, and successfully practised in 25 cases, by Square, of Plymouth, is to squeeze the loose cartilage into, but not through, the subcutaneous open- 1 When performed with the precautions of the antiseptic method, the risks of this operation are reduced to a minimum. Eighteen cases treated in this way, collected by J. H. Morgan, all terminated successfully. Gaujot, however, finds that 29 cases oper- ated on with Listerian precautions gave two deaths, while 18 cases treated without antiseptic measures gave only one death. In a case recorded by Weir, suppuration followed in spite of antiseptic precautions, and required amputation. 662 DISEASES OF JOINTS. ing in the synovial membrane, fixing the foreign body in that position by means of a compress and adhesive strips. The point at which the incision is to be made, in the case of the knee, which is the joint usually affected, is to the inner side of, and a little below, the patella. If the cartilage can- not be fixed by the surgeon's fingers, MacCormac's plan may be adopted, and the offending body transfixed with a needle or fine trocar. If there be more than one loose cartilage, it may be necessary to repeat the operation at a subsequent period. Articular Neuralgia. (Hysterical Joints.) Intense pain in a joint may arise from various causes unconnected with disease of the articulation itself. Thus, pain in the knee is, as we have seen, a common accompaniment of hip disease, and the same symptom may arise from other circumstances, as the pressure of a tumor or an aneurism. Occasionally*, however, intense neuralgic pain is felt in a joint, accompanied perhaps with slight swelling and redness, and attended with spasmodic action or, more often, rigid contraction of the neighboring muscles, and yet not dependent upon any perceptible organic change. These cases are chiefly, though not exclusively, met with in women, and usually in those who present other evidences of hysteria. The credit of first forcibly direct- ing the attention of surgeons to the true nature of these cases is undoubt- edly due to the late Sir Benjamin C. Brodie, and the subject has since been ably illustrated by Sir James Paget, who describes these, and similar cases, as instances of neuromimesis or nervous mimicry of disease. The joints most often affected are the knee, hip, and ankle, though a similar condition is occasionally seen in the elbow and shoulder, and perhaps in the vertebral column. Diagnosis.—The diagnosis from arthritis may be made by observing the diffused and superficial character of the pain and tenderness, which are not increased by pressing together the joint surfaces (as would be the case in arthritis), and are not attended with the other signs of inflammation, and with the constitutional disturbance, which would be present in an ordinary case of joint-disease. The rigid contraction will often disappear, if the patient's attention be suddenly called away, and if an anaesthetic be given, the motions of the limb will be found to be unimpaired. Treatment.—This consists in the adoption of measures to improve the state of the patient's general health, particularly by attention to the diges- tive functions, and by the use of tonics and antispasmodics, with the cold douche and frictions to the affected joint. If contraction exist, the limb may be straightened while the patient is in a state of anaesthesia, and may be kept for a few days subsequently upon a suitable splint. Moral treat- ment is quite as important as physical, and the patient should, if possible, be induced to co-operate with the surgeon in the adoption of the means employed to promote recovery. In the belief that the disease is mental, it is sometimes advised to work upon the patient's imagination by pretending to perform an operation for her relief; though such a course may* occasion- ally succeed, I believe that the surgeon will do better, in the end, by dealing perfectly honestly with his patient, and by avoiding even the appearance of deception. It is almost needless to say that such heroic measures as ampu- tation or excision, or even the application of the actual cautery, would be totally unjustifiable in the cases under consideration. Meyer recommends the application of an induced current of electricity to the affected joint. INDICATIONS FOR EXCISION IN GENERAL. 663 CHAPTER XXXII. EXCISIONS. Excision in General. The operation of resection, in cases of compound fracture and disloca- tion, appears to have been known to the ancients, and, in the case of fracture, was occasionally practised in later times, as is shown by references to the operation in the writings of Salmon and Wiseman, but as regards dislocation was entirely forgotten until revived in the first half of the last century by Cooper, of Bungay, who removed the lower ends of both tibia and fibula for compound dislocation of the ankle. The first excision for disease of a joint apjiears to have been that performed by Filkin, of Nor- wich, in 1762, in a case of arthritis of the knee. The history of the introduction of the operation of excision into the practice of surgery, is a subject of much interest, but cannot be entered upon within the limits of this work; the reader is respectfully referred, for information upon this matter, to the able monographs of O. Heyfelder and Hodges, and to my article in the International Encyclopaedia of Surgery. The applicability of excision to the various traumatic lesions of bones and joints, and to deformity resulting from anchylosis, has already been considered in pre- vious chapters (see pp. 175, 225, 655); and I shall therefore, in the follow- ing pages, confine myself to a description of the operative procedure in the different regions of the body, and to a consideration of the applica- bility of excision to diseases of bones and joints, especially to caries and arthritis. Indications for, and Contra-indications to, Excisions in General.—1. Excision is indicated (1) in case a bone or joint is so ex- tensively* diseased that its removal is imperative; here the question is between amputation and excision, and the latter operation should always be preferred, provided that the circumstances of the particular case admit of a choice. (2) Excision is sometimes justifiable where the amount of disease is not sufficient to warrant amputation, and yet where the time which would be required for a spontaneous cure would be so long as to render operative interference proper, or where the utility of the limb would be less after a spontaneous cure than it would be after removal of the joint; as in the elbow, where a cure by anchylosis would be particularly undesirable. 2. Excision is, on the other hand, contra-indicated by (1) the extent of diseased bone being so great that its removal would render the limb an in- cumbrance, and less useful than a well-formed stump ; this is particularly the case in the lower extremity, but in the arm, provided that the hand be preserved, very considerable portions of bone may often be properly removed. (2) Excision should not as a rule be practised in cases of acute disease, experience showing that amputation is under such circumstances better tolerated. Hence, if operative interference be necessary to preserve life, in a case of acute bone or joint disease, amputation will usually be indi- cated ; excision of the shaft of a bone may, however, be occasionally proper in cases of acute necrosis from subperiosteal abscess (see page 631). (3) If the soft tissues around a diseased bone or joint be extensively dis- 664 EXCISIONS. eased, infiltrated with lowly organized lymph, and riddled with sinuses, the result of an excision is less apt to be satisfactory than under opposite circumstances, though the operation is not absolutely contra-indicated by such a condition. (4) Either extreme of life is considered unfavorable to excision, on ac- count of the long period required for recovery* after the ojieration, and, in the case of early childhood, on account of the risk of interfering with the growth of the limb, which is chiefly dependent upon the integrity of the epiphyseal cartilages. Bceckel, of Strasburg, however, from an examina- tion of over twenty* cases of arrested development,1 concludes that the shortening is less due to injury of the epiphyseal cartilages than to disuse of the limb owing to pain or to muscular atrophy—causes which would be equally active if excision were not jierformed. This is confirmed by my own observation in a case of disease of the knee of twenty'-three years' duration, in which the leg was by measurement four inches shorter than its fellow ; by excising the joint and straightening the limb, which was much contracted, though a considerable portion of bone was of course re- moved, I gave the patient a limb which was practically two inches longer than it had been before the operation. (5) A bad state of the general health, particularly if dependent upon organic visceral disease, as of the lungs, liver, or kidneys, must always be considered a contra-indication to excision. The long confinement which usually follows the operation, with perhaps long-continued and exhausting suppuration, will seriously complicate the chances of recovery in such a case. Hence, if any operation at all be required in a patient suffering from advanced phthisis, or from Bright's disease, amjiutation will usually* be the preferable procedure. From the above remarks, it will be seen that, while excision is, in suit- able cases, an admirable and truly conservative operation, and in every way superior to amputation, yet it is, after all, only applicable in selected cases ; hence it is obviously unfair to attempt, as has been sometimes done, to prove that excision is a less fatal operation than amputation, by a com- parison of the statistical results of the two procedures—one being habitu- ally reserved for favorable cases, while the other is indiscriminately applied to all the remainder; greatly as I admire the operation of excision, I can- not but believe that, caeteris paribus, it is, in every region of the body, at least as fatal as the corresponding amputation. Process of Repair after Excision—The growth of the long bones in thickness is accomplished by means of the periosteum, and in length by means of the epiphyseal cartilages. Hence, in excising portions of the shafts of bones, it is of the utmost importance to preserve the periosteum, by the osteo-genetic power of which it may be hoped that the excised jior- tion will be reproduced; another advantage of subperiosteal excision is that, by preserving the membrane in question, the attachments of the various muscles are not disturbed. If the periosteum cannot be jireserved —and this can rarely be done in excisions of the short bones, as of the calcaneum—repair is effected by the wound filling with granulations, which are subsequently transformed into a dense, fibrous, cicatricial mass. In excisions of the joints (particularly among patients who have not attained their full height), it is important not to remove the entire epiphysis, nor even to encroach upon the epiphyseal line ; for, if this be done, the subse- 1 Oilier recommends in such cases an excision of the epiphyseal cartilage of the sound limb, so as to induce such shortening as will correspond with that of the other. The use of a high-soled shoe would seem to me less dangerous. OPERATION OF EXCISION IN GENERAL. 665 quent growth of the limb will be deficient. This is especially important in the case of the knee, the lower epiphysis of the femur and the upper of the tibia being chiefly concerned in the growth of the lower extremity. When this precaution is observed, the shortening is comparatively slight, and, indeed, temporary elongation may occur, as in cases of osteitis and arthritis (see pages 620, 642). An attempt may properly be made to preserve the periosteum in articular resections, particularly when, as in the case of the shoulder, elbow, or hip, a movable joint is desired—the effect of retaining the periosteum in these cases being, as shown by Oilier, to improve the shape of the new articulating surfaces, which measurably approach the form of those which were removed ; in the knee, where the great object is to obtain firm bony union, the subperiosteal character of the operation is not so essential, though still desirable, as tending to diminish the amount of consecutive shortening. Operation of Excision in General__The knives ordinarily re- quired for the operation of excision are scalpels and straight bistouries, which should be pretty thick at the back, and set in strong handles ; a strong probe- pointed knife, with a limited cutting edge, will also be found useful for clearing the soft parts from the bones in the deeper portions of the wound. Bone forceps of vari- ous sizes and shapes will be required, the most important being strong cutting pliers, and the lion-jawed forceps designed by Fergusson (Fig. 368). Gouges and gouge-forceps will also be found useful for dealing Fig. 369.—Butcher's saw. with carious bone. The saw which I prefer, in most cases, is that designed by Butcher, of Dublin (Fig. 369), which has the great merit of allowing the blade to be fixed at any angle, or even completely reversed, so as to cut from below upwards, and thus preserve the soft parts from injury. In certain cases (as in excisions of the hip), the chain saw (Fig. 370) is more convenient than any other instrument. The chain may be slipped over the part to be removed, or may be applied by the aid of a strong curved needle, or an ingenious conductor devised for the purpose by Dr. Buck, of New York. If an ordinary saw be employed, a spatula or re- tractor must be slipped beneath the bone in order to guard the soft parts ; a good instrument for the purpose is the " resection sound" of Blandin, or the probe-pointed grooved retractor described by Dr. D. Prince, of Jacksonville, Illinois; or, which in some cases will prove satisfactory, an ordinary broad lithotomy staff, grooved on the back, which may be readily 666 EXCISIONS. slipped around the bone, and then turned with its convexity upwards. Another instrument which I have found of value, is the knife-bladed forceps of Mr. Butcher (Fig. 371). This cuts like a pair of scissors, and is very efficient in removing the thickened and degenerated synovial tissues, which, if allowed to re- main, are apt to slough and impede the progress of cure. The particular operative procedures re- quired for excision in various regions of the body differ of course according to the parts to be removed; it may be stated, however, in general terms, that the ex- ternal incisions should be sufficiently free, and as much as possible in the direction of the muscular intersjiaces, so as to avoid unnecessary destruction of tissue. The incisions should, if practicable, include any sinuses that may be present, and should be made so as to avoid injury to the principal vessels and nerves. The pe- riosteum should be preserved, if possible, and the amount of bone re- moved should be as small as may be consistent with the thorough extir- pation of the diseased structure. It is a good plan, in excising joints, to remove but a thin layer with the saw, and then to attack any necrosed Fio. 371.—Butcher's knife-bladed forceps for excisions. or carious spots with the gouge or trephine. The epiphyseal line should never be encroached upon in children, and, even in adults, it is important not to lay open the medullary canal. Care must be taken not to mistake bone which is merely inflamed and softened (medullized), for that which is carious, nor bone thickened and roughened by inflammation, for that which is necrosed. The skin and other soft tissues, no matter how much altered in appearance, should be as a rule preserved entire—the flaps, though at first redundant, ultimately shrinking and resuming their natural condition. The degenerated synovial lining of the joint may, however, be advanta- geously cut away with the knife-bladed-forceps; and, indeed, Volkmann goes so far as to advise complete " extirpation" of the joint capsule. All bleeding should be checked, by ligature or otherwise, before the wound is closed, as it is very important that, when the limb is once adjusted, it should not be disturbed for several days. The ordinary antiseptic dress- ings should be emjiloyed, and precautions must be adopted to secure free drainage, by the arrangement of the incisions and by the use of Chas- saignac's tubes. Concentrated food, with tonics and stimulants, may be required during convalescence. Finally, although the case should not progress as favorably as may be wished, the surgeon must not hastily conclude that the operation has failed, and that amputation is necessary ; even if caries or necrosis should recur in the sawn bony extremities, a re-excision may often be attended with a satisfactory result EXCISION OF THE SCAPULA. 667 Special Excisions. Scapula.—Excision of the scapula, complete or partial, may be required for various causes, such as caries, necrosis, tumors, and some forms of injury, though in traumatic cases it is often necessary to remove the whole upper extremity as well (see page 123). The operation may be done with a crucial incision, or, which is probably better in most cases, a T-shaPed incision, as recommended by Syme, the transverse branch of the cut run- ning from the acromion to the posterior edge of the bone, and the other passing downwards, at a right angle from the centre of the former. If the operation be for tumor, the incisions should be merely skin-deep, the flaps being dissected off without cutting into the growth, which may, probably, be very vascular. It is advised by Fergusson and Pollock to liberate the posterior border of the scapula first, and then the inferior, turning up the bone from below- upwards as the operation proceeds. By this plan the subscapular artery can be controlled by the'finger before division, and the risk of hemorrhage is thus considerably lessened. The subclavian artery should be compressed by an assistant throughout the whole procedure. In cases of malignant disease, the whole scapula should be excised, but under other circumstances a partial operation may suffice, there being certainly an advantage in retaining the head of the bone, acromion, and coracoid, when there is no reason for their removal. The clavicle should not be interfered with unless it be itself diseased. After the operation, the arm should be supported in a sling, and an axillary pad may be sometimes advantageously employed for a few days. Cases of Total Excision of the Scapula, the Arm being Preserved. No. Operator. Result. No. Operator. Result. 1 Agnew, Died. [ed. 27 Michaux, Recovered. 2 Bellamy, Undetermin- 28 Michel, " 3 Billroth, Recovered. 29 Nixon, <( 4 Bird, deaths, the termination of one being unknown. Cases of Total Excision of the Scapula, subsequent to Amputation at the Shoulder. Ko. Operator. Result. No. Operator. Result. 1 Blair, Undetermin'd 11 Lange, Recovered. 2 Buck, Recovered. 12 Langenbeck, " 3 Busch, ti 13 Mussey, << 4 Con ant, 11 14 Rigaud, ti 5 Conklin, n 15 Id. " 6 D'Ambrosio, Died. 16 Soupart, Died. 7 Deroubaix, Recovered. 17 Stimson, Recovered. s Fergusson, t c 18 Swaine, Died. 9 Jeaffreson, (i 19 Wood, " 10 Krakowizer, Died. Total is thus but little less successful than partial excision, 206 cases of which operation, to which I have references, having given 49 deaths, or nearly* one in four. Clavicle, Ribs, and Sternum__The clavicle may require partial, or in rare instances, complete excision, on account of caries, necrosis, tumor, or compound fracture. The inner extremity of the bone may also require resection, if it be so displaced as to produce dangerous compression of the oesophagus or trachea. In cases of necrosis, the operation may be made subperiosteal, and presents no particular difficulties, a simple incision fol- lowing the course of the bone being sufficient for the purpose. In cases of tumor, the operation is both difficult and dangerous, the principal risks being from hemorrhage and the entrance of air into the veins. Complete extir- pation of the clavicle was first practised by McCrearry, of Kentucky, in 1811,1 and has since been occasionally repeated. Statistics of extirpation of the clavicle have been published by several writers, including the late Dr. Otis and Prof. Agnew, but the mistake has usually been made of swelling the list by embracing instances of partial excision, such as Dr. Mott's famous case, or of excisions a deux temps, such as those of Xelaton and Gunn, in each of which several months intervened between the removal of the outer and that of the inner portion of the bone. The following table includes only 33 cases, but they all appear to have been actual extir- pations of the entire clavicle at one sitting:— Remmer's operation, in 1732, was only a partial excision. EXCISION OF THE SHOULDER-JOINT. 669 Cases of Total Excision of the Clavicle. No. Operator. Result. Recovered. No. Operator. Result. 1 Biangini, 18 McCrearry, Recovered. o Blackman, a 19 Mazzoni, !< 3 Bo we, 11 20 Meyer, " 4 Briggs, a 21 Morin, It 5 Britton, l< 22 Owen, (( 6 Carswell, l( 23 Palmer, Died. 7 Cooley, it 24 Porquet, Recovered. 8 Curtis, a 25 Roux, Died. 9 Dawson, " [ed. 26 Segond, " 10 Despres, Undetermin- 27 Sloan, Recovered. 11 Esmarch, Recovered. 28 Travers, (< 12 Eve, Died. 29 Varick, tt 13 Field surgeon, " 30 Warren, Died. 14 Heyfelder, a 31 Wedderburn, Recovered. 15 Irvine, Recovered. 32 Wheeler, " 16 Kronlein, " 33 Wutzer, (< 17 Kuust, ii Of the whole 33 cases, only 7 proved fatal, a mortality of less than 22 per cent. I have not myself had occasion to excise the whole clavicle, but in the summer of 1884 I removed the inner two-thirds of the bone for a large osteosarcoma, in a case sent to me by my colleague Prof. Agnew. The patient, a young girl, made an excellent recovery from the operation, but died some months afterwards from a recurrence of the malady. These partial excisions of the clavicle vary in severity- from comparatively- trifling affairs to such grave operations as those of Mott and Bartlett, and that of my own just referred to. Of 76 cases of the kind to which I have refer- ences, 61 ended in recovery and 10 in death, the result in 5 being unknown ; the mortality* of determined cases therefore was but little over 14 per cent. Trueheart reports a case of partial excision of the clavicle successfully sup- plemented by the use of periosteal and osseous grafts from a dog. Portions of the ribs have been frequently excised in cases of caries, necrosis, compound fracture, wound of an intercostal artery, etc. The operation is not particularly difficult, but, except in cases of necrosis, when the periosteum can be detached, is attended with considerable risk of in- jury* to the pleura or even the peritoneum. Thirty-seven cases mentioned by Heyfelder gave eight deaths. Besections of the ribs for tumor have been performed by Langenbeck, Warren, McClellan, Kolaczek, Fischer, Park, and other surgeons. Alsberg records a remarkable case in which, beside portions of several ribs, a segment of the diaphragm was excised, and Kronlein one in which beside three ribs the pleura and a portion of lung were successfully resected. Excision of one or more ribs may like- wise be employed in cases of empyema. (See p. 395.) Kbnig has rejiorted a remarkable case of excision of the entire sternum for sarcoma: the pericardium and both pleural cavities were opened, the wound became gangrenous, and the heart was " surrounded with pus ;" after which healing slowly occurred, and the patient ultimately recovered. Resection of the sternum has also been practised by Le Fort, for caries, and by Kiister, to facilitate removal of a tumor from the mediastinum. Resection of the ensiform cartilage has been successfully employed by Linoli and Rinonapoli, Italian surgeons. Shoulder-joint.—Excision of the scapulo-humeral articulation, or of the head of the humerus, may be required in cases of arthritis, caries or 670 EXCISIONS. Fia. 372.—Excision of shoulder- joint ; longitudinal incision (Erichsen.) necrosis, compound fracture or dislocation, or non-malignant tumor. For malignant disease the operation is, as a rule, undesirable, as almost certainly exposing the patient to a recurrence of the affection. The operation may be con- veniently performed by making a single longi- tudinal incision, beginning somewhat to the outside of the coracoid process, and carried downwards and slightly- outwards—jiassing be- tween the fibres of the deltoid muscle, in the line of the bicipital groove for about five inches. The long head of the biceps being held to one side, the capsule is divided, and the tuberosities of the humerus freed by the use of the probe- pointed knife, when the head of the bone may be thrust through the wound and removed with a chain saw, or, in young children, with strong cutting forceps. If the glenoid cavity be dis- eased, it may then be attacked with the gouge- forceps, or may, if necessary, be exposed for the application of the saw by a transverse cut, as directed for excision of the scapula. Hemorrhage having been arrested, the wound may be accurately closed with sutures, one or more drainage-tubes being introduced, and the arm then supported with a sling and axillary pad, or a Stromeyer's cushion. In some cases, as of tumor, the longitudinal incision may not suffice to give access to the part, and the surgeon may then raise a flap by means of a V-snaPed cut, or one in the form of a ~|, "["> or U> as mav De thought most convenient. These all have the common disadvantage of involving a transverse division of the fibres of the deltoid, and of therefore protract- ing the healing process, as well as of entailing subsequent weakness of the limb. The first formal excision of the head of the humerus for disease appears to have been performed by Bent, of New Castle (England), in 1771, while the first complete excision of the shoulder-joint was performed by the elder Moreau, in 1786. Shaeffenberg's and Thomas's operations (1726, 1740) are, according to Gurlt, not to be regarded as true excisions. The opera- tion is quite a successful one, considering- its magnitude, 169 cases of excision for all causes having given, according to Heyfelder, but 30 deaths, a mortality of less than 18 per cent. If excisions for disease alone be considered, the sta- tistics show* an almost equally favorable result, 115 cases tab- ulated by Culbertson giving 94 recoveries and but 21 deaths. The preserved arm is known to have been useful in more than three-fourths of the successful cases. Six cases of this operation in my own hands have given excellent re- Fig. 373.—Result of excision of shoulder-joint. (From a SU'tS ( . XS- V%)> aS "1(* * patient in the University Hospital.) Seventh in which, at a Second EXCISION OF THE ELBOW-JOINT. 671 operation, I removed all the remaining portion of the humerus. The risk which attends this procedure is indeed so moderate as to render shoulder- joint excision one of the most satisfactory of surgical operations. Humerus__Excision of the shaft of the humerus may be occasionally required in cases of compound fracture, especially as the result of gunshot injury (see page 179), or may* sometimes be necessary in cases of caries or necrosis. Resection is also not unfrequently called for in the treatment of ununited fracture, and when performed with the precautions recommended by Oilier, of Lyons, and by Bigelow, of Boston, is quite a successful pro- cedure (see page 251). The operation consists in making a single longi- tudinal incision on the outer side of the arm, in one of the muscular inter- spaces, and, after carefully dividing and stripping off the periosteum (which should alway*s'be preserved), removing as great an extent of bone as may be thought necessary with a chain saw ; the resected bony extremi- ties should then be approximated and held together by means of a strong metallic suture, and the limb placed at rest on a suitable splint. Care must be taken not to wound the musculo-spiral nerve. Macewen, of Glasgow, has reported a case in which reproduction of a humerus was effected by transplanting grafts of bone taken from other patients, and Banks, of Liverpool, one in which the same operation was successfully employed upon the tibia. Dr. Trueheart, of Texas, has successfully grafted perios- teum from a dog. Elbow-joint.—Excision of this articulation may be required for chronic disease of the joint, for bony* anchylosis, or for compound fracture or luxation. The lower end of the humerus was resected by Wainman (in 1758 or 1759) and afterwards by Tyre, while the olecranon and upper part of the ulna were removed by Justamond, about 1783; but the first complete excision of the elbow-joint was per- formed by* the elder Moreau, in 1794, in a case \ of chronic disease of the articulation. The ^ operation may be conveniently done (as origi- . --lliMHPIIPS"'"---^-^ nally* suggested by Park) by means of a single \ • horseshoe, or se- milunar, incision was first practised by Mackenzie, and is still preferred by many surgeons. This method consists in raising an anterior flap containing the patella, the base of the flap reaching to above the condyles. The ligamentum patellae is divided in the first incision, when, the crucial and lateral ligaments being cut, the articulating extremity of the femur can be readily excised with a Butcher's saw. The limb being then flexed and forcibly thrust upwards, the extremity of the tibia can be made to protrude, and may be removed with the same instrument. The best, in my judgment, is the simple transverse incision across the front of the joint, which was suggested by Park, but which appears to have been first employed by* Textor, Kempe, of Exeter, and Fergusson. It makes a smaller wound than either of the other methods, and has proved quite satisfactory in fifty-four cases in which I have employed it. It is to be observed, however, that an incision which is transverse to the axis of the tibia, when the limb is flexed to a right angle (as it frequently* is in these cases), will, when the excision is completed and the limb extended, form an obliquely curved wound, with its convexity downwards, so that this is in many cases really a flap-operation. The incision should reach on either side to the posterior edge of the base of the condyle (so as to secure drainage), and should at its centre come far enough forward to pass below the patella. The joint having been laid open, the skin and fascia are dis- sected up as far as may be necessary, and an incision then made directly Figs. 385, 386.—Extremities of femur and tibia removed by excision of knee-joint. (From a specimen in the museum of the Episcopal Hospital.) 1 Treves, of Margate, reviving the plan of Jeffray and Se"dillot, recommends lateral incisions without any transverse wound, while Oilier, in traumatic cases, employs a single longitudinal incision, splitting the patella into two halves, which are after- wards joined by sutures. The same surgeon, in operations for disease, makes a small H incision, with additional lateral wounds for drainage, removing the patella. Gold- ing-Bird, following Volkmann, divides the patella transversely (trans-patellar excision), and brings the fragments together again with sutures of carbolized silk. EXCISION OF THE KNEE-JOINT. 681 down to the bone in the line of proposed section; the lateral and crucial ligaments (if these remain) having been next divided, the blade of Butcher's saw is applied beneath the bone, which is cut through from below upwards. In sawing through the articulating extremity of the femur, the natural obliquity of this bone should be borne in mind, and the section made in a line parallel to that of the free surface of the condyles ; if this be neglected, and the section be made transverse to the axis of the femur, the limb after adjustment will be found to be markedly bowed outwards. It should also be remembered that the situation of the epiphyseal line is somewhat higher on the anterior than on the posterior surface of the thigh-bone—so that it may be given as a safe rule, that, as suggested by Billroth, the section of the condyles should be in a plane which,as regards the axis of the femur, is oblique from behind forwards, from below upwards, and from within outwards. The section of the tibia should be in a plane transverse to the long axis of the bone, with a slight antero-posterior obliquity so as to cor- respond with that of the section of the condyles. The epiphyseal cartilage of the tibia is less important for growth than that of the femur, and need not therefore be so scrupulously respected. The patella should be removed, whether it be or be not diseased ; it is shown by Peiiiere's researches that, while its excision diminishes the risk of death by nearly one-third, its retention more than doubles the probability of subsequent amputation becoming necessary. The bone sections being made, and the patella re- moved, the operation is completed by clipping away with scissors curved on the flat, or with Butcher's knife-bladed forceps, all the fungous and degenerated synovial lining of the joint, taking care, however, not to sacri- fice the posterior ligament, which serves a useful purpose in preventing displacement, and in protecting the important structures in the popliteal space. If the bursa below* the quadriceps femoris be involved, it may be opened by an incision on the outer side of the limb, and either dissected out or thoroughly curetted with Volkmann's sharp spoon. The limb should be dressed while the patient is yet in a state of anaesthesia; for this purpose, the leg is brought into the extended position, the bone sec- tions accurately adjusted, and the whole limb securely fixed upon the splint on which it is to be kept. It may occasionally happen that the limb cannot be brought into the straight position by the application of any justifiable amount of force ; under such circumstances the hamstring tendons may be carefully divided, this procedure, though in itself undesirable, being prefer- able to the removal of an additional segment of bone.1 The chief difficulty to be contended with, during the after-treatment, is to prevent the anterior projection of the cut extremity of the femur, and hence some operators, particularly in cases of children, fix the bones in apposition by means of a strong metallic suture, as originally employed by Curdon Buck, of New 1 Too forcible approximation of the bones caused fatal fat-embolism in a case re- corded by Vogt. Fat-embolism has also been observed by Liicke after excision of the hip. 682 EXCISIONS. York, and since resorted to by many other surgeons, or by means of steel or bone pins, as resjieetively recommended by Mr. Morrant Baker and Mr. Willett, or silver "dowels," as advised by Mr. Stoker. To prevent se|>a- ration of the bones, Fenwick, of Montreal, makes curved sections which fit together, and Davy saws the femur in the form of a wedge or tenon, to be impacted in a mortise-like cavity- cut in the head of the tibia. A good splint for the after-treatment of knee-joint excisions is that known as Price's (Fig. 387), and excellent cures have been obtained with Butcher's box splint, or, as recommended by Watson, of Edinburgh, with a jiosterior moulded splint and an anterior wire rod to enable the limb to be suspended. The essential points to be secured are absolute immobility of the limb, and ready access to the wound; and I have myself been abundantly satisfied with a simple bracketed wire splint (Fig. 388), with a movable foot-piece, the splint being, of course, well padded, and the thigh, leg, and foot firmly fixed with bandages and broad strips of adhesive plaster. When the splint has 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 counter- Fia.3SS.—Wire splint for excision of knee, acted, as advised by Butcher, by using in ad- dition a short anterior splint, while the risk of outward bowing may be prevented by using an external splint, a metal spring and truss-pad, as Figs. 389,390.—Excision of knee-joint for recurrent arthritis with partial anchylosis in bad position. (From a patient in the Episcopal Hospital.) 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 EXCISION OF THE KNEE-JOINT. 683 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 fre- quently extended this time with advantage to six or seven 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, Pe'nieres, 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 ter- minated cases was therefore 29.8 per cent. The following table will ex- hibit the results more in detail:— Recovered 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-amputa- tion for disease in general. The following table, compiled from Culbertson's, shows in a very satis- factory manner the mortality of knee-joint excision at different ages:— Results of Knee-joint Excision at Different Ages. Age. Total. Recovered. Died. Result not determined. Mortality per cent, of termi-nated cases. 1 to 5 years 5 " 10 " 10 " 15 " 15 " 20 " 20 " 25 " 25 « 30 " 30 " 40 " Over 40 " Not stated . 19 106 99 84 67 55 65 19 89 11 88 81 58 40 34 38 9 60 7 . 17 18 25 26 20 27 10 28 1 1 "i l l i 38.9 16.2 17.2 30.1 39.4 37.0 41.5 52.6 31.8 Aggregate . 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 steadly increases, till in adult life the operation is again one of a very serious nature. We may, therefore, probably say, with Holmes, that fourteen is, all things being considered, about the most favorable age__ there being then comparatively little danger of consecutive shortening, while the operation is at the same time not attended with any particular risk of life. Excision of the knee-joint should not as a rule be performed during the first five years of life, while it must be deemed an extremely grave procedure in persons past the age of thirty. Of 54 operations in my hands, 48 have ended in recovery with useful limbs; 1 ended in re- covery after amputation ; and only 5 have terminated fatally. 684 EXCISIONS. Patella.—Excision of the knee-cap may be required in cases of com- pound and especially of gunshot fracture, of caries, and of necrosis, When the whole bone is removed, the knee-joint is almost necessarily opened (unless in some cases of necrosis, when the operation is really but a sequestrotomy), and the procedure is then attended with some risk. Twenty-two cases to which I have references, including those recorded by Fuqua, Walker, Dodd, and Page, gave three deaths, three subsequent am- putations, and sixteen recoveries. The bone may be conveniently exposed by means of a crucial incision. * Bones of the Leg__Excision of the tibia is rarely* justifiable, but may occasionally be proper in cases of acute necrosis from subjieriosteal abscess (see p. 631). 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 similar 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 dis- ease of the articulation. The operation may be performed by means of two lateral incisions, one behind either malleolus, or, which is, I think, bet- ter, 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 wound either the ex- tensor tendons or the dorsal artery of the foot. Dividing or holding to one side the peroneal tendons, the surgeon removes the end of the fibula,1 when the astragalus will be seen. If this bone be but slightly affected, it will be sufficient to re- move its upper articulating surface with saw or cutting forceps, and to gouge away such portions as may seem diseased, but under other cir- Fia. 391.—Bracketed wire splint for ankle. ClllllStanceS the astragalus should be removed 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 for- ceps, and as much of the articulating extremity 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 re- moved with a narrow saw passed across from one side to the other.2 The limb may be kept during the after treatment on a posterior wire splint provided with a foot-piece, or, which upon the whole I prefer, a long posterior gutter of binder's board, supplemented by a long fracture-box. The foot must be well supported, lest anchylosis with a "pointed toe" ensue. 1 Polaillon divides the fibula with a chain-saw above the external malleolus which he leaves attached to the astragalus and calcaneum. 2 Konig has devised an operation for excising the ankle-joint while retaining the malleoli—a modification which I agree with Volkmann in considering of doubtful advantage. Liebrecht attacks the joint from behind, dividing the tendo Achillis, the ends of which he afterwards brings together with sutures. EXCISION OF THE BONES OF THE FOOT. 685 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 124 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 determined. Mortality per cent, of termi-nated cases. Partial excision . Complete " Undetermined 68 51 5 57 45 5 4 6 7 6.6 11.8 Aggregate . 124 107 10 7 8.5 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 over 90 per cent., and Stauff, as quoted by Rose, as 75 per cent. Nine cases in my* own hands have given seven recoveries and two deaths, but neither of these as the direct result of the operation. 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 frac- ture or dislocation (or even simple dislocation, if irreducible), caries, necro- sis, 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 necessary 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 jiatients 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 necrosis of that bone, though in the majority of instances free gouging, or the extraction of sequestra, will suffice. The operation of excision of the calcaneum may be done by raising a heel flap, as in Syme's 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 carrying a longitudinal cut through the tendo Achillis to meet the former incision. 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 the os calcis. The flap thus formed, which includes the cut peronei tendons, is then reflected from 686 excisions. the bone, when, the ligaments of the calcaneo-cnboid 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 outward, and carefully sejtarated from the soft parts on its inner side. The operation is comjileted by intro- ducing a drainage tube and closing the wound with stitches, and by fixing the foot at a right angle with the leg upon a posterior moulded splint. Southam, and Lund, of Manchester, employ a single external incision, be- ginning 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. Oilier recommends a subperiosteal excision, but from a recent discussion in the Clinical Society of London, it would appear that the result of the operation has been usually most satisfactory when no attempt to jireserve the periosteum has been made. The statistics of excision of the os calcis, which ajipears to have been first performed by Monteggia, in 1814, have been studied by Burrall, of New York, Polaillon, of Paris, and Vincent, of Lyons. 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 jireserved member, 10 submitted to subsequent amputation, and 5 died, while the result in 10 cases was not ascertained. If we add 6 successful cases re- ported by- McGuire, of Richmond, Va., and Poore, of New York, we shall have a total of 75 terminated cases, giving 55 recoveries with useful limbs, and but 5 deaths, a mortality of less than 7 per cent. Vincent's statistics show that subperiosteal excision is more dangerous than the ordinary operation, having given 3 deaths out of 23 cases. Mikulicz recommends, in cases of caries limited to the ankle and os calcis, that this bone and the astragalus should be removed, together with the malleoli and the articular surfaces of the tibia, cuboid, and scaphoid, the front part of the foot being then attached to the sawn tibia in an extended position, so that after re- covery, the patient walks as in pes equinus. Of 22 cases of this operation, including one of his own, tabulated by Dr. W. B. Hopkins, 17 ended in recovery, and 5 in relapse requiring further operation. No case proved fatal. (See page 129.) 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 108 cases, including seve- ral of his own, in which two or more bones were removed at one operation, 74 of the whole number having terminated in recovery, 10 in failure, and 11 in death, the result in the remainder being uncertain. The same sur- geon has reported two cases in which he successfully removed the whole tarsus, the rest of the foot being preserved, and a third, similar case, has been recorded by H. M. Jones, an English surgeon. When excision is resorted to, the lines of incision should be regulated by the position of ex- ternal 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. wry-neck. 687 CHAPTER XXXIII. ORTHOPAEDIC SURGERY. Orthopedic1 surgery is that branch of surgical science which treats of the means of remedying deformities, congenital or acquired. Etymologi- cally, the term should be used only with reference to the deformities of childhood, and might be taken to embrace a great variety of subjects, such as the removal of tumors, the reduction of dislocations, etc. In practice, however, the application of the terra 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, Bige- low, Brown, Detmold, 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, par- ticularly the sterno-cleido-mastoid and trapezius, usually on one side only, but 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 corresponding side of the face and head. The cervical vertebrae undergo rotation on their axis, becoming twisted, and serving to maintain the de- formity, 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 recurs as a reflex phenome- non, dejiending 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 contracted muscles being tense and well defined; frequently* both portions of the sterno-cleido-mastoid seem equally rigid, but often the sternal portion is alone or principally involved. The diagnosis is usually easy ; the de- formity may be closely simulated by the contraction of a cicatrix after a burn, or by7 disease of the cervical vertebras; in the former event, the na- ture 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 1 From opflo'c (straight), and iraXt (child). 688 ORTHOPEDIC surgery. 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 rheumatic origin, a cure may* be sometimes effected by the use of anodyne and stimulating embrocations, by the external application of heat, or, as successfully practised by Dr. J. M. Da Costa, of this city, by the hypodermic use of atropia ; in some cases, in which the disease would appear to consist not so much in spasmodic contraction of the muscles on one side as of paralysis of those on the other, benefit may be derived from the employ- ment of electricity*, or from the endermic application of strychnia. Busey, of Washington, 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 occa- sionally 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 clavicle, between the two portions of the muscle, and the clavicular attachment then cut from behind forwards, with a delicate probe-pointed tenotome which is cautiously insinuated between the muscle and the bone. As soon as the tendons have been divided, the punctures should be closed with lint dipped in compound tincture of benzoin, the patient being then placed in bed with the head well supported; after a few day-s an apparatus may be applied to effect mechanical ex- Fia. 392.—Tenotome. A ■ i -i , • « Ai tension, while the cure is further promoted by the systematic employment of friction and passive motion. The operation for wry-neck is one of much delicacy, and not free from risk, the 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. Instead of a subcutaneous section, Levrat divides the muscle by an open incision, then closing the wound and dressing it antiseptically. Various forms of mechanical apparatus are employed in the after-treat- ment of wry-neck ; in y*oung subjects, it will commonly be sufficient to apply a broad adhesive strip around the forehead and occiput, and another around the chest, fastening the two together by means of a bandage or elastic band carried from above the ear of the unaffected side across the chest to the opposite side of the trunk, thus reinforcing the healthy sterno- cleido-mastoid muscle, and so causing the disappearance of the wry-neck. A more elegant appliance is that of Jbrg, which consists of a leather corset and firm head-band, connected by a steel rod worked by a ratchet-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 LATERAL CURVATURE OF THE SPINE. 689 the side of the chin, and the other on the opposite temple. B. Roth dis- penses with apparatus, and has the patient practise holding his head straight in front of a looking-glass both before and after the operation. Baines makes the patient carry a weight in the hand of the affected side so as to draw the shoulder downwards. Wry-neck accompanied with Painful Convulsive Spasm of the Affected Mxiscles is a very* intractable form of the disease, and occurs chiefly in female adults. Here division of the sterno-mastoid muscles 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 several cases, portions of the spinal accessory nerve have been excised with at least tem- porary benefit by Campbell De Morgan, Annandale, Rivington, Schwartz. Sands, Tillaux, Southam (two cases), Agnew, Pye-Smith, and myself, but without benefit, in other instances, by Sands, Southam, and Briddon. The same nerve has been stretched in two cases by Southam, in one with per- manent, but in the other with only temporary benefit. Cures by nerve- stretching have also been recorded by F. Page, and by Mosetig-Moorhof, of Vienna, but in Lange's case the operation gave little if any relief. Schwartz recommends stretching as a preliminary to resection. The actual cautery has proved effective in the hands of Dr. Mills, of this city, and Dr. Roddick, of Montreal. Lateral Curvature of the Spine. This affection, which appears, in the majority of cases, to depend simply upon relaxation and debility of the spinal ligaments and muscles, is most common in young girls from twelve to eighteen y*ears 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 vertebrae on their axis, this rotation of twisting taking place in the direction of the convexity at each portion of the curve. The bodies of the vertebrae are thus more displaced than the spinous processes, 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 liga- ments and muscles of the spine, but, in long-continued cases, may give rise to compression or partial absorption of the intervertebral cartilages, or even of the bones themselves. As a result of the twisting of the vertebrae which accompanies the lateral displacement (scoliosis), a certain degree of antero-posterior curvature is sometimes superadded—a rounded or hump- like projection occurring in the dorsal region, with a corresponding incur- vation of the lumbar spine, the former constituting thecondition known as cyphosis, and the latter that called lordosis. These are, indeed, but exag- gerations of the natural curves met with in every adult spine. In some cases, esjiecially among rachitic persons, they may exist without lateral displacement. Dr. Tuckey, an Irish physician, has described, under the name of acute lateral curvature, a condition which seems analogous to the so-called " hy*sterical" joint-affections described in Chapter XXXI. Causes—The common cause of lateral curvature is, as already men- tioned, simple debility of the ligamentous and muscular structures which normally support the vertebral column, thus allowing, as it were, the head 44 690 ORTHOPiEDIC SURGERY. 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 j)bysiological changes which occur in the female at the age of puberty, and the customary relinquishment, at that jieriod of life, of the out-door sjiorts of childhood, appear to act as powerful predisposing causes of the spinal relaxation referred to. The very constant character of the disjilaeement— 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 rightarm 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 simultaneously. 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 of 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 attention 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 complaint during the day may* lie awake in pain for several hours upon going to bed at night. Upon making an examination, the surgeon will readily perceive the wing-like projection of the £|1|k scapula, and may*, even at this early stage, recognize a slight deviation in the line of the vertebras, by tracing down the spinous processes and marking each with pen and ink. It must be, moreover, remembered that the deviation of these jirocesses by no means represents the degree of distortion of the bodies of the bones, the disjilaee- ment of the latter being, I believe, invari- ably greater than that of the former. In the early stages of the affection, the de- formity can be made to disappear by lay- ing the patient on a bed in the prone jiosi- tion and making slight extension on the spine; but in advanced cases the deformity will persist in all positions, while the whole chest and the pelvis may be likewise mark- edly distorted, and serious functional dis- turbance, or even organic disease, may result from the consequent compression of Fio. 393.—Lateral curvature of spine. , ,, . , , . , , . .-. ,„„ „„ . the thoracic, abdominal, or pelvic viscera. (Erichses.) ' ' I LATERAL CURVATURE OF THE SPINE. 691 Diagnosis.—Lateral curvature may be distinguished from the graver condition known as antero-posterior curvature, or Pott's disease of the spine (which will be described hereafter), by the fact that in the latter affection the displacement is commonly angular, rarely lateral, and unattended with axial rotation of the vertebrae. There are besides, usually, marked immobility, thickening, and tenderness of the affected portion of the spine. From the spinal distortion of rickels, lateral curvature may* be distinguished by observ- ing the different ages at which the diseases respectively occur, and by noting that in rachitis the primary displacement 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 a later period the most that can be done is to prevent further increase of the deformity. The treatment consists in the adoption of measures to imjirove the general health, the administration of tonics, especially iron and quinia, and the abandonment of any injurious habit or occupation. The patient should take exercise in the ojien air, and may often derive great advantage from gymnastics, swinging by the hands from bars placed above the head, the use of light dumb-bells, etc. The. object is to put in motion and thus to strengthen the various 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 patient should be encouraged to keep the recum- bent posture, lying upon a firm mattress or sofa with a single pillow, so as to relieve the vertebral column from pressure. If the curvature persist while lying down, a cushion may be placed under the projecting portion of the spine, so as gradually to press the bones into their normal position. Barwell recommends, under the name of rachilysis, the employment of bands, cords, and pulleys, to draw the bones into place. Friction of the muscles on either side of the sjiine, 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 princijile 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 vertebras 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 bandage, 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. 692 ORTHOPEDIC SURGERY. If a case of lateral curvature be recognized at an early* jieriod, and promptly and judiciously treated, it may be, if not cured, at least kept in check until the critical period of adolescence has passed by, when there will be comparatively little tendency- to increase of the deformity. It thus happens that, while a very large number of young girls suffer from incipient lateral curvature, its advanced stages are comjiaratively seldom seen—the disease being, as it were, "outgrown" in a great many* instances. Myotomy, or subcutaneous division of the spinal muscles and aponeu- roses, for a long time almost entirely- abandoned in the treatment of lateral curvature, 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 relaxa- tion, not contraction, I do not understand why such a procedure should be expected to jirove ultimately successful. Deformities of the Upper Extremity. Contraction of the Shoulder.—Duplay has described, under the name of scapulo-humeral periarthritis (see page 653), 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 may be recognized by observing the localization of the pain and swelling in the sub-acromial 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. Contraction of the Elbow, apart from disease of that joint, may be owing to the contraction 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. 496, 550). In hysterical cases, the proper constitutional treatment for that condition should be employed, the arm being, if necessary, extended while the patient is in a state of anaesthesia, and then kept in a straight position for a few days. In the rheumatic form, when the contraction is permanent and accompanied with organic change, tenotomy may be required. The opera- tion 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 cut- ting with a slight sawing motion while the arm is forcibly extended. The wound should then be closed and the arm placed in a sling, extension being applied after a few days by means of a screw-splint or weight. Contraction of the Forearm and Hand is occasionally met with as the result of excessive use of certain muscles, with disuse of others: the treatment consists in a change of occupation, with the employment of a straight splint, friction, galvanism, etc. Club-Hand is a rare affection, analogous to club-foot. It is usually complicated with a deformed condition of the lower end of the radius, and sometimes of the carpal bones. Two forms of club-hand are met with, in one of which the part is in a state of extreme flexion, and in the other of extension. The affection is sometimes congenital, but usually results from infantile paralysis, and is, according to Holmes, always accompanied by other deformities. The treatment consists in supplementing the action of DEFORMITIES OF THE UPPER EXTREMITY. 693 the paralyzed muscles by means of India-rubber bands, attached to a light metal frame, and passing beneath a ring at the wrist. In inveterate cases, tenotomy may* be required, followed, after the healing of the wound, by passive motion, aided by the use of friction and galvanism. Contraction of the Fingers into the palm of the hand is not unfre- quently* met with, usually in old persons, as the result of an indurated state of the palmar and digital fascia, due apparently to a gouty* condition or to one analogous to that of rheumatoid arthritis, though Lange regards the affection as one originating in the central nervous system. The ex- citing cause of the affection (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, and Abbe believes that in all cases the contraction is a reflex condition due to peripheral irritation from traumatism. A similar contraction may be due to burns or other injuries (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 defor- mity now under consideration consists in the cautious subcutaneous division of the contracted fascia, which may be affected by slipping a very small flat- edged tenotome beneath the skin—between it and the fascia—and cutting Fio. 394.—Dupuytren's finger contraction. Fio. 395.—The same hand after operation. 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 have resorted to with most gratifying success in three cases, from one of which the annexed illustra- tions are taken (Figs. 394, 395). Busch and Madelung advise that a tri- angular flap of skin should be dissected up, and the palmar fascia notched 694 ORTHOPAEDIC SURGERY. at every* point at which it 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 direct incision, and, like Adams, lays stress upon the importance of making immediate extension. Reeves dissects out the contracted band. Lange suggests nerve-stretching or neurectomy. In order to increase the mobility of the fourth finger in pianists, Prof. Forbes, of this city, divides subcutaneously the fibrous bands which unite its extensor tendon to those of the adjoining fingers.. The result in Dr. Forties's cases has been entirely successful. Trigger Finger__This is the name given to a condition in which a joint of a finger suddenly becomes locked, either in flexion or extension. The condition has been attributed to rheumatism, to tenosynovitis, to the presence of a "loose cartilage," and, by Marcano, to the existence of a nodular swelling of the flexor tendon itself, producing the characteristic jerk by rubbing against the sesamoid bones or the tendinous sheath. Elec- tricity, tenotomy, and section of the palmar fascia have been employed as remedies, but without much benefit. A similar condition has been observed in the toes. Webbed Fingers.—This annoying deformity may be remedied by perforating the base of the web and allowing the parts to cicatrize around a metal rin<>\ 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 recom- mended and successfully employed by Yogel, 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 spas- modic 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, jiectineus, tensor vaginae femoris, and rectus. Division of these muscles is performed in accordance with the principles of tenotomy in general, the knife being introduced behind the part to be divided, and the section then cautiously effected by cutting from behind forwards. Dr. C. T. Poore has reported a remarkable case of cross-legged progression, due to the contraction following double hiji-disease, and refers to four simi- lar cases, one recorded by Esmarch (a case of double congenital dislocation), two by Lucas, and one by Tyson. A sixth case came under my observa- tion a few years since, at the University Hospital. Knock-knee or Genu-valgum is a not uncommon deformity, con- sisting 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 ligament is rendered tense, together with the vastus externus and outer ham-string tendon. The inner condyle of the femur is, as comjiared with the outer, disproportionately large and prominent, while the popliteal space is somewhat obliterated. According to Prof. Humphry, however, there is rather deficiency of the outer than hypertrophy of the inner con- dyle. Macewen and Keetley believe that the deformity is rather in the DEFORMITIES OF THE LOWER EXTREMITY. 695 shafts of the bones than in the epiphyses. The affection is probably never congenital, but conies on during childhood, and is apparently connected in many instances with a rachitic tendency. Both knees are usually simul- taneously affected, though the disease may be more marked in one than in the other. The treatment in the early stage consists in the adaptation of an apparatus such as is shown in Fig. 396. An iron rod, hinged at the hip, knee, and ankle, extends from a pelvic band to the sole of the shoe, and is pro- vided 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 gradually recti- fied by means of the adjusting straps or a ratchet-screw. Division of the external ham-string tendon is occasionally resorted to as a preliminary measure, but, according to Little, does not appreciably hasten re- covery, and is therefore not to be recom- mended. J. S. Ellis advises exercises such as raising a weight by cord and pulleys, or bell-ringing, which compel the patient to bring the foot to the position of extreme -'tiptoe." Forcible straightening of the limb is a favorite mode of treatment with French and German surgeons, but, accord- ing to De Santi, should only be employed in rachitic cases, and never at a later period of life than 14 years. A special apparatus for fracturing the deformed bone has been devised by Mr. Grattan, an Irish surgeon. 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. Excision 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 precau- tions, is practised by Barwell. Reeves 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 Fig. 396.—Apparatus for knock-knee. Fio. 397.—Macewen's osteotome. middle, while the latter removes from the condyle a wedge-shaped portion of bone. Macewen, of Glasgow, divides with a chisel or osteotome (Fig. 397) 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, 856 cases operated 696 ORTHOPEDIC SURGERY. on by one or other method having furnished, according to Dr. Poore, only 6 deaths, while Macewen's method alone has, in i'>2'2 eases, given but 8 deaths. Mv own experience in these operations is limited to six cases, in one of which I operated (on both sides) by Ogston's jilan, and in the others by Macewen's method. The latter I consider much the more satisfactory Figs. 398, 399.—Result of Macewen's operation for knock-knee. (From a patient at the Children's Hospital.) operation, and indeed this is generally acknowledged by surgeons who have tried both. The result in all my cases was favorable. Figs. 398 and 399. from photographs, show the appearances before and after operation in one of my patients at the Children's Hospital. I have twice success- fully operated, once with the osteotome and once with the saw, for out- ward displacement of the knee (genu-varum) due to badly treated fractures. Outward Bowing of the Knee, Genu-Varum, or Genu-Ex- trorsum is a condition which is the reverse of Genu- Valgum ; the external lateral ligaments are relaxed, and the tibiae themselves are commonly Figs. 400, 401.—Result of osteotomy for bow-legs. (From a patient at the Children's Hospital.) curved, giving the appearance known as " bow-legs." This deformity is sometimes traceable to premature attempts at walking, and is usually con- nected with a rachitic vice of constitution. The treatment consists in the CONTRACTION OF THE KNEE. 697 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 for- cible straightening of the curved tibiae, or even partial division of these bones with a narrow saw, and fracture of the remaining fibres and of the fibulae, and reports several cases, in which this apparently severe opera- tion was resorted to with good results. A similar mode of treatment has been successfully resorted to by Billroth, Macewen, Poore, and other sur- geons, who, however, employ a chisel instead of a saw. Macewen has performed ten osteotomies on the same patient, both femora, and both tibiae and fibulae (the latter at both upper and lower ends), being divided at one operation. I have ojierated with good results in seven cases, from one of which the annexed illustrations (Figs. 400, 401) are taken. Contraction of the Knee, dependent upon shortening of the ham- strings, may occur in connection with anchylosis of the joint, or indejiend- ently; 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 be- ing in the prone position, an assistant renders the parts tense by fully ex- tending 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 ; or the knife may be passed between the skin and tendon, and the latter cut by careful pressure in the opposite direction. The semi-tendi- nosus, being superficial and prominent, is readily* divided, but the semi- membranosus requires a fre'er use of the knife ; it, however, comparatively seldom needs to be cut. In operating on the inner hamstrings, the teno- tome should be introduced close to the outer (popliteal) side of the semi- tendinosus, as there is thus less risk of wounding the important structures Fig. 402.—Anterior curvature of Fig. 403.—Result of osteotomy for anterior curvature of bones of leg. (From a patient in the bones of leg. (From a patient in the Children's Hospital.) Children's Hospital.) in the popliteal sjiace. After the operation, the wounds should be instantly closed with a firm compress (to prevent extravasation, or the entrance of air), and no attempt at forcible extension should be made until the parts 698 ORTHOPEDIC SURGERY. 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 ajiparatus, 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 jiassive motion, aided by friction, douches, etc. Anterior Curvature of the bones of the leg is occasionally met with in rachitic cases, and, when sufficiently aggravated to interfere with loco- motion, may properly be treated by osteotomy of the tibia and fibula, or, if this is not sufficient, by the excision of a wedge-shaped segment from the former, and of a disc from the latter bone. The fibula should be operated on first, in both this affection and in bow-legs, as it is difficult to keej) this bone fixed when once the tibia has been divided. I have o|ierated in four cases of this kind, Fig. 404 showing the result in one under my care at the Children's Hospital. Congenital Absence of the greater portion of both tibial was noted in a case at the University Hospital under the care of Dr. J. K. Young. Club-Foot___Talipes or Club-foot is a common deformity, which may affect one or both extremities, and may occur in either sex, though more frequently in boys than in girls. It may be congenital or acquired. There are four primary and as many secondary varieties of the deformity. The primary forms of club-foot are Talipes Equinus, Talipes Calcaneus, Talipes Varus, and Talipes Valgus, while the secondary forms are com- binations of these, receiving the names of Equino- Varus, Equino- Valgus, Calcaneo- Varus, and Calcaneo- Valgus. All forms of club-foot depend upon contraction of various muscles and tendons, which may result from spasm of the contracted parts themselves, or from paralysis of the antago- nistic muscles; in most cases the bones of the feet are not altered in struc- ture, but in inveterate cases of varus (which is the most common form of congenital talipes), the astragalus, scaphoid, and cuboid will all be found more or less atrophied and twisted, the ligaments 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 mal- formed from the moment of birth, the malformation probably being due to the pressure of the adjacent bones during intra-uterine life. In non-con- genital club-foot, the muscles commonly undergo fatty degeneration, ren- dering the prognosis in these cases less favorable than in those which are congenital. The first application of tenotomy to the cure of club-foot was an opera- tion performed by Lorenz, in 1784, on the recommendation of Thilenius, of Frankfort. The operation consisted in a simple incision, involving the skin and subjacent tissues as well as the contracted tendon, and a perfect cure is said to have been obtained. Delpech, in 1816, transfixed the limb beneath the tendo Achillis, and cut towards the skin, which was, however, carefully protected from injury. To Stromeyer, of Hanover, in 1831, is due the credit of first resorting to subcutaneous tenotomy as it is now practised, while to 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 CLUB-FOOT. 699 Fig. 401.—Talipes equinus. (Pirrie.) down the shortened muscle, but remains permanently, though gradually assimilating itself in structure and appearance to the original tendon. 1. Talipes Equinus.—This is very seldom, if ever, a congenital 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 eleva- tion of the heel, which may be so slight as merely* to prevent the foot from being flexed beyond a right angle,1 or may be so marked as to force the patient to walk upon the toes and extremities of the metatarsal bones, as seen in Fig. 404. When the arch of the foot is contracted without elevation of the heel, the deformity is called talipes arcuatus by Mr. F. R. Fisher. The cause of this deformity (in children) is very often disturbance of the nervous system during dentition, or from the irritation of in- testinal worms, though some cases dejiend 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 frac- tures, etc.), by which the patient acquires a " pointed toe." The treatment consists in the subcutaneous division of the tendo Achillis, about an inch above its point of insertion. The patient being jirone, and the tendon rendered tense by depressing the foot, the tenotome is introduced flatwise (on either side, as most convenient), and carried across in close contact with the tendon, so as to avoid wounding the posterior tibial artery*; the edge of the knife being then turned 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 operation, when the heel can be immediately brought down an inch or two further than before. The elder Pancoast 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 facili- tate 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 former), and may be conveniently effected by Adams's modifi- cation of Scarpa's shoe, which differs from those in ordinary use, chiefly in having a transverse division of the sole-plate, corresponding to the 1 Dr. Shaffer has particularly insisted upon the effect of this " non deforming" variety of club-foot in hindering locomotion, leading to the formation of painful corns, etc. 700 ORTHOPEDIC SURGERY. transverse tarsal joint. In using this, as with all other forms of ortho- jiaidic apparatus, care must be taken to guard against excoriation, by fre- quently removing the instrument and bathing the skin with some stimu- lating lotion. The extension must be effected very gradually, the maxim "festina lente" being in no cases more important than in these. I believe this to be the best plan when the surgeon can watch the apjilication 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 normal 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 recontraction. 2. Talipes Varus is the most frequent variety of congenital club-foot, being met with, according to Tamjilin, in ninety per cent, of such cases. The deformity of varus is twofold, consisting in an inversion of the anterior two-thirds of /^^^ the foot, which rotates upon a centre of a§K M motion constituted by the astragalo-scaphoid fOl\^<-<^;^\ and calcaneo-cuboid joints, with an elevation E^mfm^ ^jk of the posterior third by the contraction of \ 1 a the muscles of the calf. When the latter si 1 1 displacement is particularly* marked, the Villi jfflf affection receives the name of equino-varus. St! vww Fig. 405.—Talipes varus. (Fergusson.) 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 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 incases 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 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, advocates div ision of the muscular substance of the abductor pollicis ; Guerin, subcutaneous division of the internal lateral ligament of the ankle, and of the calcaneo-scaphoid t'm. 406.—Varus shoe, with jointed sole-plate. CLUB-FOOT. 701 or calcaneo-cuboid ligament; and R. W. Parker subcutaneous section of the- inner tarsal ligaments, and especially* of the astragalo-scaphoid. A. M. Phelps makes an open section of all the contracted tissues. The tibi- alis anticus tendon deviates from its normal direction, curving downwards and backwards across the inner malleolus, while the posterior tibial ten- don passes from behind the inner ankle directly downwards, or even with a slight backward obliquity*. In dividing the latter tendon, there is some risk of wounding the posterior tibial artery*; hence it is well to adopt Tamplin's suggestion of making 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 instantly applied. 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. 406). The second stage of treatment consists in dividing the tendo Achillis, and in subsequently* bringing down the heel, as in a case of simple talijies equinus. Here, as in pes equinus, unless the surgeon can have the case under personal observation, it will be found better to divide all the contracted tendons at one operation, and apply plaster-of-Paris. 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 Tarsal Bones for Talipes Varus.—Excision of the cuboid bone, suggested by Little and first practised by Solly in a case of Fig. 407.—Result of cuneiform excision of Fig. 408.—Inveterate varus. (From a patient in tarsus (both sides), for talipes varus. (From the University Hospital.) a patient in the University Hospital.) talipes varus in an adult, has been lately revived with good result in sev- eral cases by R. Davy, and the same surgeon, as well as Bryant, West, Bennett, Kbnig, Rose, Poore, and Swan, has further extended the opera- tion to removal of a wedge-shaped portion of the tarsus. Davy reports 702 ORTHOPEDIC SURGERY. 22 operations of this kind upon 18 patients, with only one death, and Swan has operated in 34 cases. I adopted this plan with success in a case of in- veterate varus of both feet sent to me by Dr. A Sydney Roberts (Fig. 407), but in another case (Fig. 408), in which I tried it, acute gangrene occurred, requiring amputation and followed by death. Davies-Collcy has, in a case of varus, excised the cuboid, with portions of the astragalus, calcis, scaphoid, cuneiforms, and outer metatarsals'; while Lund, of Man- chester, has in a similar case successfully excised the astragalus on both sides. Davies-Colley*'s operation has been twice successfully employed by Dr. Fairbank. Mason, of New York, excised the astragalus and external 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 Yerelelyi, Stokes, Margary, Raffa, Bceckel, and Renton (two cases), and the cuboid (also successfully) by Poinset Gross, of Nancy, recommends that the head of the calcaneuni should be removed as well as the astragalus. Fitzgerald, of Melbourne, contents himself with a tarsotomy, cutting across the astragalus and cal- caneum with a chisel, and forcing the foot into place. 3. Talipes Calcaneus (Fig. 409) is very rare as a congenital affection, though as a non-congenital disease, resulting from infantile paralysis (par- ticularly in combination with talipes valgus), it is, according to Adams, comparatively common. This form of club-foot depends ujion contraction Acquired Congenital Fig. 410.—Talipes valgus. (Pirrie.) Fig. 409.—Talipes calcaneus. (Bryant.) of the muscles of the front and outer jiart of the leg, the deformity, which is the reverse of talipes equi- nus, 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 in- stances tenotomy will be required, the tendons to be divided being those of the tibialis anticus, extensor communis digitorum, extensor pro- prius pollicis, and jieroneus 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. Mr. Willett recom- mends resection and "splicing" of the latter tendon, and reports three cases in which this operation was advantageously resorted to, as it has been also in four eases recorded by Mr. Walsham. This form of talipes is occasionally- combined with varus, constituting ealcaneo-varus. 4. Talipes Valgus, flat-foot, or splay-foot, is rare as a congenital, but sufficiently common as an acquired, affection. The deformity is hen- the reverse of that seen in varus, the sole being flattened, the arch of the instep obliterated, and the foot everted. In severe cases, the heel is commonly depressed as well, constituting calcaneo-valgus ; or, on the other hand, the CONTRACTION OF A TOE. 703 heel mav be elevated, constituting equino-valgus. Congenital cases of talipes valgus may often be cured by simple manipulation, or by bandaging the foot to an inside splint with a wedge-shaped pad, as in Dupuytren's mode of treating fractured fibula. In other instances, tenotomy- will be required, the parts to be divided being the tendons of the peroneus longus and brevis, extensor longus digitorum, and peroneus tertius, with some- times the tendo Achillis, or even the tendons of the tibialis anticus and extensor pollicis. The two first-named tendons may be divided about an inch above the external malleolus, the tendo Achillis an inch above its in- sertion, as in pes equinus, and the other tendons in front of the ankle-joint. The after-treatment consists in applying an apparatus to jiroduce gradual inversion, with a pad to restore the arch of the foot. Mr. Ellis recommends the " tiptoe" position as in cases of knock-knee. Mr. Ogston, in invete- rate cases, resects the astragalo-scaphoid joint, so as to restore the arch of the foot, and fastens the parts together with pegs of ivory. He has thus operated without any bad result in 47 cases occurring in 35 patients. Stokes records a case successfully treated by partial excision of the head of the astragalus itself. Gerster removes a wedge-shaped segment from the inner side of the tarsus. Weak Ankles, which often precede the development of acquired talipes valgus, should be treated by attention to the hy-gienic 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. Bar- well opposes the practice of tenotomy, in the treatment of talipes, on the ground that the affection is always the result of paralysis, and thatdivided tendons seldom reunite. He recommends instead, the employment of an apparatus 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 ojierative, mechanical, and physiological means." The chief advocate of Mr. Barwell's views, in this country, is Prof. Sayre, of New York, who is however too judicious a surgeon to re- commend 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 anaes- thetize the patient and then, having put the parts on the stretch, to jiress with the finger or thumb on the stretched tendon; if this pressure pro- duces 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, andthusaiding 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, as already mentioned, 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. 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, 704 DISEASES OF THE HEAD AND SPINE. opposite the base of the second phalanx, the toe being then straightened, and secured to a small pasteboard or wooden splint. If the deformity recur, osteotomy (Terrier), resection, or amputation may be resorted to. Accord- ing to Nunn, some cases of contracted toe (hammer toe) are of spinal origin. Contraction with abduction of the great toe, sometimes called Hallux valgus, has already been referred to in sjieaking of bunion (p. 5(12). Mr. Barker has sucessfully treated this deformity- by simple osteotomy of the first metatarsal. For contraction with flexion (Hallux flexusx) Davies- Colley recommends excision of the jiroximal half of the first phalanx, and a similar operation is recommended by W. Anderson for hammer-toe. 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 con- stituting the affection sometimes described as Fungus of the Skull. Sur- gical 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, and 15 operations of the kind referred to in the Medical News, gave 13 recoveries and only 2 deaths. 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, form- ing a semi-fluctuating mass, sometimes crackling on pressure, pulsating, attended with much pain, and accompanied with various cerebral symji- toms, such as double-vision, deafness, convulsions, and, in the later 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 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 clinically speaking, of a malignant char- acter. The disease may originate either beneath the pericranium (outside the skull), or between the cranial wall and the dura mater, or, as hajipened in Mr. Tait's own case, in both situations simultaneously, the skull thus undergoing erosion on both sides, until the masses meet and amalgamate, when pulsation is developed. 1 According to Dr. Lang, however, hallux ftexus is but a symptom of one variety of flat-foot. ENCEPHALOCELE, MENINGOCELE, ETC. 705 The Diagnosis from vascular tumor of the scalp, which is the only disease with which the affection is likely to be confounded, may be made by observing that the growth cannot be moved laterally upon the skull, and (in cases in which the bone is perforated) can be often partially reduced within the cranial cavity. The existence of optic neuritis is regarded by Dr. Drummond as pathognomonic. 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 recommends that the growth should be excised, or otherwise extirpated, after removing 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 underlying exuberant granulations. Any partial operation, in view of the malignant character of the affection, would be worse than useless, while complete extirpation would, in all probability, but hasten the fatal issue. Fungus of the Brain, or Hernia Cerebri, has been sufficiently alluded to in a previous portion of this work. (See page 336.) Tumors of the Brain.—A gliomatous tumor of the brain has been excised by Mr. Godlee in a case under the care of Dr. Hughes Bennett. The position of the growth was determined by "cerebral localization," and the mass was removed from beneath the gray matter of the upper part of the ascending frontal convolution. The patient died from meningitis on the thirty .eighth day. Two cases of removal of tumors from the brain are also attributed to Macewen, of Glasgow, and four more, in which the patients recovered from the operation and were much improved as regards their cerebral symptoms, to Mr. V. Horsley. Successful cases have also been reported by Markoe, Pean,1 Weir, Keen,Williams, and Durante, but two cases of Weir's, Hirschfelder's and Morse's, Bradford's, Agnew's, one of Keen's, Hammond's, Suckling's, Fischer's and Roberts's cases terminated fatally. Encephalocele, Meningocele, etc.—These are the names given to congenital tumors, consisting of a protrusion through a suture, or part of the skull which in fcetal life is membranous, of portions of the cranial con- tents. The meningocele contains merely a bag of cerebral membranes with subarachnoid 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 compli- cated 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 symptoms of cerebral compression; the tumor swells up and becomes tense when the child cries, and sometimes partakes of the motions of the brain. The affection is occasionally complicated with naevus, and not unfrequently with other congenital malformations. The Diagnosis from congenital cyrstic tumor, when the meningocele is sessile, is sometimes very difficult, but in most cases may be made by 1 Pean is said to have removed successfully about 20 tumors from the brain or its coverings. 45 706 DISEASES OF THE HEAD AND SPINE. observing the situation of the malformation, its variations of tension, and the fact that it is not movable upon the skull; if, however, the communica- tion 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 eases terminat- ing fatally- during infancy, though occasionally patients thus affected have survived to adult life. Death is usually- preceded by convulsions, due to cerebral jiressure, 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-pereha cap lined with cotton wadding; and in cases evidently* complicated with general hydroee)>halus, nothing further is admissible; comjiression with a plate of sheet-lead proved successful in a case recorded by W. S. Hill, of Maine. If the tumor be rapidly increasing, without general symptoms, rejieated tappings may be .resorted to, with precautions against the entrance of air; the asj>irator has been thus successfully employed by J. F. West. In cases of menin- gocele, if pedunculated, iodine injections may* be tried with some hojie of benefit, and Noble Smith has reported a case cured in this way by employing the iodo-giycerine solution used for spina bifida by Morton, of Glasgow, and injecting it outside of but close to the sac. Strangulation with the elastic ligature proved successful in a case recorded by Lazzari, and liga- tion has also succeeded in the hands of W. 0. Roberts. 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 may be occasionally justifi- able, the pedicle of the tumor in such a case being first comju'essed by means of a clamp, which should be allowed to remain for twenty-four hours. Alberti and Marshall have reported cases treated in this way, the former's case ending in recovery, but the latter's in -death. A remarkable case was reported some years ago by Dr. Leasure, in which a meningocele (or, as the author termed it, hydrencephalocele) was said to have been radically and permanently cured by evacuating the contents of the sac and invaginating its coverings, so as to plug the cranial aperture—very much as is done with the scrotal tissues in Wutzer's operation for the radical cure of hernia. Paracentesis Capitis__The operation of tapping the head is occa- sionally required in cases of acute, or even of chronic, hydrocephalus (an affection which, except when the question of an operation arises, comes under the care of the physician rather than of the surgeon), 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 SPINA BIFIDA. 707 point being then directed inwards and backwards so as to penetrate the lateral ventricle. If the fontanelle is closed or the sutures ossified, a small disk of bone may be removed with the trephine as a preliminary to tap- ping. A small quantity only (about two fluidounces) of fluid should be evacuated, the sides of the skull being compressed during the ojieration by the bands of an assistant. As soon as the instrument has been withdrawn, the puncture should be closed with an adhesive strip, and an elastic, per- 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 Fig. 411.—Chronic hydrocephalus. (From a patient in the Children's Hospital.) 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. Spina Bifida (Hydrorachis).—This is a congenital malformation, which consists in a deficiency* of the spinous processes and lamina? of one or more vertebra?,1 allowing the protrusion of the spinal membranes, which form a tumor containing cerebro-spinal fluid and usually some of the spinal nerves, or even a part of the spinal cord itself.2 Spina bifida in the 1 In rare cases observed by Emmet, Thomas, and others, spina bifida has affected the, anterior part of the vertebral column. 2 The Committee of the London Clinical Society gives the proportion of cases in which the cord is involved as 95 per cent. It recognizes three varieties of spina bifida, viz., spinal meningocele, in which the membranes only are involved ; meningo-myelocele, in which both cord and membranes are implicated; andsyringo-myelocele, in which the cavity of the sac is formed by the central canal of the cord itself. Similarly, Prof. Humphry describes hydrorachis externa anterior, corresponding to the second variety (the most common) ; hydrorachis externa posterior, or hydro-meningocele, corresponding to the first; and hydrorachis interna, or hydro-myelocele, corresponding to the third. 708 DISEASES OF THE HEAD AND SPINE. cervico-dorsal region, however, according to Giraldes, contains no nervous filaments, and I was told by Dr. J. B. S. Jackson, of IJoston, that in nu- merous dissections of spinae bifida?, ho 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 lumbar and sacral regions; maybe 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 a skin of more or less normal character, though in some instances there is no cutaneous in- vestment, 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 inspi- ration and when the child is laid on itn face. Fluctuation is sometimes observed, and partial reduction may be often effected by pressure—the bony aperture through which the protrusion has taken jilace being then perceptible to the touch. Spina bifida often coexists with other deformities, and is frequently complicated with hydrocepha- lus. Death usually occurs within a short time of birth, from convulsions or spinal meningitis, though occasionally life is pro- longed to adult age (74 years in a case ob- served by Callender), and in some rare in- stances, as in one recorded by Mr. Lithgow, it would appear that a spontaneous cure has been effected by the channel of commu- nication with the cavity of the spinal membranes becoming obliterated. The fluid of spina bifida, according to Halliburton's analyses, uniformly contains sugar, the proteids being diminished in quantity and apjiearing to consist entirely of globulin. 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 irritable, the tumor maybe painted with collodion, thus taking advan- tage of the contractile properties of that substance. If the child be other- wise healthy, and life seem to be endangered by the rapid growth of the tumor (threatening ulceration and rupture, or inducing convulsions or paralysis), paracentesis may be tried; the sac is tapped with 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), a few drachms 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, Yelpeau, J. Morton, Watt, Eate, Ewart, Lbbker, and other surgeons. Weltering, however, records a case in which death within half an hour followed its employment. According to Morton, the iodine treatment is not applicable in cases accompanied by paralysis. The formula recom- Fio. 412. Spina bifida.' (Druitt.) ANTERO-POSTERIOR CURVATURE OF THE SPINE. 709 mended by* this surgeon is iodine, 10 grains; iodide of potassium, 30 grains; glycerine, 1 fluidounce. Of 29 cases treated in this way up to 1881, 23 are said to have terminated successfully; but of 71 cases since collected by the committee of the London Clinical Society, only 39 had received benefit. Ligation and excision have been occasionally resorted to, and each has proved successful in a few instances, but, in other cases, has but served to hasten death; the Clinical Society's committee, however, reports 16 cures out of 23 cases treated by* the latter method. Mayo Rob- son, Atkinson, Jessop, Bayer, and Evans, have successfully employed exci- sion with separate suture of the sac and of the integuments. The use of the elastic ligature, with or without paracentesis, has been employed by Laroyenne, Ball, Colognese, Baldossare, Mouchet, and Turetta, 1 cases treated in this manner having given 4 recoveries and 3 deaths. It is best adapted to cases in the cervical and dorsal regions, as in these nerve-ele- ments are less apt to be involved. Excision, supplemented by the trans- plantation of a strip of periosteum from a rabbit, has been successfully resorted to by Mayo Robson, and by* R. T. Hayes, of Rochester, N. Y. False Spina Bifida.—Under this name are included three distinct con- ditions, viz: (1) a true spina bifida, the connection of which with the spinal membranes has become obliterated ; (2) a congenital tumor, cystic or fatty, which originates within the spinal canal and protrudes through an aperture due to a deficiency- in the vertebral lamina? ; and (3) a tumor containing foetal remains, constituting the malformation properly described as included fcetation. If the surgeon can satisfy- himself by careful and repeated examination, that, in a case of this kind, there is really no com- munication 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 resorted to; if the tumor were evidently cystic, iodine injection would be the proper remedy, but under other circumstances ex- cision would be preferable. Congenital Cystic 2'umors, 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, may 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, as already mentioned, has in cases of spina bifida been found to contain a decided trace of sugar. Antero-posterior Curvature of the Spine (Disease of the Spine, Pott's Disease).—This disease usually originates in osteitis of the bodies of the vertebra?, though occasionally* it would appear that the disease had begun in the intervertebral fibro-cartilages. In some instances—and in these the prognosis is least unfavorable—the case is one of ordinary oste- itis (spondylitis), 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 ex- citing cause of the affection, but in most instances no explanation of its origin can be given. Any* part of the vertebral column may be the seat of the disease, which is, however, most common in the dorsal region. The bodies of several vertebra? are usually simultaneously affected, be- coming softened and disintegrated, and leading to disorganization of the intervertebral fibro-cartilages—the superincumbent weight of the head and upper part of the body eventually* giving rise to the posterior angular de- formity which is characteristic of the fully develojied affection. In most cases the osseous change runs on to caries (whence the disease is frequently* spoken of as caries of the vertebrae), abscess forming as a consequence, 710 DISEASES OF THE HEAD AND SPINE. 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 page 425). In a few in- stances the disease runs its course without any evidence of pus-formation whatever, the pathological change in these cases, therefore, being more properly designated as interstitial absorption than as caries (see page 626). 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 thus pressed upon or otherwise injured. This is evidently owing to the gradual nature of the change, which allows the cord to accommodate itself to its altered circuni- Fio. 413.—Anteroposterior curvature of spine. Fio. 414.—Caries of the vertebrae. (Liston.) (Liston.) stances; and to the occurrence of anchylosis, which prevents injurious motion. Anchylosis 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, meduUization, and eburnation in different parts. In cases in which anchylosis is deficient (as may happen when the angular protection is not marked, the diseased vertebral bodies being then separated and prevented from coalescing), spinal meningitis may occur, leading to paralysis, either from pressure or from secondary changes in the cord; while in the cervical region, where the vertebral column has a considerable range of motion, consecutive frac- ture or dislocation may take place, and, by compressing or bruising the cord, lead to a rapidly fatal issue. Symptoms.—The early symptoms of spine-disease, particularly in chil- dren, are somewhat equivocal, consisting chiefly in evidences of spinal irritation, such as weakness, numbness, and tingling of the lower extremi- ties, a difficulty* in standing or walking, with a tottering gait, and a tend- ency 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 ANTERO-POSTERIOR CURVATURE OF THE SPINE. 711 himself in bed without assistance. Examination may reveal an undue prominence of some of the dorsal spines, with perhaps thickening of the surrouuding 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, as shown by B. Lee, an early and characteristic symptom of this affection. As the disease advances, paralysis may be developed, involving the lower or upper ex- tremities according to the jiart of the spine affected. Incontinence of feces and retention of urine sometimes form further disagreeable complica- tions. Abscess sometimes occurs quite early in the course of the disease, and not unfrequently before the development of angular deformity. Par- alysis and abscess are seldom met with in the same case. According to 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; indeed, it is sometimes quite impossible to distinguish spine-disease, partic- ularly in children, from inflammation of the suri-ounding ligamentous structures, until the milder course of the latter affection reveals its true nature. From neuralgia of the spine, an affection analogous to the hys- terical knee-joint, the diagnosis may be made by observing the absence, in the neuralgic affection, of rigidity or other physical evidence of disease, even in cases of long duration. The wincing of the patient, upon the application of a sponge wrung out of hot water to the suspected part of the spine, is looked upon by many surgeons as a sure proof of the existence of caries. According to my experience, this test is not to be implicitly- relied upon ; at least, I have known it to fail in cases in which the de- formity and other sy*mptoms 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 pages 648 and 651.) When the character- istic deformity appears, there is little difficulty in recognizing the nature of the affection. This deformity* consists, as already mentioned, in a pos- terior angular projection of the diseased vertebra?, 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 position—and from that of rickets, by its angular character. This angular deformity is accompanied, after the occurrence of anchylosis, with compensatory forward curvatures above and below ; the gibbosity of the spine is thus thrown into a plane behind that of the pelvis, while 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 impression that the case was one of lateral curvature; the diagnosis may be made by observing that in true spine-disease there is no axial rotation of the vertebra?, such as always exists in the other affection (see page 689). When the vertebra? involved are those of the cervical region, particularly the atlas and axis, the case mav be mistaken for one of wry-neck. The sterno- mastoid muscles are, under these circumstances, tense and prominent, and the neck stiff; while the patient often involuntarily supports the head with both hands, so as to guard against sudden movements. The diagnosis from wry-neck may be made by noting the localized tenderness and thicken- ing 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 atten- 712 DISEASES OF THE HEAD AND SPINE. tion. The situation of the abscess, in these cases, varies with the jiart of the vertebral column which is involved. Thus in disease of the cervical vertebra?, 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 vertebra? commonly makes its way down- wards, 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 jiass forwards along the ribs, opening at the side of the trunk, or may go directly backwards, forming a dorsal or lumbar abscess; finally, it may, in some rare cases, burst into the air-passages or gullet. When the lumbar and lower dorsal vertebra? are affected (the most common situation of the disease), the abscess usually descends in the sheath of the psoas muscle, on one or both sides, constituting the condition known as psoas abscess.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 jierineum, on the outer side of the hip, in the iliac fossa, or in the in- guinal 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 increased by the cir- cumstance 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, com- monly 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, jioints above Poupart's ligament, and is gradu- ally developed. Psoas and iliac abscesses must also be distinguished from inguinal aneurism which has become suddenly diffused, from femoral hernia, and from fatty, serous, or hydatid tumors. The diagnosis from aneurism 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 dis- eases the swelling is reducible, and there may be an impulse transmitted by coughing), and the situation of the femoral vessels, which in hernia are to the cutside, and in abscess usually to the inside, of the tumor. Fatty and other tumors may be recognized by their not being reducible within the abdomen, and, if necessary, by the use of the exploring needle. Prognosis.—The prognosis of antero-posterior .curvature of the spine is never favorable ; the best that can be hoped for is the occurrence of anchy- losis, with a permanent angular deformity. If the spine retains its straight position, fatal inflammation of the membranes is apt to occur, while if abscess forms, the patient almost always perishes from exhaustion or from secondary visceral disease. In a case at the Episcopal Hospital, some 1 Psoas abscess, however, according to Stanley, Bryant, and others, sometimes origi- nates independently of spinal disease. ANTERO-POSTERIOR CURVATURE OF THE SPINE. 713 years ago, a psoas abscess caused ulceration of a branch of the internal iliac artery, leading to rapid death from hemorrhage. Treatment.—In the treatment of disease of the spine, rest of the part is of the utmost importance: if the cervical vertebra? be affected, the head must be carefully supported with sand-bags or other mechanical contriv- ance, so as to prevent any sudden movement which might cause death by producing dislocation. In ordinary* cases, the patient may be confined to the horizontal position on a suitable couch, the prone being more desirable than the supine posture. No attempt should 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 interfering with the occurrence of anchy- losis ; if, however, the part were very painful, it might be proper to give a cautious trial to continuous double extension, as recommended by J. Wood. The horizontal position must be rigidly maintained for many months, until indeed the surgeon can satisfy himself that bony* uniou 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, issues, or the actual cautery) was highly* com- mended by Pott, who first accurately investi- gated the nature of this disease, and is still in much repute with many surgeons. I am not myself very enthusiastic with regard to these severe applications, believing with Shaw and Holmes that, in most cases, the milder re- medy of painting the tincture of iodine on either side of the affected vertebra? will be quite sufficient. If there be much pain, ten- derness, and other evidence of inflammation, there can be no better local remedy than dry cold applied by means of an ice-bag. In most cases, it will be desirable to com- bine mechanical support with rest in the prone position, and this may be conveniently done by the use of a moulded gutta-percha, leather, felt, or paste-board 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 (Fig. 415), as recommended by Prof. Sayre, or lying prone in a canvas hammock (which is itself included by the bandage), as advised by R. Davy. Adams and Hutchison apply a " poro-plastic felt" jacket, while the patient is suspended, and consider this material, upon the whole, bet- ter than the plaster-of-Paris. Stillman and Wyeth employ* a double plaster jacket, with extending bars secured to perforated zinc plates jilaced between the layers of plaster, and a somewhat similar device is adopted by Whitehead. Yance employs a brace made f»«■ «»-s»y«'» -"pension aPPa- c , , -r-r r*~ -.** -, ratus for application of the plaster-of- of glue and paper. H. C. \\ ood suggests Pari8 bandage. 714 DISEASES OF THE HEAD AND SPINE. that the patient should be siisjiended daily by the jilaster jacket itself—a plan which obviously* could only be of service when the disease was in the lower portion of the spinal column. Mitchell advises that susjionsion should be effected from beneath the elbows rather than from the armpits. When anchylosis is well advanced, the patient may be allowed to get up, wearing the leather, felt, or plaster jacket, or a well-fitting apjiaratus con- sisting 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 vertebra? be involved, a firm but well-fitting leather collar, so arranged as to fix the neck and support the head and chin, may be em- ployed, or an occipito-mental sling, suspended from Sayre's "jury mast" (Fig. 416), attached to the plaster or leather jacket, or to the ordinary "spinal apparatus," 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. Fleming, of Glasgow, employs an India-rubber collar which can be in- flated after adjustment. The treatment of spinal abscess is that of cold or chronic abscesses in general (see page 425). Every effort should be made, in the first place, to induce absorption of the fluid, it being remem- bered that, even if a residual abscess follows at a later period, the jirognosis will then probably be more favorable than if the collection had been evacuated in the first instance. Even if the opening of a psoas abscess appear inevitable, it is better in most instances to leave the case to nature, rapid sinking not unfrequently following 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, the abscess cavity being washed out with a solution of carbolic acid, or, finally, the surgeon may open and drain the abscess, apply- ing1 the ordinary antiseptic dressings. S. W. Gross advised that after the abscess had been evacuated, its walls should be supjmrted with adhesive strips and a flat sponge, and that opium should be freely admin- istered. Fischer, Riedel, and Gangolphe have evacuated psoas and pelvic abscesses by trephining the ilium. Israel effected the escajie of pus from the spinal canal by partial resection of a vertebra, but the case ter- minated fatally on the 37th day. A similar operation in the hands of A. Jackson is said to have afforded some relief, though no pus was found. Treves advises that spinal abscesses should be opened from the loin, and the disease of the vertebra?, whether necrosis or caries, submitted to direct treatment as similar affections of other bones. Operations of this kind have been performed by Bceckel, Byrd, Davy, Macewen, Andrews, and myself. Podres records a successful operation for caries of the cervical spine. The antiseptic lumbar incision of spinal abscesses is likewise recom- mended by Kbnig, Chiene, and Chavasse, of Birmingham; but it is not free from risk, as 28 cases collected by Lacharriere gave five deaths. The paraplegia of spinal disease (which is due either to pressure or to Fig. 416 —Sayre's "jury mast" for disease of the cervical ver- tebrae. DISEASES OF THE CONJUNCTIVA. 715 the development of a secondary transverse myelitis) often subsides spon- taneously under the influence of rest, or yields to counter-irritation and the use of ergot, mercury, iodide of potassium, etc., in the early* stages, followed by strychnia and galvanism at a later period. Suspension has jiroved effective in the hands of Mitchell, Wood, Sinkler, and others. Tre- phining has been employed, under these circumstances, by Macewen, of Glas- gow, five cases in his hands having given three recoveries and two deaths. Southam's and White's cases proved fatal on the second day*. Maydl's patient recovered from the operation, but the ultimate result of the case is not mentioned. Wright's patient seemed to be temporarily relieved, but, ultimately*, was not benefited. Abbe's and Lane's patients recovered. Arthritis occasionally attacks the articulations of the vertebra?, 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 appliances, so as to prevent injurious movements, and to give free vent to any pus that may* be formed, lest suffocation should result from pressure of the abscess upon, or its bursting into, the air-passages. Necrosis of the bodies of the cervical vertebra? is occasionally seen in cases of syphilitic ulceration, or as the result of gunshot or other injuries; and cases in which recovery has followed the discharge of large sequestra, under these circumstances, have been recorded by Wade, Keate, Syme, Mercogliano, Morehouse, 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, Yon Studen, and Sturge, the latter of whom proposes for the affection the name of spondylitis deformans. Tumors of the Spinal Cord.—Mr. Yictor Horsley has successfully removed a tumor from the dorsal region of the spinal cord. The growth was below the dura mater, and had caused spasms, pain, and paraplegia. A similar operation in the hands of Dr. Deaver, of this city, terminated fatally on the third day. In Dr. White's case no tumor was found. An cxtra-dural tumor of the cord has been successfully removed by Dr. Abbe. 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 there- with. I shall, therefore, chiefly confine my attention, in the following pages, to a brief reference to those more common affections of the eye which every surgeon may be called upon to treat, and to a short description of the more important operations which are performed upon this organ. Diseases of the Conjunctiva, Acute Conjunctivitis (Catarrhal Ophthalmia).—An inflammation of the conjunctiva, usually caused by cold or other local irritation, occasion- 716 DISEASES OF THE EYE. ally rheumatic, but sometimes prevailing epidemically in certain localities, and manifestly transmissible by contagion. In the form of acute conjunc- tivitis known as "pink-eye," Weeks has demonstrated a special form of micro-organism, which is its essential cause. Symplom.s.—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 or sulphate of zinc, or antiseptic washes of corrosive sublimate (gr. TV to f3j) or i>01'acic iVC>d> witn n"°- quent ablutions with cold water,1 and, in severe cases, the application once; or twice daily to the everted lids of a solution of nitrate, of silver (gr. j-ij f|j)- The 1'ds may be smeared at night with simjile ointment, to jirevent their adhering together. The constitutional treatment consists in regula- ting the digestive functions, and in improving the general health by the use of tonics, especially iron and quinia. A shade, or, which is better, smoked glasses, may be worn if there is much photophobia, and cocaine, with or without atropia, should be instilled if this becomes an aggravated symjitoni. Chronic Conjunctivitis, or Chronic Ophthalmia, may occur as a sequel of the affection just described, or may originate from the irritation of inverted lashes, from reading or sewing with an insufficient light, as the result of uncorrected ametropia, or on account of obstruction in the lach- rymal juissages—the lachrymal conjunctivitis of Galezowski. In the milder forms of this affection, especially when caused by errors of refraction, the term Hypersemia of the Conjunctiva is more suitable than conjunctivitis. Treatment.—The cause must, if possible, be removed, by taking away anv sources of local irritation, forbidding overuse of the eyes, etc. Even if obstruction of the lachrymal duct does not exist, advantage results from its dilatation and irrigation with antiseptic fluids. Mild astringent and antisejitic washes, together with the occasional application of the alum mated cop|>er (lapis divinus), are the best local remedies. 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, and marked dread of light. The treatment, after any acute irritation has been subdued by the use of boracic acid and atropia, consists in dusting into the eye with a camel's-hair brush a little finely powdered calomel, in the application to the inside of the lids of an ointment of the yellow oxide of mercury (gr. iv-viij to gj), or in dropping into the eye, thrice daily, a weak solution of the bichloride of the same metal.2 Purulent Conjunctivitis, or Purulent Ophthalmia, is a very high grade of conjunctival inflammation, attended with a profuse muco-purulent discharge which is fully developed in from 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 purulent ophthalmia of adults, and gonorrhoeal ophthalmia, which has already been considered. (See page473.) Ophthalmia Neonatorum__This form of the disease sets in com- monly from 12 to 48 hours after inoculation, the third day after birth being 1 L Connor, Heyl, and many other surgeons, however, advise douches of hot water in inflammatory affections of the eyes. 2 The following formula, which corresponds to the preparation known as Aqua Con- radi, will be found satisfactory : &. Hydrarg. chlorid. corrosiv. gr. \ ; Mucilag. cydonii f3ss ; Vin. opii gtt. v ; Aquae destillat. f^ij. M. PURULENT OPHTHALMIA OF ADULTS. 717 the most usual date at which the discharge is first noticed ; it involves both eyes simultaneously or consecutively, and sometimes, if neglected, ends in total loss of vision. The affection appears most frequently to originate during birth, from direct contact with an infectious vaginal discharge in the mother, but sometimes after birth, from contact with soiled linen or fingers; in a few rare instances, as for instance that recorded by Magnus, it may arise in utero. The severer forms of the disease are probably caused by the jiresence of the gonococcus of Neisser, but in the milder forms this special micro-organism is said to be absent. Symptoms.—Itchiness and slight redness of the conjunctiva are soon followed by intense congestion, and by a discharge, at first serous, but soon becoming muco-purulent or purulent, whitish or yellow, and rapidly increas- ing in quantity, with swelling of the lids and chemosis of the ocular con- junctiva. If the disease be not checked, opacity, ulceration, or even sloughing of the cornea will probably occur, with, of course, total loss of sight. Lucas and Debierre record cases of jiurulent conjunctivitis in in- fants , accompanied by inflammatory joint-affections, analogous to gonor- rhoeal rheumatism. Treatment.—The discharge should be removed as fast as it accumulates, by syringing the eye with antiseptic solutions—either of the bichloride of mercury (1 to 5000), or of boracic acid (gr. xv to f£j)—every half hour, day and night, the lids being gently separated with the thumb and finger of the left hand, while the syringe is worked with the right; when free discharge sets in, the lids may* be everted, and a solution of nitrate of silver (gr. x-xx to f§j) mav be applied with a camel's-hair brush, once a day, any excess of the caustic being immediately neutralized with a solu- tion of common salt; the lids should be greased also with simple ointment, to prevent their sticking together. A high grade of inflammation calls for cold compresses, according to the belief of some surgeons, but usually very hot comjiresses are more acceptable in infants, especially if corneal ulceration threatens. Other local ajiplications which have been recommended are the permanganate of potassium, by Power; alum (gr. v to f^j); solutions of tannin and benzoate of sodium, by Dor; and borax, followed by atropia, and, in bad cases, cauterization with the lapis mitigatus, by Wolfe. (See page 720.) Diluted chlorine water is employed by Moore, of Xew York. Iodoform has been highly extolled, but has not met with the success which was expected. Tweedy recommends the local use of a solution of quinia. If corneal ulceration occur, quinia should be given internally in doses of half a grain, three times a day*. If the ulcerated surface be central, in- stillations of atropia should be practised ; if peripheral, a solution of sul- phate of eserine should be used, and hot compresses should be assiduously ajiplied. As a prophylactic measure, Crede advises that the ey*e-lids of children exposed to the disease should be washed with plain water, and that a single drop of a two-per-cent. solution of nitrate of silver should be dropjied into the conjunctival cul-de-sac ; while Olshausen recommends the application of carbolic acid, beginning his treatment even before the child has been comjiletely born. Weeks advises a solution of bichloride of mer- cury, used in the same manner, but many obstetricians rest satisfied with absolute cleanliness during delivery. Crede's method has yielded the best results. Purulent Ophthalmia of Adults in its mildest form resembles catarrhal ophthalmia, but often runs a course quite as severe as the affection which results from the contagion of gonorrhoea; as a matter of fact, it is most frequently produced by direct inoculation, from the urethral dis- charge being carried by the fingers to the eyes. Purulent ophthalmia is 718 DISEASES OF THE EYE. eminently contagious, and often prevails as an epidemic, in barracks, prisons, and schools. It may originate sjioradicallv from various forms of local irritation, and any matter which is infectious from the presence of micrococci may determine its occurrence by coming in contact with the mucous membrane of the eye. Symptoms.—A muco-purulent and afterwards purulent discharge, with great chemosis, and inflammation and swelling of the lids, with burning pain, and a good deal of constitutional disturbance. One or both eyes may be attacked. Opacity, ulceration, or sloughing of the cornea may ensue, or the inflammation may spread to the deeper tissues of the eye; or a jier- sistent granular condition of the lids may be developed. Treatment.—If only* one eye be affected, the other should be effectually closed by means of Buller's bandage (page 473), or a compress of charpie covered with a disk of adhesive plaster, and the whole coated with collodion. This may be removed twice a day, to wash and inspect the organ. In mild cases, astringent and detergent applications, as recommended for catarrhal ophthalmia, will probably prove sufficient; but, if the disease assume a severe type, no time should be lost in adopting those measures which were fully detailed in speaking of Ophthalmic Gonorrhoea. (See page 473.) In order to cleanse the ujiper cul-de-sac of the conjunctiva. Dr. J. A. Andrews em- ploys an eye speculum, the arms of which are hollow, and the claws fur- nished with numerous perforations through which medicated fluids may be injected. The application of copaiba to the lower eyelids, cheeks, and temples, is recommended by A. R. Hall. Planat and Dabney speak well of the topical use of ergot. Diphtheritic Conjunctivitis, in which there is a board-like, very- painful swelling of the lids; a scanty, sero-purulent or serous discharge; an exudation within the layers of the conjunctiva, leading to the death of the invaded tissues and tending to de- stroy the nutrition of the cornea, is rarely met with in this country, but a few cases have been observed in the Children's Hosj>ital of this city, and the disease has been well described by Dr. De Schweinitz, and by Dr. Sattler, of New York. The treatment consists, in the earlier stages, in the apjili- cation of iced compresses or hot fomentations, with fre- quent syringing with anti- septic solutions, and the instillation of atropia. Berg- meister recommends insuf- flation of the flowers of sul- phur; Fieuzel applies lemon- juice, which is washed away and followed by a two-per- cent, solution of nitrate of silver ; and Galezowski emjiloys the oil of cade (one part to ten). Fin. 417.—Diphtheritic conjunctivitis. (From a patient under the care of Dr. De Schweinitz, in the Children's Hos- pital.) GRANULAR LIDS. 719 Membranous or Croupous Ophthalmia (Croup of the Con- junctiva) differs from true diphtheritic ophthalmia in that it is characterized by a soft, usually painless, swelling of the lids, and by a membranous exudation upon the surface of the conjunctiva. According to Lotz, it is never seen among the new born, nor in adults, but usually in children between one and three years of age. The treatment consists in the removal of the membrane, in the application of compresses wrung out of cold water, and in frequent cleansings with a boracic-acid solution. Caustics are con- tra-indicated.1 Granular Conjunctivitis may be studied as occurring in two forms, first the presence of acute, and secondly that of chronic granulations. Acute Granular Conjunctivitis.—This disease begins with swell- ing of the lids and of the mucous membrane, which is studded with nume- rous prominent papilla? or granules, and is characterized by great photo- phobia and lachrymation, and by a marked tendency to the formation of superficial ulcers in the cornea. Subsequently the secretion becomes muco-purulent or purulent, and the disease may end in an absorption of the granulations and consequent cure, may proceed unfavorably to the develop- ment of an intense and destructive purulent ophthalmia, or may take on the characteristics of chronic granular lids. To a disease of this type the term Contagious or Egyptian Ophthalmia, from its prevalence as an en- demic in Egypt, is often given. Howe, of Buffalo, however, believes Egyptian ophthalmia to be not a granular conjunctivitis, as ordinarily taught, but an acute, purulent conjunctivitis characterized by periodicity, and propagated largely by the ordinary house fly- Granular Lids (Chronic Granulations, Trachoma) is a condition which consists of a rough, villous, granular state of the palpebral conjunc- tiva, keeping up a chronic, muco-purulent discharge, causing pain, and inducing, by friction, a vascular and hazy condition of the cornea. There are two conditions to which the name of granular lids is com- monly applied, one consisting merely in a hypertrophied state of the papilla?, and the other in the development of true or vesicular granulations, which are by some authors regarded as new formations, the result of inflammatory action, and by others as enlargements of the closed lym- phatic follicles. It is usually taught that the prominences are not "granula- tions," in the pathological sense, though Ilaehlmann disputes this view. Since Sattler's experiments in 1881 and 1882, fig. 4i8.—Granular lids. (Jones.) in which he demonstrated that trachoma was probably due to a sjiecial form of coccus, much work has been done in this line by many observers, but the microbe has not yet been undoubtedly isolated. The vesicular granulations appear as little round bodies, like the grains of boiled sago, arise insidiously, often occur epidemically, and are transmissible by contagion. Chronic granular lids result frequently from over-crowding, or from a low state of health, and appear especially among 1 Many modern writers, like Nettleship, are disinclined to maintain a distinction between croupous and diphtheritic ophthalmia, but the evidence seems sufficient to warrant a separate description of the two varieties. 720 DISEASES OF THE EYE. certain races—the Irish, the Jews, etc., while negroes, according to S. M. Burnett, are practically exempt, Symptoms.—Heat and a sensation as of sand in the eye, with slight photophobia, and enough discharge of muco-pus to glue together the eye- lids during the night. The caruncle and tarsal margins of the lids are reddened, and the upper lid is thickened and droops over the eye. The cornea becomes nebulous, uneven, and extremely- vascular (Trachomatous Pannus), and ulceration sometimes occurs. Pannus commences in the upper portion of the cornea, but in many cases, at a later stage, extends to its whole surface. This condition is believed by many to be due to mechanical irritation, but Raehlmann regards it as an indejiendent disease, in fact as a peculiar localization of trachoma on the cornea. The palpebral conjunctiva may eventually undergo contraction, causing Entropion and Trichiasis; or shrinking of this membrane may result, forming one variety of xerosis of the conjunctiva. Treatment.—The object is to produce absorption of the granulations, and, when discharge is present, the treatment does not materially differ from that of the acute ophthalmia. In other cases it may be necessary to apply astringents or caustics to the granulations themselves. Various articles are emjiloyed for this purpose, such as a solution of nitrate of silver, gr. v-xx to f^j (Lawson), the " lapis mitigatus," or nitrate of silver in substance diluted by fusing with it nitrate of potassium (Wells), the undiluted liquor pjotassse (Dixon), or, which is a favorite in this country, the blue-stone, or crystallized sulphate of copjier. These applications may be re|ieated at intervals of two or three days, the precaution being taken, if nitrate of silver be used, to neutralize it at once by the injection of salt and water. Sulphate of quinia, dusted into the eye, is recommended by Bader, and jiowdered boric acid has been emjiloyed in the same manner. Wolfe, of (rlasgow, recommends scarification of the conjunctival cul-de-sac, and the application of the syrup of tannin (5'j-f.l.i)- Carbolic acid is favorably sj»oken of by Chisolm and E. Treacher Collins, as are chlorine water and the glycerite of tannin by the younger Siehel, and iodoform by Hayer. Boro-glyceride, the yellow oxide of mercury, in ointment, and beta-naphthol, have been highly recommended, and the first-mentioned is often a very useful application. If the cornea be ulcerated, instillations of atropia should be practised, and if perforation be threatened, the cautious use of a compressing bandage. Stokes, of Dublin, has suggested the use of delicate ivory- plates, applied within and without the lid, and held together by a spring or screw, so as to maintain constant pressure upon the granula- tions. Hotz, and recently* many other surgeons, have advocated squeezing out the granulations between the thumb nails, or with forceps. The opera- tion should be followed by irrigation with a sublimate solution. In severe trachoma, where the granulations are discrete, Armaignac and Panas have employed the galvano-cautery. The practice of inoculation with the matter from a case of purulent ophthalmia, which has been successfully eni|iloyed in inveterate cases by Bader, Dixon, Lawson, E. Williams, and others, has been largely substituted by the jilan introduced by De Wecker, of painting the everted lids with an infusion of jequirity. This is best em- ployed in old chronic cases with extensive vascularization of the cornea, and has been successfully* resorted to by many surgeons. Syndectomy or Peritomy, which is an operation consisting in the excision of a very narrow band of conjunctiva and subconjunctival tissue from around the cornea, may be practised in cases of pannus which persist after the relief of granular lids. This operation, which was introduced by Furnari in 1862, is also recommended by Lawson as a preliminary to purulent inoculation. PEMPHIGUS OF THE CONJUNCTIVA. 721 Canthoplasty, or slitting up the outer canthus, and stitching together the skin and mucous membrane above and below so as to prevent readbesion, is recommended in these cases by Althof, Noyes, C. R. Agnew, and others. Follicular Conjunctivitis (swelling of the conjunctival follicles) is a form of catarrh of the conjunctiva, in which numerous round pinkish bodies are scattered along the retrotarsal folds, associated with slight hvperaemia, smarting pain, and inability to continue at close work. It is a tedious form of disease, lasting sometimes for months; but when the tumefied lymph follicles finally disapjiear, the mucous membrane is as healthy as before the attack. Many writers, like Xettleship, look upon this disease as a form or early stage of granular conjunctivitis, and are disin- clined to accord it a separate classification. Bacteriologically, Reich and other observers have not succeeded in differentiating follicular conjunctivitis from genuine trachoma. Atropine and Cocaine Conjunctivitis. — The long-continued use of atropia sometimes jiroduces a form of conjunctivitis (atropine conjunctivitis) which manifests itself as a hyperemia or swelling of the mucous membrane, or as a tumefaction of the conjunctival follicles. This disease has been recently well studied by E. T. Collins. M. Krcemer thinks it due to the presence of fungoid growths in the atropia. The treatment consists in discontinuing the use of the drug, and in applying astringent lotions, as of alum or tannin. Granulations of the conjunctiva produced by long-continued instillations of cocaine (cocaine conjunctivitis) have been described by W. C. Ayres, Kipp, and Mittendorf. Spring Catarrh (Fruehjahrscatarrh, Saemisch; Phlyctenula Pallida, Hirschberg) is an affection which begins like an ordinary conjunctivitis, with but little secretion and the apjiearance of circumscribed pericorneal injection, and the formation in this region of small, gray, semitransparent nodules. In severe cases flattened granulations cover the tarsal portion of the conjunctiva. The characteristic behavior of the disorder is its return with the early* spring, and its subsidence in the fall and winter. In the negro, according to Burnett, a deposit of brownish discoloration apjiears in the conjunctiva. The prognosis, as far as sight is concerned, is favorable, but the disease tends to return stubbornly year after year. Tuberculous Ulceration of the Conjunctiva, the cornea being unaffected, is a rare affection described by* Sattler as occurring in the later stages of general tuberculosis, but also seen without such association. The best treatment, according to Fontan, consists in scraping out the ulcers and dusting the surface with iodoform. Lupus of the Conjunctiva is usually secondary to a similar con- dition of the neighboring skin, but, according to Sattler, may* occur as a primary affection. The treatment consists in repeated cauterization with the solid nitrate of silver and the application of the ointment of yellow oxide of mercury*, or in the use of the galvano-cautery, suitable constitu- tional remedies being at the same time administered, as in cases of lupus occurring in other parts. Amyloid Degeneration of the Conjunctiva is a rare disease seen most often in the palpebral, but also in the ocular portion of this membrane, its starting-jioint being frequently from the plica semilunaris or caruncle. The amyloid tumors, according to Raehlmann, are inde- jiendent of trachoma. Hyaline degeneration has also been observed; it is, in fact, an earlier stage of the amyloid change. Pemphigus of the Conjunctiva is an extremely rare disease, in which bullae, attended with pain, dread of light, and excessive lachryma- tion, form upon this membrane in association with Pemphigus Vulgaris of 46 722 DISEASES OF THE EYE. other parts of the body. Succeeding attacks occur, until finally the con- junctiva undergoes cicatricial contraction and atrophy, the lids become adherent to the ball, and the cornea becomes opaque, ulcerated, and, it may- be, staphvlomatous. The disease has been well described in this country by R. Tilley. Under the title of Essential Shrinking of the Conjunctiva, Brailey, Lang, Critchett, and Juler have described a condition of slow atrophy and contraction of the whole conjunctiva, through the formation of cicatricial tissue, which they look upon as a primary disease unassociated with pemphigus. These conditions must not be mistaken for trachoma. Treatment, except in the form of palliative measures, is of little avail. Pterygium—This is a peculiar, fleshy growth, consisting of hyper- trophy of the conjunctiva and subconjunctival tissue, which is most com- mon in warm climates. One or both eyes may be affected, thegrowth almost invariably oceujiyiiig the inner or nasal part of the eye, aris- ing by a fan-shaped expansion from the semilunar fold and lachrymal caruncle, and converging as it ap- proaches the cornea, the centre of which it rarely passes. Arlt's theory, which regarded ulceration of the cornea as the primary cause of ptery- gium, has sometimes been called in question, and recently Dr. Theobald, of Baltimore, has urged that its origin may be due to the influence exerted by the use of the internal recti muscles over the blood supply of the conjunctiva covering their insertion. The inciting causes usu- Fio. 419.—Pterygium. (Stellwag vok Carion.) ally given are the effects of dust, smoke, and heat. Bacteria have been invoked by* Poncet, Lopez, and others, to explain the origin of jiterv- gium. The treatment consists in excision, which is performed by seizing the pterygium with toothed forceps, raising it from the surface of the eye, and shaving it off" from its corneal attachment, then turning it backwards and carefully dissecting it from its base ; the growth is apt to recur, to prevent which the seat of attachment may be touched every two or three days with a crystal of blue-stone. Another operation, called transplanta- tion, consists in dividing the corneal attachment, turning the pterygium back, and fixing its free extremity in an incision in the lower jiart of the conjunctiva by means of a fine suture; or the growth may be removed by means of a ligature threaded upon two needles, and introduced as seen in Fig. 419. When the needles are cut off, the pterygium is transfixed by three ligatures, by the tightening of which it is effectually strangulated. Prince and Wright have obtained good results by tearing loose the ptery- gium with a strabismus-hook (evulsion). According to Dr. Dabney, the growth of a pterygium may be checked by the local use of ergot. Pinguecula is a small, yellowish elevation in the conjunctiva, usually situated near the margin of the cornea, and composed of connective and elastic tissue. It requires no treatment, but if it becomes disfiguring, may be excised. Psoriasis and Pityriasis of the conjunctiva are described by Terrier and Blazy respectively. DISEASES OF THE CORNEA. 723 ' ***tf!Pi<*!''" Fio. 420.—Sarcoma of the conjunctiva. (From a patieat under the care of Dr. De Schweinitz.) Tumors of various kinds grow from the conjunctiva, and may be readily excised with toothed forceps and deli- cate scissors, curved upon the flat. For serous cysts occur- ring in this region, it is suffi- cient to cut away the anterior wall of the cyst, and then touch the part with a jiointed stick of nitrate of silver. Sarcomata (Fig. 420), either pigmented or non-pigmented, generally arise at the sclero- corneal junction; removal of the eyeball is, in the majority of cases, the best method of treatment. Epitheliomata, if movable and not involving the cornea, may* be cut off, but are likely* to recur. Diseases of the Cornea. Keratitis (Corneitis, Inflammation of the Cornea).—Essentially a disease of malnutrition, most common in children, sometimes arising from injury, not unfrequently the local expression of a constitutional disease, such as malaria, or in- herited or acquired syphilis, occa- sionally an indication of disease of the deeper structures of the eye, but sometimes arising from no obvious cause. Both ey*es are usually consecutively affected, the course of the disease, depending upon the type, extending from a few weeks to six months or two years. The symptoms in general are pinkness (not the redness of conjunctivitis) in the ciliary re- gion (see page 733), with hazi- ness of the cornea, dimness of vision, photophobia, lachryma- tion, pain, and a sensation of dust in the eye, with (in the stage of repair of certain forms) a red ap- pearance of the cornea due to its increased vascularity, the resulting con- dition of Pa units sometimes involving almost the whole cornea. In favor- able cases this increased vascularity gradually fades away*, and the part resumes its normal appearance, but in other cases corneal ulcers are de- veloped and retard recovery. Permanent dimness of vision may remain, due to a general haziness of the cornea, or to the formation of a Nebula in the pupillary region. Treatment.—Internally, attention to the digestive functions, with the administration of tonics, such as iron and quinia, and of opium or bella- F[« 42'.—Pannus. (Jonks.) 724 DISEASES OF THE EYE. donna, if there be much pain and photophobia, together with such remedies as are known to be efficient in relieving the constitutional disorder which may be the cause of the disease. Locally, the use of sedatives, particularly belladonna or atropia, and in selected* cases eserine, with counter-irrita- tion, and in adults leeches to the temples, the eyes being protected from light by a shade or dark-colored glasses. Bull recommends the use of iodoform, both internally- and as a topical ajijilication. Ojipenheimer em- ploys instillations of iced water. Chronic Interstitial Keratitis, as was originally jminted out by Hutchinson, is a frequent manifestation of hereditary syjihilis (see page 498). The proportion of cases in which syphilis has been demonstraied as the cause of this affection, is variously given by different authors as be- tween 60 and 70 per cent., and, according to Hirschberg, the proportion would probably be still higher if the separation of typical forms was made from such as are only similar in ajijiearance. The disease is a diffuse keratitis, in which the entire cornea becomes involved, until, usually with- out ulceration, it passes into a condition of universal thick haziness. Bloodvessels, derived from the ciliary vessels found in the layers of the cornea, are thickly set, and produce a dull red color, tlie " salmon jiatch" of Hutchinson, the " vascular keratitis" of some writers. Ciliary pain, iritis, and even secondary glaucoma, are not infrequent acconijiaiiimeiits. Under favorable circumstances, and if judiciously treated, the vascularity subsides, the opacity of the cornea lessens, and, while perfect transparency may not be regained in all instances, cases which at the outset apjicar unfavorable frequently clear up in a surprising manner. The subjects of this disease usually- give other evidence of inherited syphilis, in the vertical notching of the central incisors, fissures at the angles of the mouth, clefts in the pharynx, deafness, nodes on the tibia?, and chronic tumefaction of the jiost-cervical and ejiitrochlear glands. Both eyes are almost invariably affected ; the disease is essentially chronic in its character, requiring from six to eighteen months until its subsidence. As regards treatment, Hut- chinson recommends the use of mercury, apjilied especially by inunction behind the ear ; certainly in the earlier stages, mercury administered by inunction is the best remedy. Attention to the digestive functions, and the administration of tonics, especially the tincture of the chloride of iron together with the bichloride of mercury, are also necessary. Locally, atropia should be instilled, and, if iritis develop, leeches should be applied to the temjile. If struma be present, cod-liver oil and the phosphates are indicated, and if malaria be in any way suspected, as Sedan, of Toulon, has recommended, quinine and arsenic should be exhibited. Bader advises the administration of croton chloral hydrate, in doses of gr. v-x, three times a day. When all irritation has subsided, absorption of the remain- ing opacity may be hastened by the local use of a salve of the yellow oxide of mercury, after the manner of Pagenstecher. Phlyctenular Keratitis is an affection which is also known as Phlyctenular or Scrofulous Ophthalmia, and is sometimes inaccurately called Herpes Corneae; it frequently accomjianies phlyctenular conjunc- tivitis (p. 716). This disease, which occurs in quite young children, is attended with intense photojihobia and spasm of the orbicularis j>al|ie- brarum (blepharospasm), which may render the induction of general ana?sthesia necessary before a satisfactory examination can be made, though usually* the instillation of a few drops of cocaine solution will suffice. The affection receives its name from the existence, usually near the corneal margin, of phlyctenular vesicles, which burst, leaving superficial but healing ulcers. When the phlyctenula? are arranged around the border of PARACENTESIS C0RNE2E. 725 the cornea, the disease is named Marginal Keratitis; when, as sometimes bapjiens, the ulcer creeps from the margin of the cornea towards its centre, drawing after it a leash of bloodvessels, it constitutes one form of Fasci- cular Keratitis; most dangerous is that variety in which a single pustule (Pustular Keratitis) forms near the corneo-scleral junction, spreads in- ward, and may* even perforate the cornea, causing prolapse of the iris. The disorder is most frequent in scrofulous subjects ; it follows in the wake of the exanthemata, has been ascribed to the influence of micrococci, is often associated, as Turnbull especially insists, with disorders of the ali- mentary tract, and, as Augagneur has pointed out, may be dependent upon the presence of rhinitis. The treatment is essentially* that of kera- titis in general; if, as often happens, there is eczema of the lids, advantage may be derived from the use of boracic-acid lotions. The diet must be strictly regulated; tonics, especially cod-liver oil and iron, should be administered: and, if possible, fresh air and exercise should be insisted on. The administration of arsenic is recommended by Wells, in some cases, as is calomel insufflation, when the disease has become chronic. Power speaks favorably of the internal administration of belladonna. A solution of sulphate of eserine (gr. ij to f^j) is recommended by H. W. Williams as a local application. The affection is apt to recur, and frequently* produces permanent opacity or even perforation of the cornea. For the accom- panying blepharospasm, C. R. Agnew and Cornwell recommend forcible separation of the eyelids, and exposure of the eye to the air. Suppurative Keratitis.— This affection may be excited by* traumatic causes, or may* be secondary to other inflammatory diseases of the eye. Suppurative keratitis is, as its name implies, attended with the formation of pus between the layers of the cornea, in one part only, or throughout its structure. The resulting Abscess of the Cornea usually* bursts exte- riorly, leaving an unhealthy-looking ulcer, but occasionally opens into the anterior chamber of the eye, giving rise to the condition known as Hypopyon. A small abscess at the lower part of the cornea, from its fancied resemblance to the lunula of the thumb-nail, is called Onyx. The treatment consists in the use of tonics and anodynes, with good food and stimulants if necessary. Locally*, atropia should be freely- used, with a compressing bandage, or, in cases unattended with pain or intolerance of light (the non-inflammatory* form of Wells), warm chamomile fomentations. Paracentesis of the cornea may be performed once or oftener, serving to relieve in- traocular tension, and to evac- uate the pus if hypopyon be present. If the abscess be cen- tral, an iridectomy should be performed opposite a clear por- tion of the cornea. Paracentesis Corneae is performed by puncturing the cornea near its lower margin with a broad needle held flat- wise, the point being kept well forward, so as to avoid wound- ing the lens; by rotating the needle slightly on its loug axis, the opening is rendered patulous, allowing the slow escape of the aqueous humor and of any pus that may be present. The operation is completed by restoring the needle to its original position, and quickly withdrawing it. Fio. 422 —Paracentesis cornes. Gen- eral anaesthesia may be employed, if desired, but the local application of cocaine is usually sufficient. Ulcers of the Cornea.—These may result from the various forms of conjunctivitis and keratitis, or may apparently* originate jirimarily, as the result of depraved health and malnutrition. Hutchinson believes that they may be caused by gout. Several varieties of corneal ulcer are described by systematic writers, as the superficial and deep, the transparent, and nebulous, the sloughing, and the crescentic or chiselled ulcer. These names sufficiently explain themselves. The deep and sloughing ulcers, especially that form which is called Ulcus Serpens (Saemisch's Ulcer, In- fecting Ulcer), on account of its characteristic tendency to spread over the surface of the cornea, and which, according to the investigations of Leber, is due to the presence of a fungus (Aspergillus), are apt to lead to perfora- tion, previous to the occurrence of which, the membrane of Descemet, with, according to Stellwag, the posterior layer of the cornea, may bulge for- wards through the site of the ulcer, forming a transparent vesicle which is called Keratocele or Hernia of the Cornea. During the stage of repair, in any case of corneal ulcer, enlarged vessels may be seen running from the margin to the ulcerated surface ; should these vessels remain perma- nently after cicatrization, the condition usually known as chronic vascular ulcer results. Treatment.—The treatment of ulcers of the cornea usually requires the administration of tonics and good food, with attention to the digestive functions. In rebellious cases, the condition of the teeth, of the lachrymal passages, and of the posterior nares, should always be investigated. Locally, soothing applications are commonly indicated, such as very hot fomentations of water, jilain or medicated with belladonna or poppy-heads, the instillation of atropia or eserine, hypodermic injections of morphia, etc. For the relief of the accompanying ciliary pain, antipyrin has been especially recommended by Kazaurow, Urandclement, Post, Ryerson, and other surgeons. Hay*er recommends the employment of iodoform. It is only in chronic cases that stimulating applications are projier, and even in these they should be used with caution. They consist in the use of a salve of the yellow oxide of mercury, scraping the floor of the ulcer with a small curette and subsequently* dusting in iodoform, the careful applica- tion to the ulcer of a 10 or 20 grain solution of nitrate of silver—an old mode of treatment recently strongly advocated by Brudenell Carter, in England, and by Callan, in New York—and, finally, the application of the actual cautery. Syndectomy (see page 720) has been occasionally employed with advantage in the treatment of the crescentic ulcer, which is a very intractable form of the affection. Paracentesis corneas is often of use in cases of sloughing ulcer and hypopyon. This operation should be per- formed (through the floor of the ulcer) whenever perforation is threatened, a compressing bandage being subsequently applied ; or, preferably still, the method of Saemisch, which consists in the division of the ulcer with a Graefe's cataract knife, may be resorted to. The point of the instrument is entered close to the margin of the ulcer, within the healthy tissue, and, having been passed through the anterior chamber, a counter-puncture is made near the opposite border of the ulcer, the edge of the knife is turned upwards, and the section is completed. In recent years this operation has been largely supplanted by the use of the actual cautery, a plan originally advocated by .Martinache, of San Francisco, and since strongly recom- mended by Neiden, Schweigger, Snell, Knapp, Gruening, and De Henne. OPACITIES OF THE CORNEA. 727 The operation is rendered painless by the application of cocaine, and may be performed with a small Paquelin cautery, or with the galvano-caustic loop, or, in the absence of these, as suggested by Gruening, with a delicate platinum probe heated in the flame of a spirit-lamp. If the intraocular tension be very great, iridectomy may be preferable. During the stage of repair, the patient should be encouraged to take exercise in the ojien air, and, if the part fall into the condition of the chronic vascular ulcer, a com- pressing bandage and a seton in the temporal region will often prove of service. The compressing bandage is desirable in any form of corneal ulceration in which perforation is threatened, provided that there be an absence of dacryocystitis or catarrhal inflammation of the conjunctiva. Fistula of the Cornea may result from a wound, or from the imper- fect healing of a perforating ulcer. The treatment consists in the applica- tion of a compressing bandage, in touching the edges of the fistulous orifice with nitrate of silver, or, if these fail, in the performance of an iridectomy.. Sometimes the fistulous condition is maintained by the irritation caused by a wounded lens, which should then be removed. As a last resort Law- son recommends paring the edges of the fistula, and bringing them together with a fine silk suture. The intentional formation of a corneal fistula te- recommended (under the name of Keratectomy) in some cases of ophthal- mitis, by Sjiencer Watson. Opacities of the Cornea.—Nebula is the slightest form of opacity, consisting of a mere filmy cloudiness which may be superficial or interstin- tial, and which commonly results from keratitis or superficial ulceration. Albugo or Leucoma is a dense opacity, due to the cicatrization of a deep ulcer, as of a smallpox pustule, and may be either adherent or non-adherent to the iris. It is occasionally* seen as a congenital defect, due either to intra- uterine inflammation or to an arrest of development. According to W. F. Wilson, of Colorado, and other observers, temporary- opacity of the cornea may follow the use of cocaine as a local anaesthetic to the eye, and Jackson, of this city*, has dwelt upon the irregularity of the corneal surface which may* result from the use of strong solutions; while Bunge and Wood- White have described a parenchymatous opacity which ensued after using a corrosive-sublimate wash as an antiseptic in cocainized eyes. Dubois and Panas have observed opacity of the cornea following inhalations of bichloride of ethylene, due to a serous infiltration of the part. Treatment.—Various remedies are employed for nebula, such as the in- sufflation of calomel, or the use of lotions containing corrosive sublimate, oil of turpentine, sulphate or chloride of zinc, iodide of potassium, sulphate of sodium, or common salt. A weak ointment of the red or yellow oxide of mercury is most frequently employed, particularly* in the form of Pagen- stecher's ointment, that surgeon having been the first to specially recom- mend this means of treating corneal opacities. With this ointment as an adjuvant, or, according to some, with simple cosmoline, massage of the cor- nea is the most efficient means which we jiossess of clearing up its ojiacities. This method of treatment, since Pagenstecher's original recommendation, has been specially* insisted upon by Snell, of Sheffield, and by Pfalz, of Dusseldorf. It has been successfully carried out by* De Schweinitz at the Philadelphia Hospital. Dr. Hall, a naval surgeon, recommends the em- ployment of galvanism. Leucoma, which is usually incurable, may require the formation of an artificial pupil opposite a clear portion of the cornea. Opacity resulting from the injudicious apjilication of preparations of lead to an ulcerated cornea, may be remedied by shaving off the deposit with a delicate knife, convex on its cutting edge; after the operation, the abraded surface should be protected by applying a drop of olive or castor oil, and 728 DISEASES OF THE EYE. by the use of cold w*ater-dressing. The same treatment may be required if calcareous degeneration occur, in an ordinary leucoma. In order to obviate the deformity caused by opacities of the cornea, Wecker, C. B. Taylor, Levis, of this city, and others, recommend that the opaque spots should be tinted with various coloring matters, as in the familiar ojieration of tattooing. Power, Gradenigo, Schoeler, and more recently Von llijijiel, in Germany, and Webster Fox, Chisolm, and Straw-bridge, who have re- peated his ojieration in this country, go further, and having removed the opaque portion, transplant a segment of a rabbit's or dog's cornea to suj>- ply the deficiency*. These operations have occasionally been followed by irido-cyclitis, and should not be resorted.to, therefore, without due caution. Sellerbeek and Wolfe have reported successful transplantations of portions of the cornea from the extirpated eyes of other patients. Martin, of Bor- deaux, and Strawbridge, of this city, suggest the formation of an artificial pupil through the sclerotic coat of the eyeball. Other Forms of Inflammation of the Cornea.—Keratitis Punc- tata, characterized by the formation of a triangular accumulation of black dots upon the back of the cornea in its lower quadrant, is in most instances secondary to some disease of the iris, choroid, or vitreous, and occurs in serous iritis and sympathetic ojihthalmia. A few cases, however, are seen, perhajis of a syphilitic nature and appearing in young subjects, in which the corneal dots form the princijial lesion. Neuro-paralytic Keratitis is an ulceration of the cornea, which is seen in cases of jiaralysis of the ophthal- mic branch of the trigeminus. Formerly believed to be a trophic process, it is more likely* that the affection is caused by* a loss of sensation which causes foreign substances on the cornea to be unnoticed and hence not re- moved. (See pp. 41 and 52.) This disorder has been carefully described in this country by W. F. Norris. Keratomalacia (Infantile Ulceration of the Cornea with Xerosis of the Conjunctiva) is, as the name implies, an extensive, sloughing ulceration of the cornea, associated with dryness or xerosis of the conjunctiva. It was originally described by Yon Graefe as occurring in children who were subjects of encephalitis, but, according to Weeks, is seen in ill-nourished subjects indejiendently of this disorder. Many attempts have been made by Leber, Fraenkel, and Franke, to culti- vate the bacillus which has been supposed to be its cause. 'Transverse Cal- careous Film of the Cornea (Riband-like Keratitis, the keratitis en bande- lette of French writers, keratitis trophica of Magnus) ajipears in the form of a horizontal band of opacity which crosses the cornea, and which has been seen most frequently in the eyes of elderly jieople, or in those of sub- jects of increased intraocular jiressure from irido-cyclitis or glaucoma. It may be mistaken for the opacity which occurs from the injudicious appli- cation of lead. Keratitis Bullosa is characterized by the formation ujion the cornea of large vesicles filled with clear fluid, and is a somewhat rare disease, the etiology of which is quite obscure ; it has been seen associated with glaucoma, iritis, and inflammation of the uveal tract. Tangeman, of Cincinnati, has observed jieriodicity in this affection, and, susj)octing ma- laria, has administered quinine with good results. Conical Cornea__The cornea retains its transparency, but assumes a conical form, the ajiex of the jirojection being commonly central. It is most frequently seen in women, is sometimes associated with chronic dys- pepsia, and, according to Henry Power, menstrual disorders may consti- tute a factor in its development. Vision is interfered with by the produc- tion of myopia (short-sightedness) and astigmatism, the latter being a general term for want of symmetry in the state of refraction of different meridians of the eye. In slight cases, vision may be aided by the use of STAPHYLOMA. 729 concave glasses, with a diaphragm containing a circular or slit-shaped per- foration, and even in very* pronounced types of this affection, Thomson and Wallace, of this city, have achieved excellent results by the cor- rection of the existing error of refraction, requiring in some instances unusual sphero-cylindrical combinations. Wallace recommends the local use of eserine, preceding the attempted correction, and Steinheim has obtained reduction of the keratoconus by the prolonged use of eserine and the application of a pressure bandage. In advanced cases, an ojiera- tion is required, having for its object the substitution for the-tissue at the ajiex of the cone of a contracting cicatrix, which shall diminish the exces- sive curvature. The plan suggested by Von Graefe is the formation of an ulcer on the apex of the protrusion, by cutting off a small superficial flap and subsequently* cauterizing the surface. The contraction which accom- panies the cicatrization of the ulcer, diminishes the conicity. Bader and Nunneley have modified Von Graefe's operation by cutting off the flap and bringing the edges of the wound together with delicate sutures. Bow- man's method consisted in cutting, with a trephine, a small disk from the apex of the cornea. Multiple punctures have been recommended by Tweedy; Chisolm perforates the cornea with a needle heated to redness; and Swanzy and other surgeons have produced the desired loss of substance by the use of the galvano-cautery. If there be much intraocular tension, a small upward iridectomy is indicated. Kerato-globus, Hydrophthalmia, or Buphthalmos, is an affec- tion consisting in a uniform, spherical bulging of the whole cornea, with increase in the depth of the anterior chamber, and thinning of the sclerotic coat. Its initial lesions are believed to be intra-uterine, and, in fact, it may be looked upon as a form of congenital glaucoma. If the disease be rapidly increasing, a large iridectomy may* be performed, while if vision be lost, and the protrusion prevent the closure of the eyelids, excision may be indicated. The local use of eserine has been reported to be of service in some cases. Staphyloma___When perforation follows an ulceration of the cornea, the iris commonly falls forwards. If the corneal aperture be very small, no protrusion may occur, the iris merely adhering to the inner corneal sur- face (anterior synechia); under other circumstances prolapse of the iris takes jilace, the protrusion increases by the distention produced by the pres- sure of the accumulating aqueous humor, adhesion to the margin of the ulcer follows, and the surface assumes a cicatricial character. The portion of cornea immediately surrounding the protrusion also yields, and a dis- figuring projection of the front of the eye results, which is called staphy-' loma. Various forms of staphyloma are described by systematic writers, as staphyloma of the iris, partial or complete staphyloma of the cornea, and staphyloma racemosum (in which perforation occurs at several points); again, surgeons speak of ciliary staphyloma or anterior1 staphyloma of the, sclerotic—this condition consisting of a series of bulgings of the weakened sclerotic (through which the dark hue of the ciliary body is per- cejitible), and resulting from injury of the part, or from chronic irido-cho- roiditis. When the staphyloma entirely surrounds the cornea, it is said to be annular. 1. Partial Staphyloma of the Cornea and Prolapse of the Iris—Prolapse of the iris may sometimes be prevented. If the threatened perforation be central, the pupil should be dilated with atropia so as to 1 Posterior Staphyloma is a projection of the posterior half of the eye, met with in severe cases of myopia. 730 DISEASES OF THE EYE. Fio 423.—Prolapse of the iris. (Miller.) keep the iris out of the way, while, on the other hand, if the ulcer be mar- ginal, the Calabar bean should be used to contract the pupil. The alter- nate use of these substances may also jirove useful in breaking up an anterior synechia. If prolapse of the iris have actually occurred, an atteiiqit may be made to replace the protrusion with a delicate probe, aided by the instillation of atropia. If this fail, the prolapsed iris should be punctured, so as to let it collapse, a compressed bandage being then applied; or the prolapsed or staphylomatous iris may* be juinc- tured, and then excised close to the cornea with curved scissors, a compressing bandage being used as before. Finally, if the prolapse or stajihyloma be extensive, a large iridectomy may be performed in an opjiosite direction, this operation diminishing the intraocular tension, and thus lessening, or at least preventing, the increase of the projection, while it also affords an artificial pupil if that should be required. Another plan of treating pro- lapsed iris consists in touching the protruding portion with a pointed stick of nitrate of silver, as recommended by Dixon. 2. Complete Staphyloma of the Cornea signifies a stajdiyloma- tous condition of the entire corneal surface. Its occurrence may be some- times prevented by an early removal of the lens, either immediately after the sloughing of the cornea, or at a later period—when the operation may be performed as directed by Bowman, by the use of a broad needle to break uj> the lens, and a curette to favor the evacuation of any part that is diffluent. Fully formed, complete staphyloma may be treated by abscis- sion, the seton, strangulation, or excision of the eye. (1) Abscission may be performed by either Beer's, Scarpa's, Ci-ilehctfs, or Carter's method. The first consists in transfixing the staphyloma with a Beer's knife (Fig. 424), at the junction of the ujiper and mid- dle thirds, and cutting down- wards. The remaining bridge of tissues is then divided with scissors,, and the broad wound left to heal by granulation. Scarpa's plan differs from the above, in that a flap is formed from the upper part of the sta- jihyloma and laid down over the wound. Critchett's method consists in passing four or five curved needles, armed with silk, across the base of the staphyloma, and then removing an elliptical seg- ment with probe-pointed scissors introduced through a puncture made with a Beer's knife. The operation is completed by carefully tying the sutures, when a linear wound results (Fig. 425). Carter's plan is to unite the recti muscles by catgut sutures, and then close the wound superficially by stitches passed through the conjunctiva only. (2) A seton may be formed through the base of the staphyloma as re- commended by Von Graefe, the thread being removed in the course of Fio. 424.—Abscission of staphyloma. (Stellwag von Carion.) DISEASES OF THE SCLERA AND CILIARY BODY. 731 twenty-four or forty-eight hours. Suppurative choroiditis ensues, which induces shrinking and atrophy of the globe, allowing the application of an artificial eye. Wecker employs a thread of carbolized catgut. Fia. 42o —Critchett's operation for staphyloma. (Lawso.v.) (3) The staphyloma may be strangulated, in part or wholly*, by Borelli's method, which consists in transfixing the prominence with two needles, introduced at right angles to each other, and throwing around them a fine ligature, as in operating for na?vus. (4) Excision of the eye (the mode of performing which will be described hereafter) is particularly indicated in any case of staphyloma in which the deep portions of the eye are believed to be diseased. 3. Ciliary Staphyloma, when resulting from irido-choroiditis, may* be occasionally arrested in its early stages by iridectomy, but when caused by a rupture of the sclerotic, is probably* incurable. If, in such a case, vision be entirely- lost, and the staphylomatous globe be a source of irrita- tion, excision may be properly* resorted to. Diseases of the Sclera and Ciliary Body. Episcleritis (Scleritis, more correctly) is the name given to a small, dusky red, subconjunctival swelling, which usually appears in the ciliary region, on the temporal side of the cornea, though patches may occur in any portion of the zone, and which sometimes causes a good deal of irrita- tion and pain, running a subacute course, reaching its height in about three weeks, and being prone to recur. Severe cases become complicated with iritis and choroiditis, and develop that disease which has received the name of Sclero-keratitis or Anterior Choroiditis, in which the inflammation is characterized by a deep scleral congestion of violet tint, with severe pain and photophobia, opacity* of the cornea, and iritis having a great tendency to relapse. Episcleritis is a disease of adult life, more common in women than in men (according to Nettleship, however, a simpler form of epi- scleritis, in contradistinction to anterior choroiditis, is commoner in men), is often associated with rheumatism, has been seen in association with menstrual disturbance, occurs in scrofulous subjects, and is occasionally caused by tertiary* syphilis (Gummatous Scleritis). A point of some im- portance is to ascertain the condition of sufficiency of the external eye muscles, insufficiency of one or other being sometimes in apparent associa- tion with the relapses of this affection. The treatment consists in sub- duing the irritation by the use of atropia, and then employing collyria of boracic acid. Power recommends the internal administration of a com- 732 DISEASES OF THE EYE. bination of aconite, colchicum, and camphor, while Wecker employs iodide of potassium and hypodermic injections of pilocarpine. Darier has recently strongly recommended colchicin in doses of gr. g1., to jls. Seely, of ('in- cinnati, advocates the local use of eserine. Bull, of New York, has em- ployed with advantage the actual cauterv. Massage, after the manner of Pagensteeher, has proved very beneficial. The rheumatic, strumous, or syjihilitic taint, if present, must be combated with suitable remedies. Tumors of the Sclerotic.—Knajip has recorded a remarkable case of intraocular enchondroma, originating from the inner layers of the >cle- rotic. The growth was removed by Cbisolm, of Maryland, and ten days afterwards the common carotid artery was tied for secondary hemorrhage, the patient dying from tetanus three days subsequently. Cyclitis (Inflammation of the Ciliary Body) is divided by systematic writers into three varieties—the plastic, serous, and sujipurative—the latter being the graver form of the affection. Symptoms.—There are pain and tenderness in the ciliary region, with photophobia and lachrymation, impairment of vision, increased intraocular tension, sub-conjunctival injection (constituting a distinct j>ink zone around the cornea), cloudiness of the vitreous, dilatation of the veins of the iris, inactivity or distortion of the pupil (from coincident iritis), with, )>erha|>s, turbidity of the aqueous humor, and, in the worst cases, hypojiyon. Cyclitis may appear as a primary affection, without relation to any morbid diathesis, and is commonly* the result of injury ; its jilastic and jiurulent forms may follow cataract extraction. Syphilitic inflammation may give rise to cyclitis, and Hutchinson has described the disorder as resulting from gout in a jirevious generation. The milder forms of the disease go on to recovery ; the severer forms are liable to eventuate in glaucoma, shrinking of the eyeball, and the jiroduction of symjiathetic ophthalmia in the other eye. Treatment.—If the pain be very great, a few leeches may be applied to the temple, followed by warm fomentations and the administration of opium. The state of the primae viae should be attended to, and the strength of the patient maintained by means of nutritious food, and stimulants'^ necessary*. Quinia may usually be given with advantage, together with the iodide of potassium, and the oil of turpentine, (in drachm doses) if the iris be much involved. Copaiba is recommended by A. R. Hall. In a very urgent case it may be proper to administer mercury, either by inunction, or internally in combination with opium. Frequent instilla- tions of atropia should be practised throughout the course of the disease, unless there be increased tension, when, in the absence of iritic adhesions, eserine should be substituted. Iridectomy may occasionally prove bene- ficial at an early stage of the affection, while, in cases resulting from injury, excision of the globe should be resorted to without hesitation, if the other eye be threatened with sympathetic imjilication. Ossification of the Ciliary Body has been observed by Haynes Walton, and by Lundy, of Michigan. Diseases of the Iris. Iritis, or Inflammation of the Iris, may be a primary or a secondary affection. Primary iritis may be due to some systemic disease, such as syphilis or rheumatism, or may result from exjiosure to cold, from injuries etc. When >econdarily involving the ciliary body or choroid, it receives the name of Irido-cyclitis or Irido-choroiditis. Secondary iritis is caused by the extension of inflammation from neighboring structures, as the DISEASES OF THE IRIS. 733 cornea, choroid,1 etc. Different classifications of iritis are adopted by authors, the best perhaps being that of Wells, who speaks of the Simple, Serous, Parenchymatous, and Syphilitic varieties. Si/mptoms.—The following sy*mptoms are common to all forms of iritis: (1) Marked sub-conjunctival injection, giving rise to the characteristic ciliarv zone, which is easily recognized by its pink color, its deep sub-con- junctival character, and the radiating course of the enlarged vessels. It is often accompanied by general suffusion of the conjunctiva, and sometimes by chemosis. (2) A contracted and sluggish state of the pupil, which, owing to the formation of adhesions between the iris and capsule of the lens (synechia posterior), assumes, when acted upon by* atropia, an irregular and distorted outline. If the syne- chia be comjilete, the pupil is not at all dilatable, and soon becomes occluded by in- flammatory lymph. In serous iritis, how- FlG- 426._Irltl.. showing gnb.con. ever, the pupil is often abnormally dilated, junctivai injection forming the cm- (3) The iris loses its natural bistre, and be- ary zone. (Pirrie.) comes discolored; its striated apjiearance is obscured, owing to inflammatory swelling; its vessels may become enlarged and varicose ; while beads of lymph may* perhaps be detected upon its surface. The change of color is even greater apparently than in reality, owing to the state of the aqueous humor, which is often turbid from the admixture of flocculent lymph or pus. This may accumulate in such quantities as to form a hypojrvon. (4) Vision is impaired, partly by the diminished transparency- of the aqueous humor, but also in many* cases by the coexistence of cyclitis, which alters the accommodation of the eye, and often causes turbidity of the vitreous (p. 732). (5) Pain is usually* a prominent symptom of iritis, though in some cases, particularly of the syphilitic form of the affection, it is almost or altogether absent. Accord- ing to the younger Hutchinson, " quiet iritis" is most often due to heredi- tary syphilis, to sympathetic inflammation, or to an inherited arthritic ten- dency, and occurs only exceptionally- with acquired syphilis or in the ordinary* rheumatic form of the disease. The pain of iritis is deeply seated in the eyeball, and often extends to the forehead, temple, and nose, assuming a neuralgic character, and being worst at night. Tenderness in the ciliary region indicates the presence of cyclitis. (6) Photophobia and lachryma- tion are not usually very intense—much less so, indeed, than in many cases of keratitis. Simple or Idiopathic iritis presents the symptoms above described in a mild, and Parenchymatous iritis in a severe, form, the latter variety being that in which suppuration chiefly* occurs, leading sometimes to perforation of the cornea and permanent loss of sight. Serous iritis, or, as Priestly* Smith prefers to call it, serous cyclitis, is especially* characterized by the absence of lyniphy deposits, and by an increase in the amount of aqueous humor, leading to augmented intraocular tension and consequent dilatation of the pupil. Serous iritis often accomjianies choroiditis and retinitis, and is the form sometimes assumed by Sympathetic Ophthalmia; it is also seen in connection with hereditary syphilis (see page 498). The so-called Rheumatic iritis belongs to one or other of the above varieties, and is often associated with sclerotitis in cases of gonorrhoeal rheumatism (page 475). 1 Hence some systematic writers describe choroido-iritis separately from irido-choroi- ditis. 734 DISEASES OF THE EYE. Gonorrhoeal iritis is a rare affection, and does not coincide with nor immediately- follow the gonorrheal attack; an arthritis of the knee, or sometimes of the ankle, always intervenes. The true Syphilitic iritis be- longs to the parenchymatous variety of the affection, being an accompani- ment of tertiary syphilis, and characterized by a dejiosit of yellow tubercles which are strictly analogous to gummatous tumors (p. 494); the iritis of secondary syphilis, on the other hand, is an ordinary iritis, jiresenting no clinical characteristics essentially differing from those of the simple jdastic form, yet doubtless due to the syphilitic taint, and in many cases, according to Fuchs, probably- parenchymatous, or even gummatous. S. M. Burnett describes, under the name of spongy or fibrinous iritis, a form of the dis- ease characterized by intense pain and very rapid and extensive exudation of a fibrinous material, which is subsequently absorbed, the absorption beginning at the periphery. Gout is a cause of both acute and chronic iritis, and the gouty, like the rheumatic form of the disease, tends to relapse, and attacks only one eye at a time. The children of gouty jiarents are liable to a destructive form of iritis associated with disease of the vitreous. Any form of iritis may be met with as a recurrent affection, particularly in persons affected with rheumatism or gout, the tendency to relajise being much more frequent in the varieties connected with these diseases than in those caused by the syphilitic taint. Chronic Iritis occasionally appears in adults in the form of a jilastic irido-choroiditis, of a progressive and destructive character, complicated by disease of the vitreous and choroid, and by the formation of a cataract. Treatment.—The use of atropia is unquestionably- the most important point in the treatment of iritis. A strong solution should be employed (at least gr. iv to fjj), and this may be applied in very urgent cases, as ad- vised by Wells, at intervals of five minutes, for half an hour, three times a day-. The advantages gained by the use of atropia are the dilatation of the pupil, thus preventing the occurrence of synechia posterior, the phy- siological rest secured to the iris by paralyzing its circular fibres, and the relief given by the local sedative influence of the drug. Even if adhoions to the capsule of the lens are already formed, these can often be stretched and even ruptured by the unsparing use of atropia, the effect of which may be increased by the addition of cocaine. Hyjiodermic injections of morphia may be administered to relieve pain, and the same remedy may be em- jiloyed as an antidote in the rare event of a jioisonous effect being produced by the passage of atropia through the lachrymal puncta into the throat. Leeches to the temple are often serviceable in relieving the intense ciliary neuralgia, and are also of use in lessening intraocular tension, and thus preparing the way for the action of atropia. Paracentesis of the Cornea may* also be employed for the latter purpose, and is jiarticularly indicated if the aqueous humor be cloudy, or if hypojiyon be jiresent. Mercury is certainly* a valuable remedy in those cases of iritis in which there is an abundant formation of inflammatory lymph, and in those which are due to syphilis; it should be pushed to just short of the point of salivation for several months, and may be followed by the exhibition of iodide of jiotas- sium, either alone or in conjunction with corrosive sublimate. It may be given internally, in combination with opium, or may be emjdoyed by inunction. Iodide of potassium, oil of turpentine, and colchicum are jiar- ticularly* useful in cases of gouty and rheumatic iritis. Copaiba is recom- mended by Macnamara, Hall, and other Indian surgeons, and the salicylate of sodium by Chisolm, of Baltimore. Pilocarpine often affords relief. OPERATIONS ON THE IRIS. 735 Finally, iridectomy may be required, if there be extensive and firm adhe- sions between the iris and capsule of the lens, or if, as in some cases of serous iritis, there be a marked increase of intraocular tension. In recur- rent iritis, according to Nettleship, the cases best suited for iridectomy are those without much change in the aqueous humor or in the iris, except at its points of adhesion, and those cases of the chronic variety which present circular synechia? and bulging of the iris. Keratitis punctata, chronic thickening of the iris with very extensive attachments, the existence of myopia, and a tendency to spontaneous bleeding and hypopyon, render the operation less desirable. Tumors of the Iris.—If of a cystic nature, the proper remedy is iridectomy, the cyst being removed with its seat of attachment. Excision of the entire iris was suggested by Mr. R. B. Carter in a case in which both irides were the seats of round-celled sarcoma, which in rare cases occurs as a jirimary affection ; and excision of the growth alone, by an operation analogous to that of iridectomy, has been successfully practised by Kippand other surgeons. Recently Andrews has reported the removal of a primary round-celled sarcoma, but the eye was lost. If occurring as an extension of the disease from other structures, excision of the globe is the only mode of treatment to be recommended. Other forms of new growth described are the granuloma, benign in itself, but by filling the anterior chamber causing ulceration of the cornea; tubercle, which may call for enucleation to avert general tuberculosis, as in Deutschmann'scase; and gummata, already referred to. Mydriasis (Dilatation of the Pupil) may result from rheumatism affecting the nerve-sheaths, from syphilis, from contusions or other injuries, from irritation of the sympathetic, from cerebral disease, or from any dis- ease of the eye which produces increased tension of the globe. Paralysis of the ciliary muscle often coexists, producing disturbance of the accommo- dation. The accompanying impairment of vision, if due to mydriasis alone, may be relieved by the use of a diaphra.srm with a pin-hole perfora- tion ; while the paralysis of accommodation will often yield to the apjilica- tion of a blister behind the ear, and the administration of iodide of potassium. In chronic cases, a weak solution of Calabar bean may be dropped into the eye. Myosis (Contraction of the Pupil) may result from excessive use of the eyes, as in watchmaking or engraving, or may depend upon disease of the cervical portion of the spinal cord, the pressure of an aneurism or tumor on the cervical, sympathetic, etc. Little can usually be done in the way of treatment, though temporary relief may sometimes be afforded by the instillation of atropia. Persistent Pupillary Membrane occurs in the form of vestigial remains of the foetal covering of the lens, which jiass like cords across the pupil, and may be mistaken for the sy-nechiae of iritis. Irideremia is a condition in which there is congenital absence of the iris, either partial or complete. Coloboma of the Iris is a congenital defect in which a cleft, some- what resembling that following the operation of iridectomy, is caused by* imperfect closure of the choroidal fissure. These anomalies are frequently- seen in association with other vices of conformation. Operations on the Iris. Iridectomy.—This operation consists in the excision of a portion of the iris. When done for the relief of intraocular tension (as in glaucoma), 736 DISEASES OF THE EYE. or as a preliminary* to extraction of cataract, the section should, as n rule, be made upwards; though as the outward section is an easier procedure, this may be sometimes preferred by an inexperienced operator. The advantage of an ujiward iridectomy is that the lid subsequently covers the seat of operation, thus cutting off the irregularly refracted jierijdieral rays of light, and at the same time partially- hiding the resulting deformity, if, on the other hand, an iridectomy is to be jierforiued as a means of making an artificial pupil, a small inward section is jireferable—the visual line cutting the cornea on the inner side of its central point—though, in eases of cornea] opacity, the surgeon may- be forced to make his section at any jioint opposite to which the cornea may hajipen to be clear. Iridectomy is thus performed: The jiatient being in the recumbent position, and under the influence either of a general ana'sthetic or of the instillation of cocaine, the sur- geon separates the lids by means of a Liebreich's, Noyes's, or ordinary spring-stop sjieculum (Fig. 425), and, standing behind the jiatient's head, fixes the eye by seizing with firm catch-forceps the conjunctiva and subja- cent fascia, at a point directly opposite to that of the jiroposed section. A lance-shaped keratome or iridectomy knife (Fig. 427)—straight for the outward, but angular for the upward or inward section—is then to be thrust through the sclerotic at about half a line or a line from its junction with the cornea, the handle being well depressed, so as not to wound the iris or lens, while the blade is slowly thrust onwards, until the section is of the desired extent. The knife is then cautiously withdrawn, so as to allow the slow escape of the aqueous humor, when the first stage of the operation is conqdeted. The fixation forceps are now handed to an assist- ant, who may rotate the globe a little downwards, and steady it while the surgeon excises a jiortion of the iris; this second stage of the operation is accomplished by introducing curved iris forceps (Fig. 428), expanding the Fig. 427.—Lance-shaped iridecloray knife. Fio. 428.—Curved iris forceps. blades so as to grasp the pupillary margin, cautiously withdrawing the forceps with the included portion of iris, and snipping off the latter close to the wound by one or two cuts with delicate curved scissors. When the object of the operation is to reduce intraocular tension, the iris should be excised close up to its ciliary margin. Sometimes, immediately after the withdrawal of the knife, the iris prolapses, when it may be instantly seized with forceps and excised. If the anterior chamber be very shallow, it may be safer to substitute, for the lance-shaped instrument, the knife used by Von Graefe for the modified linear extraction of cataract, making a puncture and counter-puncture, and then cutting outwards as in the ope- ration referred to. If the section of the iris cause hemorrhage into the anterior chamber, the escajie of blood may be facilitated by carefully intro- ducing a curette (Fig. 433, b), and making cautious ju-essure with the fixation forceps. The speculum being removed, the lids are gently closed, and a compressing bandage applied. This is done by covering the closed lids with an oval disk of soft linen, spread with simple ointment or gly- cerin to prevent its adhering, filling up the inequalities of the orbit by CORELYSIS. 737 carefully packing the part with fine charpie, and finally securing the whole with a Liebreich's (Fig. 429), Theobald's, or other light bandage. For the first few days, both eyes should be excluded from the light. Iridectomy for Artificial Pupil requires a smaller section, which should be made through the cornea __as in this case it is desirable to leave the ciliary attachment of the iris, so as to cut off some of the peri- pheral rays; the portion of iris which is to be excised may be drawn out with forceps, or with a blunt silver or platinum Tyrrell's hook. R. B. Fib. 430.—Tyrrell's hook. Carter has modified this operation by cutting off a portion of the iris with delicate scissors (Wecker's) introduced into the anterior cham- ber of the eye, and subsequently withdrawing the severed fragment with forceps. Iridodesis.—This operation was introduced by Critchett for the pur- pose of forming an artificial pupil in cases of opaque or conical cornea, or of lamellar cataract. After making an incision with a broad needle, a fold of the iris is drawn out and fastened by a loop of fine silk tied around it over the incision ; the loop soon drops off, and a pear-shaped pupil is the result. This operation has not infrequently been followed by severe irri- tation and even destructive irido-cyclitis, and has hence been abandoned. Artificial Pupil by Incision (Iridotomy).—This operation may be practised in cases in which the lens is absent ( as after cataract extrac- tion), and in which the pupil is entirely occluded. It is performed by simply splitting the fibres of the iris with a broad needle, the retraction usually affording a sufficient pupil. Under other circumstances, a Tyrrell's hook may be introduced, and the operation converted into a small iridec- tomy. Bowman has modified this operation by excising a triangular- shaped piece of iris, with delicate scissors introduced through a corneal wound. Iridotomy is also employed by Bowman and Wecker in cases of zonular cataract, opacity of the cornea, etc., the former surgeon employing a knife blunt at the point and back, which is introduced behind the iris and made to cut forwards, and the latter employing a triangular keratome and delicate forceps-scissors. Wecker's operation has also been successfully employed in a number of cases by Dr. H. D. Noyes, of New York. Corelysis is an operation practised by Streatfield and Weber, for the detachment of adhesions passing between the pupillary margin of the iris and the capsule of the lens. It consists in making, with a broad needle, a corneal wound at a convenient point, Fig. 429.—Liebreich's bandage. (Lawson.) Fig. 431.—Spatula-hook. and then with a spatula-hook (Fig. 431) passed behind the adhesion, drawing forwards and slowly rupturing the latter. 47 738 DISEASES OF THE EYE. Passavant's Operation, for the accomplishment of the same object, con- sists in making a small opening at the edge of the cornea, introducing suitable forceps and seizing a fold of the iris in close proximity to the synechia; the latter is then torn loose from its attachment to the lens, and the forceps disengaged and cautiously* withdrawn, care being taken to guard against the occurrence of prolajise of the iris. Iridodialysis is an operation employed in cases of extensive central opacity- of the cornea; it consists in tearing loose the ciliary attachment of the iris, thus forming a peripheral artificial pupil. Cataract. An opaque condition of the crystalline lens, of its cajisule, or of both, is called cataract, the several conditions being distinguished by the names lenticular, capsular, and capsulo-lenticular. Lenticular cataract is either partial and stationary (lamellar, and anterior or posterior polar cataract), or is progressive and becomes total (senile, nuclear, cortical cataract, etc.). When cataract forms without known connection with other disease of the eye, it is called primary; when in association with other diseased condi- tions of the organ, secondary—a name also given to the proliferation of the capsule which remains after extraction of the lens. A collection of lymph or blood in front of the lens is sometimes called spurious cataract. Cataracts are classified according to their mode of origin, as idiopathic, traumatic, or congenital; according to their color, as black, amber, etc.; and according to the consistence of the cataractous lens, as hard or soft. Calcification and ossification of the crystalline lens have been observed by* Walton, Keyser, and Voorhies, of Memphis. The causes of the changes in the crystalline lens are not definitely determined. Deutsch- mann has found albumen in many cases, and diabetes is known to exist in others. Recently Michel has suggested lowered blood supply from atheroma of the carotid, but in many instances, not senile, an exact reason for the lenticular opacity cannot be given. Symptoms.—The first symptom of cataract which attracts the attention of a patient, is dimness of vision, as if from a cloud or mist, which in idio- pathic cases, comes on gradually; the sight is usually best in a somewhat dim light, for the pupil dilates under such circumstances, and allows light to penetrate the periphery of the lens, which is usually less opaque than its centre. The appearance of a cataractous patient differs from that of one who is amaurotic: the former has not the vacant stare of the latter; instead of helplessly rolling up his eyes to the sky, he is able to direct them towards any object with some certainty, and, to a moderate extent, he can find his way about by himself; there is no involuntary oscillation of the eyeball, nor divergent squint, and the pupil reacts normally to the stimulus of light. In a case of uncomplicated cataract, the power of distinguishing day from night is never lost. In a case of advanced cataract, the opacity can be readily recognized by the unaided eye of the surgeon, but in an earlier stage more careful examination may be necessary. The Catoptric Test, which was proposed by Sanson, is now, since the introduction of the ophthalmoscope, seldom employed, but is still worthy of mention : if a lighted candle be moved before a healthy eye, three images of the flame will be seen; two erect, formed by reflection from the convex cornea and anterior surface of the lens, and one inverted, from the concave posterior surface of the latter. If now the lens be opaque, the inverted image will be wanting, the deeper erect image similarly disappearing when the opacity involves the capsule, and the corneal image being then alone TREATMENT OF CATARACT. 739 perceptible. The diagnosis of cataract may be most satisfactorily made by means of Oblique Illumination and the Ophthalmoscope. Oblique illu- mination (Fig. 199) is practised by placing the patient in a darkened room, and with a convex lens concentrating the light from a suitably-placed Argand lamp upon the pupil, previously dilated with atropia—if not for- bidden by increased intra-ocular tension—when any opacities may be readily recognized by their whitish-gray color. When now the light is reflected by means of the ophthalmoscopic mirror into the eye, the opacities appear as streaks or spots, which are black from the interference with the return of light from the fundus oculi ; or if the opacity be of a diffused character, the ordinary red hue of the fundus may be partially or completely obscured. The most important practical points in the examination of a cataract are to determine—first, whether it be or be not complicated by the presence of some more deeply* seated lesions, and, secondly, whether it be hard or soft. In a case of uncomplicated cataract, the patient should be able to distinguish the light of an ordinary Argand burner at a distance of fifteen or twenty feet. Hard cataracts usually occur in persons over fifty years of age, and are probably never met with in those under thirty-five. They are commonly of a smoky-ash color, and frequently present a regularly striated appearance ; after extraction they have an amber tint. Soft cata- racts are most frequent in the young, jiresent a bluish-white appearance, and are irregularly, if at all, striated. Congenital cataracts are always soft. Treatment.—Various operations are practised for the relief of cata- ract—all having for their object the immediate or gradual removal of the opaque lens. In cases of lamellar or zonular cataract, however (a variety of cataract met with in children, and, according to Arlt, in connection with a history of convulsions, and in which an opaque lamella or zone inter- venes between the nucleus or cortical portion, which are both clear), the choice of operation lies between iridectomy for the formation of a new pupil, discission, and extraction. Before resorting to any operation for cataract, the surgeon should test the sensibility of the retina to light, as unless the patient, when placed in a dark room, is able to recognize the presence and general position of the flame of a lamp at a distance of from fifteen to twenty* feet, the jirospect of benefit from an operation will be com- paratively slight. With regard to the lime for an operation, it may be said that congenital cataracts should be operated upon at an early period, after the completion of teething, as otherwise a disfiguring involuntary habit of oscillation of the eyeballs (nystagmus) is apt to be developed ; in other cases it is better, as a rule, to wait until the cataract is fully ripe or mature, or, in other words, until the whole lens has become opaque.1 In cases of double cataract, that which is furthest advanced should be first operated upon, so that the patient may* continue to use the second eye while the process of cure in the first is going on. An anaesthetic may be administered in any operation except that of flap extraction, but, except with extremely nervous patients, the local use of cocaine is preferable to general anaesthesia ; the jiatient should lie on a table of convenient height, with a good side light, and with the pupil well dilated by atropia. I shall not attempt to describe all the varieties of operation which have been and are practised for the cure of cataract, but shall speak merely of the flap 1 Attempts have been made to hasten the ripening of a cataract by puncturing the lens. Forster, of Breslau, recommends, as safer, that an upward iridectomy should be practised, and that when the lens falls forward on the cornea the latter should be stroked with a smooth instrument so as to exercise pressure on the lens. This plan has also been tried by Dr. Noyes and Dr. Mittendorf, of New York, but according to the latter is not free from danger. 740 DISEASES OF THE EYE. operation (extraction without iridectomy), the linear extraction, the modified or peripheral linear (Von Graele), the short flap (De Wecker), the needle operation (or that of solution), and the suction method. The simple linear and the last two are adajited for soft, and the others for hard cataracts. The old operation of Reclination. depression, or couching, by which the lens was forcibly thrust down into the vitreous (where it con- stantly gave rise to destructive inflammation), is now hajipily almost totally abandoned, and is mentioned merely as a matter of historical in- terest. Nicati, Kipp, and others have reported the spontaneous absorption of senile cataracts. Fig. 432.—Flap extraction of cataract. (Wells.) Operations for Cataract. Extraction by Flap Operation__In this operation the use of an anaesthetic is not admissible. The eye should be rendered ana'sthetic bv instillation of a freshly prepared, 2-4 per-cent. solution of cocaine made with boric acid. On the evening preceding the operation a mild purge should have been administered. The face of the patient, the area of operation, the hands of the operator, and his in- struments, must be made abso- lutely aseptic. Various antisejitic solutions have found favor with surgeons ; those usually employed for irrigating the eye are the bichloride of mercury (1-5000),di- luted chlorine water, and Panas's solution,1 which is preferred by Knapp. The instruments im- mediately before the operation are to be placed in boiling water, then removed to a bath of absolute alcohol, and finally, according to the method of some operators, laid in a one-per-cent. solution of carbolic acid. The surgeon, if able to use the knife with his left as well as with his right hand, may stand behind the patient's head, no matter which eye is to be operated upon ; under other circumstances, he should take this position for the right eye only, standing on the patient's left side and in front, for an ojieration on the left eye. The peculiarity of this method consists in making a large semicircular flap, involving two-fifths of the corneal edge of the limbus conjunctivae, and the operation may be done either by an upward or downward section, the former being usually preferred. The following description refers to t be operation by upward section on the right eye. It is usually best to dis- pense with specula in this procedure, the eye being fixed by the fingers of the surgeon and his assistant;2 the former with his left forefinger raises the upper lid, and holds its tarsal edge firmly beneath the upper border of the orbit, while his midde finger is fixed steadily on the inner canthus, the assistant in the same way depressing the lower lid, and fixing the outer canthus ; the eye is thus securely held without injurious compression. If, 1 Biniodide of mercury, gr. f; absolute alcohol 13vj ; add a quart of distilled water, shake, and filter. 2 Chesshire, of Birmingham, recommends division of the external canthus as a pre- liminary to all cataract operations, so as to avoid the risk of injurious pressure from sudden contraction of the orbicularis palpebrarum muscle. EXTRACTION BY FLAP OPERATION. 741 however, the patient be very restless, the surgeon may himself fix the eye with forceps, intrusting the raising of the upper lid to his assistant (Fiir. 432). The surgeon then, standing behind the patient and holding the triangu- lar extraction knife1 lightly in his right hand, or in front of the patient and with the knife in his left hand, enters its point at the junction of the cornea with the sclerotic (in the old method one millimetre or half a line within the sclero-corneal junction), on the temporal side, at first in the direction of the radius of the corneal curve, so as not to split the lamellae of the cornea, but keeping the blade subsequently* in a plane parallel to that of the iris. If the triangular knife is emjiloyed, the flap is made by simply pushing the blade across the anterior chamber, the point of exit being diametrically opposite to that of entrance; the peculiar shape of the blade causes it to constantly fill the wound, and thus prevents the premature escape of the aque- ous humor. The flap being completed, the eyelids are allowed to close for a few seconds, when the surgeon proceeds to the second stage of the operation, the laceration of the lens capsule. This is effected by introducing the cystotome (Fig. 433, a), the patient looking downwards, and the upj>er lid being slightly elevated; when the cystotome has reached the inner side of the pupil, its point is turned downwards, and the capsule freely divided as far as the outer pupillary margin ; the instrument is then cautiously withdrawn, when the eyelids may again be allowed to close. Peripheral opening of the cajisule, as recommended by Gayet and Knapp, has, according to the latter surgeon, disadvan- tages in this form of ojieration, though carrying the instru- ment high up and adding a horizontal stroke after the manner of Von Graefe, is useful. The third stage of the operation con- sists in the evacuation of the lens, which is effected by* making gentle pressure with the back of the curette (Fig. 433, b) upon the lower lid, while counter-pressure is made with the forefinger upon the upper portion of the eyeball. The curette should at first press backwards, and then backwards and up- wards, so as to cause the lens to present itself edgewise at the corneal wound. The pressure must be very cautiously made, lest rupture of the hyaloid membrane and loss of vitreous follow. As soon as the lens has escaped, the ope- rator must address himself to the " toilet of the wound." The eye should be freely* irrigated with the antiseptic fluid, clots should be gently wiped away, the iris carefully reduced, and the pupil freed from any cortical remains. Irrigation of the anterior chamber is proposed and practised by* McKeown and Wicherkiewicz, and is likewise employed by Panas and other surgeons. The operation is now completed, and a solution of eserine is instilled ; De Wecker injects it into the anterior chamber, to prevent prolapse of the iris. Before applying the after-dressing the surgeon should again, in a n . ~ o? Fig 43S few minutes, separate the lids, to make sure that the corneal „ p„.'lnm„ a i t -i -i i a Oystotome. nap is properly adjusted, and that no prolapse of the iris has &. curette. 1 Some surgeons use the triangular (Beer-Richter) knife, or a modification of this ; others, like Knapp, prefer to employ the narrow Graefe's knife in this as well as in the peripheral linear extraction. Jackson has devised a knife to combine the advantages of both Beer's and Graefe's instruments, and Randall has advocated the " Holz- schnitt" knife of Von J aeger. 742 DISEASES OF THE EYE. occurred. The after-treatment consists in applying a compressing band- age (see p. 736) to both eyes, over jiads of cotton-wool soaked in a bichloride solution. The patient should be confined to bed for three or four days. Chisolm, of Baltimore, and Michel, of St. Louis, close both eyes with a strip of plaster, or even leave the eye not ojierated u|ion oj»en, and allow the jiatient to be up from the first day. Dr. II. W. Williams (Boston Citij Hospital Reports, 1870, p. 378) recommends the insertion of a delicate suture in the centre of the wound after the ojieration of flap extraction; his statistics do not, however, show any particular gain by the proceeding i—102 cases with suture having given 85 successes, 8 partial successes, and 9 failures, while 104 cases without suture gave 87 successes, 7 partial suc- cesses, and 10 failures. Fuchs has tried the same procedure with an un- favorable result in two out of nine cases. If all goes well, the eye should not as a rule be opened until the end of a week, though the external dress- ing may be renewed once or even twice a day. Should, however, the occurrence of any unfavorable symptom, such as great jiain, swelling, or muco-purulent discharge, lead the surgeon to fear that the case is not pro- gressing satisfactorily, the lids should be gently separated and the eve in- spected (by the light of a candle), that the exact condition of things may be recognized, and appropriate treatment resorted to. The chief complications which may arise during the operation are as follows: (1) the iris may fall in front of the knife—to be remedied by gently disentangling the point of the instrument, and by making cautious pressure through the cornea; if this fail, the section may be completed, the resulting iridectomy* not being of any* particular disadvantage; (2) the corneal wound may* be too small—to be remedied by cautiously enlarging it with blunt-jiointed knife or scissors; (3) the lens may drop down into a fluid vitreous—the lens must be instantly extracted with a suitable sjioon or hook, and a compressing bandage applied; (4) prolapse of the iris may occur—to be remedied by* gently repressing the protruding portion with a fine probe, or by softly rubbing the lids in a circular direction; if this fail, the prolapse should be seized with forcejis and excised; (5) portions of the cortical matter of the lens may be detached during its exit—these should, if possible, be removed by very gently rubbing the eyelids in a circular direction, so as to bring the fragments into the anterior chamber, whence they may be removed with a scoop or spoon, or by irrigation, after the manner of McKeown. If, from its transparency, the cortical matter at first escape observation, subsequently swelling and jiroducing irritation, atropia must be freely used; it may even be necessary to make a small corneal incision, facilitating the escape of the remaining lens substance by means of the curette or suction apparatus (see jiage 746). The escape of a considerable quantity (more than one-third) of the vitre- ous humor is usually followed by loss of the eve, and an equally bad result attends deep intraocular hemorrhage, which may occur during the ojiera- tion, or some hours subsequently. Failure after flap extraction may occur from these causes, or from inflammation attacking the cornea or iris, or even the whole globe; the treatment of these accidents must be conducted upon general principles—the application of a few leeches to the temples, and the free use of atropia, are to be recommended during the early stages, followed by warmth and moisture, and the compressing bandage, if sup- puration occur. Collins and Nettleship advise the application of the gal- vanic cautery along the line of infiltration, and frequent bathing with warm antiseptic solutions, the eye remaining unbandaged. Historically, the flap operation is the earliest. It was superseded by the perijiheral linear method and its various modifications, with iridectomy. PERIPHERAL LINEAR EXTRACTION. 743 Within the last two years, however, a disposition has arisen to return to the flap or simple operation, which is now strongly advocated by Knapp and Bull, of New York; by Panas, Abadie, Galezowski, and many other French surgeons; by Sehweigger, in Germany; and by Powers and others in England. Strict antisepsis, with the use of cocaine and eserine, has greatly aided a return to this method of ojierating. Linear Extraction.—In this operation (which originated with Von Graefe and has been modified by Waldau, Critchett, and others), anesthesia, either local or general, may be employed, and the eyelids may be held apart with the stop-speculum. The surgeon, standing behind the patient, fixes the eye with forceps, and makes with an iridectomy* knife, or a Graefe's linear-extraction knife, an incision in the upjier part of the sclero-corneal junction, involving one-third of the corneal circumference; the fixation forceps are then intrusted to an assistant, and the surgeon, cautiously introducing delicate iris forceps, makes a broad iridectomy as directed at page 736; or the iridectomy may be omitted (simple linear extrac- tion). The capsule of the lens is next freely lace- rated with the cystotome, and the lens itself drawn FlG, 434._TractIon spoons. out with a silver spoon (Fig. 434), provided with a barbed or recurrent edge, which allows it to slip easily between the lens and the posterior capsule, and then catches the lower edge of the lens and holds it firmly as it is withdrawn. Care must be taken in the introduction of the spoon, not to push the lens before it, and not to rupture the hyaloid membrane, which would allow loss of vitreous. This operation is only suited for quite soft cataracts, or those with a small nucleus. Peripheral Linear Extraction ( Von Graefe's Method), with its lamented author's latest modifications, is considered by some surgeons the best operation vet devised for the extraction of cataract. The peculiarities of this method are the peripheral position of the incision, the fact that this does not form a flap,1 and that no traction instrument is employed. The same precautions in regard to cleanliness and antisepsis which have already been described, must be exercised. The speculum having been inserted, the surgeon steadies the eyeball and draws it downward with a fixation-forceps, by taking hold of a fold of conjunctiva below the inferior border of the cornea, and opens the extreme periphery of the anterior chamber with a narrow knife represented at Fig. 435 in its actual size, Fig. 435 —Von Graefe's cataract knife. by an incision A B (10 millimetres, 4^-4| lines long) through the sclerotic, at the point A (Fig. 436), 1 millimetre external to the margin of the cornea, and 2 millimetres below the tangent to its summit. The point of the knife, on entering the anterior chamber, is, in the first instance, directed, not to the point of counter-puncture B, but to about the point C. After the knife has been entered fully 7 or 8 millimetres into the anterior cham- ber, its handle is depressed, counter-puncturation at B effected, the knife edge directed obliquely forwards, and the section completed by a gentle 1 The incision is usually said to be linear (whence the name of the operation), but this distinction is not mathematically correct, the section in this method no more cor- responding to the geometrician's definition of a line than does that of the ordinary flap operation. The curve in Graefe's incision is that of the eye itself. 744 DISEASES OF THE EYE. upward sawing movement. To cut the conjunctival tissue, the edge; of the knife is directed forward, or a little upward, if, as some surgeons prefer, a conjunctival flap is desired. The next step of the operation consists in an iridectomy, either a portion of the iris corresjionding with the entire length of the wound being excised, as in the original Von Graefe operation, or a smaller segment being removed. The instrument employed for catch- ing the iris is the ordinary iris-forceps, or, which Meyer and Weber prefer, a blunt hook. Capsulotomy is next performed in the manner already de- scribed. If the centre of the capsule is thickened, it is well to remove the pupillary* portion with forceps. Various instruments have been devised for this purpose, Mathieu's iris-forceps being preferred by Knapp. To remove the lens, a spoon of vulcanite or tortoise-shell is employed, not being used as a traction instrument, but simply to exercise pressure from without. The convex back of the instrument is applied to the lower border of the cornea, when, by using a little pressure, the wound at its upper part begins to gape. Then the sjioon is given a slight turn (so that its ujiper border buries itself a little in the outer surface of the cornea) at the same time that it is moved a little upwards, in consequence of which the Fro. «6.-Diagram of Von Graefe's equator 0f the lens presents itself at the wound. operation for cataract. (Laurence.) -•-> ,. ■ .1 j 1 • v ' By continuing the manoeuvre and making slight counter-pressure on the scleral border of the wound, the exit of the lens is effected. Any cortical matter which may have become detached is to be coaxed out by* gently stroking the cornea from below upwards with the back of the sjioon, as long a time as may be necessary being devoted to the satisfactory accomplishment of this final part of the operation.1 Complications and irregularities in the process of healing must be met as directed on page 742. If in any case the evacuation of the lens in the manner described be found impracticable, it may be extracted with a silver spoon, or (which Graefe prefers) a blunt hook (Fig. 437). The after-treatment in this and in the traction method is the same as in the flap extraction, except that in these the eye may be safely examined after twenty-four hours; the patient is allowed to leave his bed from the fourth to the seventh day. From four to six weeks after a successful extraction, glasses may be pre- scribed for the eye, which, if it has been originally emmetropic, by the removal of the lens becomes highly hypermetropic, the power of accommo- dation being lost. Two lenses are hence required, one for distance, and one for reading. Astigmatism in high degree is often present after cataract operations, and requires cylindrical glasses for its correction. Glasses must not be worn continuously until all signs of inflammation have jiassed away. The disadvantages of the method of peripheral linear extraction are the risk of hemorrhage from the conjunctiva into the anterior chamber; the risk of loss of vitreous, which is favored by the peripheral position of the i McKeown, of Belfast, has devised a "scoop-syringe" for washing out the cortical matter by injection of warm distilled water. Wicherkiewicz employs a boric-acid, and Panas a sublimate solution. C. G. Lee prefers irrigation to simple injection. Fig. 437.—Von Graefe's hook. NEEDLE OPERATION, OR OPERATION FOR SOLUTION. 745 wound; and the risk of cyclitis and consequent sympathetic danger to the other eye. For these reasons the peripheral linear incision has been aban- doned by many operators, while various modifications of Graefe's method, or combinations of it with the old operation of extraction, have been proposed by Warlomont, Liebreich, and Bader, who make the section downward, its plane forming an angle of about 45° with that of the iris; by Lebrun, who extracts through a small flap in the superior half of the cornea (cor- neal section), iridectomy in this and the two previous-named modifications being usually dispensed with; by* Edward Jaeger, who has devised a special knife for his incision (" Holzschnitt") ; by De Wecker, and by other surgeons. Short or Three-Millimetre Flap Operation (De Wecker's method).—After the usual preparation of the patient and the field of ope- ration, the knife (Graefe's) is entered exactly at the sclero-corneal junction, at the outer extremity of a horizontal line which would pass three milli- metres below the summit of the cornea. The flap embraces about one-fourth of the diameter of the cornea. The remaining steps of the operation are conducted as in Graefe's method. Swanzv recommends that a solution of eserine should be instilled before the section is begun. In this operation the objections to the original method of Von Graefe are obviated. Extraction of the Cataract in its capsule is recommended by Pagen- stecher, the entire lens being removed by introducing a large scoop behind it. The operation must be reserved for over-ripe or for semi-fluid cataracts. Needle Operation, or the Operation for Solution.—This is the method ordinarily* to be preferred for the removal of soft cataracts. If thought proper, anaesthesia may be employed, but it is not usually required. The pupil being well dilated, and the lids separated by the stop- speculum, the surgeon fixes the eye with forceps, and enters a lance-headed, or, if preferred, a Hays's knife-needle, through the cornea at its outer side, and carries it across to the centre of the pupil, when the edge is turned to the lens, and a slight laceration made in the capsule. The operation usually has to be repeated at intervals. Care must be taken not to use so much force as to dislocate the <-■ t lens, and not to lacerate the capsule too freely in ,,,„ .„Q „ , , , ' .,iii n *l(i- 438.—Bowman's stop-nee- the first operation, lest the lens substance, swell- dle. ing up from the contact of the aqueous humor, should produce injurious pressure on the iris and ciliary body. When the bulging lens matter has disappeared by absorption, the operation may be repeated, the needle this time being used more freely. The only after- treatment required is the closure of the eye for twenty-four hours, and the maintenance of pupillary dilatation by means of atropia. If the lens be dis- Fio. 439.—Hays's knite-needle. located, it should, as a rule, be removed by means of a corneal incision and the introduction of a scoop, an iridectomy being at the same time per- formed ; C. R. Agnew fixes the lens with a two-pronged fork, or " bident." If the swelling- of the lens be so great as to threaten injurious consequences, a small incision, with a keratome or broad needle, may be made, and the escape of the offending substance aided by* the introduction of a curette.1 Wharton Jones practises an operation, under the name of discission from 1 The operation is thus essentially converted into the true "linear extraction," which originated in 1811 with Gibson, of Manchester. 746 DISEASES OF THE EYE. behind, in which the needle is introduced through the sclerotic, behind the iris, and made to lacerate the posterior wall of the cajisule. Suction Method__This ojieration, which was introduced by Teale, is specially adajited to cases of fluid cataract, such as are frequently met with in diabetic patients. Mr. Teale used a "suction curette," consisting of a curette roofed in to within a line of its extremity, with a handle and a piece of India-rubber tubing furnished with a mouth-piece. The anterior capsule of the lens being lacerated with two needles, the curette is introduced through a small corneal wound into the area of the pupil, and the fluid lens matter sucked out by the application of the operator's mouth. Mr. Bowman has devised a "suction syringe," which is in some respects more convenient than the curette. If the cataract is not sufficiently soft, the lens may be broken up first by discission, and several days allowed to intervene before the suction is applied. Treatment of Capsular and Secondary Cataract—It some- times happens that, after the removal of a cataractous lens, the field of vision is still obscured by an opaque or wrinkled condition of the remaining cap- sule, containing, perhaps, some portions of lenticular matter inclosed within its layers; the obstruction may be aggravated by the presence of nodules of inflammatory lymph. No operation should be practised for the relief of this condition until all the irritation caused by the original operation has passed away, an interval of several months being usually required. The safest mode of treating secondary or capsular opacities is to tear through the occluding membrane with a Hays's needle, introduced through the cornea. If the cajisule be very dense and resisting, two needles, introduced at opposite sides of the cornea, may be used, as advised by Bowman—one serving to fix the membrane while laceration is effected with the other. Other plans are to divide the capsule with delicate "canula-scissors" (Fig. 440), to tear it with toothed forceps, as jiractised by Higgens, of Guy's Hospital, or, as recommended by C. R. Agnew, to perforate and fix the membrane with a needle, and then with a sharp hook, introduced through a small corneal opening, to tear and roll up the membrane, which, if not Fit*. 440.—Canula-scissors. too closely attached, may be drawn out with the instrument. The late Dr. E. G. Loring employed a very delicate and narrow knife, with which he punctured the sclero corneal junction, and then freely cut through the iris as well as the capsular cataract. When complicated by iritis or irido- cyclitis, these cases require cautious handling: iridectomy and iridotomy are the operations usually practised ; Knapp jirefers the excision of a piece of capsule and iris to all other methods. After these, as after other cata- ract operations, the pupil should be kept for some time well dilated with atropia. THE OPHTHALMOSCOPE. 747 Diseases of Vitreous Humor, Choroid, Retina, and Optic Papilla. (Amaurosis and Amblyopia.) Amblyopia and amaurosis are, strictly speaking, symptoms, the former word denoting obscurity, and the latter more or less complete loss of vision.1 These terms are ordinarily applied to all cases of partial or total blindness, which are dependent neither on external obstructions (such as cataract or opaque cornea) nor upon optical defects of the eve, but are limited by Von Graefe and many* other modern ophthalmologists to cases of lost or impaired vision which are caused by primary atrophy of the optic nerve, or by such irregularities in the circulation of the nervous system as may* eventually lead to such atrophy*. Looking, then, upon these conditions (amblyopia and amaurosis) as symptoms of disease, rather than as definite pathological states which can be referred to any particular cause, I shall first speak of the morbid changes in the deejier structures of the eye, to which their manifestation may be due, and subsequently of those cases of nervous blindness to which alone Von Graefe and his followers would apply the term amaurotic. The Ophthalmoscope.—These cases can only be investigated by the aid of the ophthalmoscope, a brief account of which instrument may, there- fore, be appropriately given in this place. The ordinary form of ophthal- moscope consists essentially* in a perforated mirror, by which the light from a suitably placed lamji is reflected into the patient's eye, and thence back to that of the surgeon, who looks through the central perforation. Liebreich's portable ophthalmoscope, which is convenient for general use, consists of a polished, concave, metallic mirror, about 1^ inch in diameter and from 6 to 8 inches in focal length. It has a central perforation about a line in diameter, and is mounted in a light frame with a handle of convenient length. A movable arm, attached to the side of the frame, supports a clip, in which may be placed, behind the sight-hole, an ocular lens, either con- cave or convex, according to the needs of the observer. Accompanying Flo. 441 —Loring's smaller ophthalmoscope. the ophthalmoscope is a double-convex object lens, for use in the method of indirect examination. More perfect but more complicated forms of ophthalmoscope are Loring's (of which a simple form is shown in Fig. 441), Knapp's, and those of Shakespeare, Risley, Randall, and Jackson, of this city. Fixed Ophthalmoscopes and Binocular Ophthalmoscopes (in which the surgeon uses both eyes at once) have each some particular advantages in 1 Etymologically the words are synonymous, both signifying, literally, dimness of vision. 718 DISEASES OF THE EYE. special cases. Prof. Beale has devised a self-illumi noting ophthalmoscope, which, by an ingenious arrangement of lamp and mirror (the latter of which is inclosed with the object lens in a darkened tube), can be used without the necessity* of previously darkening the room. The ordinary ophthalmoscope is used in a darkened room, the patient being firmly seated, and the surgeon standing or sitting in front of him; an Argand lamp or gas-burner is placed to one side of and a little behind the patient's head, with the flame on a level with his eyes. The patient's pupil may*, if deemed necessary, be dilated with atropia. For the indirect method of examination, the surgeon holds the mirror close to his own eye, and about a foot and a half from that of the patient. Looking through the central perforation, the surgeon is soon able, by a little manoeuvring, to catch the rays from the lamp and reflect them directly into the patient's eye, the pupillary space of which now apjiears of a red- dish-yellow colour. Then taking in the other hand the object lens, the surgeon holds it from an inch and a half to two inches in front of the eye which he is observing, fixing it in that position by resting his fingers on the patient's forehead. But now moving his own head a little backwards or forwards, the operator obtains an inverted aerial image of the fundus of the observed eye. By directing the patient to turn his eye in various directions, the surgeon can explore the whole fundus of the eye, it being remembered that, in the aerial image which is seen, the position of every part is inverted. In the direct method of examination, as shown in Fig. 442, suggested by an illustration of Dr. Loring's, no object lens is used. The surgeon, seated in front of and facing the patient, and using his left hand for the left Fio. 442.—Use of the ophthalmoscope. (After Lorino.) eye and his right for the right, at first holds the mirror about a foot from the eye of the patient, and then, by gradually approximating it more closely, illuminates and examines in succession the cornea, crystalline lens, and vitreous; the fundus oculi is not fairly brought into view until the mirror CHANGES IN THE VITREOUS HUMOR. 749 is within about two inches of the observed eye, when a virtual erect image becomes apparent, seeming to be placed some distance behind the patient's eye. If either the surgeon or patient be short-sighted, a concave lens must be placed behind the sight-hole of the mirror. The entrance of the optic nerve, which is usually* the part first inspected, may be brought into view in indirect examination, by causing the patient to look at that ear of the operator which corresponds to the eye under ex- amination ; thus, the right ear for the right eye, and the left for the left. The optic papilla gives a whiter reflection than the rest of the fundus, and, when brought into distinct view by the adjustment of the object lens, appears as a pinkish, white, or gray disk, marked by the convergence of the retinal vessels; of these, one artery and two veins commonly pass upwards, and as many downwards, each soon dividing and ramifying over the fundus. The veins may be made to pulsate by pressing on the eye, and sometimes do so spontaneously* in a normal state. Spontaneous pulsa- tion of the retinal arteries, on the other hand, is an evidence of increased intra- ocular pressure, and a symptom of glaucoma. The maculo lutea, or yellow spot, may be brought into view by directing the patient to look at the central perforation of the mirror, and may be recognized by the absence of retinal vessels. The macula lutea is frequently* the seat of hemorrhagic ex- travasations or other lesions. By the direct method, in addition to ascer- taining the condition of the various media, the surgeon obtains a highly magnified virtual erect image of the fundus ; that is, unless the eye be myopic, the parts are seen in their true position, the upper part of the image corresponding to the upper part of the fundus, etc. It is not my purpose to offer any detailed account of the various ophthal- moscopic appearances observed in different morbid states of the eye ; the limits of this volume would not justify my doing so, and, indeed, as justly remarked by Dixon, it is not possible to convey, by mere verbal descrip- tion, any information upon these topics which would be of much real value. The use of the ophthalmoscope can only be satisfactorily acquired by long and continued actual practice, and the assistance which the student can derive from any* verbal description of what he is expected to see will not prove of material advantage. Those, however, who cannot pursue their labors in this branch under the direction of an experienced and skilful ophthalmoscopist (which is much the best manner of acquiring a practical knowledge of the instrument), may study with benefit the works of Loring, Noyes, Schweigger, Wells, and Meyer, and the colored illustrations of ophthalmoscopic appearances published by Jaeger, Liebreich, Stellwag, Power, and others. The morbid changes of the deep structures of the eye which induce amaurosis and amblyopia may* now be briefly referred to. Changes in the Vitreous Humor. Opacities of the Vitreous.— These may consist of filaments of lymph, shreds of pigment, or the con- tracted remnants of blood clots. They result frequently from diseases of the iris, retina, or choroid, especially when of a syphilitic character—in which case they are to be treated by means of remedies addressed to that condi- tion. Dense membranous opacities have been successfully treated by Von Graefe by means of a needle-operation, as in cases of capsular cataract, and C. S. Bull has obtained good results by a similar operation. He plunges an ordinary discission needle in front of the equator of the eyeball, and just below the lower border of the external rectus muscle, and cuts through the membrane. The operation must be done with the aid of cocaine, and with the strictest antiseptic precautions. The use of the continuous gal- 750 DISEASES OF THE EYE. vanic current is recommended in these cases by Oninius and Camus, by Lefort, and by Teulon, who reports 22 cures among 24 cases thus treated. Muscae Volitantes are floating opacities of the vitreous, consisting of filaments, cells, or cell-debris derived from that structure, which are not unfrequently- observed by those who are short-sighted, or who strain their eyes by fine work ; they frequently jiersist for years, causing annoyance by their presence, but being productive of no further evil consequences. The only treatment to be recommended is the administration of tonics to improve the general health, with rest for the eyes, and the use of dark glasses. Hemorrhage into the Vitreous is a much more serious affair than hemor- rhage into the aqueous humor. In the former situation, absorption takes place very slowly, and shreds of clot are apt to be left, which permanently interfere with vision. In certain cases, generally in young male adults, spontaneous hemorrhage into the vitreous occurs, together with hemor- rhage into the retina. According to Kales, such patients are liable to con- stipation, irregularity of circulation, and epistaxis ; Hutchinson thinks that gout may be the cause in some cases. The treatment consists in local de- pletion, with regulation of the circulation, and especially of the portal cir- culation, by the administration of laxatives. Subsequently, small doses of iodide of potassium may be tried. Synchisis is a term used to denote a softened and fluid condition of the vitreous. In some cases, the vitreous holds in suspension numerous scales of cholestearine, with, according to Poncet, tyrosine and crystallized phos- phates, giving a sparkling apjiearance when examined with the ophthalmo- scope ; the condition is then called synchisis scintillans. Fluid vitreous may result from injuries, or from various non-traumatic inflammatory affections of the eye; it usually causes diminished tension of the eyeball, though it may* be met with in cases of glaucoma. The condition is, I be- lieve, irremediable. Inflammation of the, Vitreous (Hyalitis) is a condition the jiossibility of the existence of which is denied by Pagenstecher ; Spencer Watson has, however, recorded an instance of its occurrence, in which a cure was effected by the administration of mercury and the local use of atroj>ia, and Hansell has described cases of spontaneous inflammation of the vitreous body, a prominent cause being the debility and exhaustion following low fevers. Cysticercus is occasionally found in the vitreous. It is a rare affection in this country and in England, but has not infrequently been observed in Germany. Changes in the Choroid__The changes revealed by the ophthal- moscope may* consist merely of increased vascularity, of cloudiness due to serous effusion, or of yellowish white patches which fade gradually into the surrounding choroid, but which subsequently may become atrophied and be associated with retinitis and opacities in the vitreous, constituting the condition sometimes spoken of as simple plastic choroiditis. Its origin is obscure. It is associated with various conditions of disturbance of the general health, and has been seen in association with syphilis, although not the form of choroiditis usually caused by that affection. Bull, of New York, has observed that irido-choroiditis often follows neuralgia of the trigeminal nerve. The treatment consists in the cautious administration of mercury, or iodide of potassium, with tonics, especially iron and quinia, and local blood-letting to relieve hyjieraemia. In addition to the variety of choroiditis just mentioned, it is important to distinguish the following clinical forms of choroidal disease:— CHANGES IN THE CHOROID. 751 Disseminated Choroiditis appears in two varieties, the discrete and the confluent. In the former, numerous round white spots, with irregu- larly pigmented margins, are scattered through the fundus, especially in the jieriphery ; in the latter, larger areas of incomplete atrophy, which shade by imperfectly defined borders into the choroid, are commingled with sepa- rate patches, or with areas in which the pigment epithelial layer has become absorbed, exposing the vascular network of the choroid. Choroiditic atrophy of the optic nerve may* ensue, and opacities in the vitreous not infrequently appear. Disseminated choroiditis in the vast majority of cases is due to acquired syphilis, but in some instances depends upon an inherited syphilitic taint. As Hutchinson has pointed out, moreover, disseminated choroiditis affecting both eyes is occasionally encountered as a family disease, indejiendently of syphilis, and associated with disorders of the central nervous system. The treatment should consist in a mild but pro- longed mercurial course, alternated with the use of iodide of potassium and the muriated tincture of iron. The prognosis is grave, especially if the disorder is widely spread and the retina and disk are inflamed. Atrophy of the Choroid, commonly of a local character, is seen in the severe myopia caused by the elongation which occurs at the posterior pole of the eye, and which receives the name of posterior staphyloma. The term sclerotico-choroiditis posterior is also applied to this variety of cho- roidal change, just as anterior sclerotico-choroiditis is the name given to that inflammatory affection which attacks circumscribed portions of the anterior part of the choroid, with the corresponding portions of the scle- rotic, and which, in aggravated instances, may* give rise to staphylomatous bulging and gradual loss of vision, by opacity of the vitreous and cornea (see pp. 729, 731). Semi-atrophic and atrophic crescents also appear at the outer margin of the optic nerve in astigmatic ey*es, and in such as are undergoing change owing to the distention of their coats under the influence of close eye-work, aggravated by imperfectly or improperly corrected errors of refraction. In superficial atrophy of the choroid the pigment epi- thelium is absorbed, and the larger vessels become distinct. Such epithelial choroiditis often covers large areas in the eye-ground. Central Senile Choroiditis is confined to the region of the macula, and presents the appearance of a white patch, often of considerable extent, or of a circular area exposing the deep vessels, which may themselves be atrophied and converted into white lines. In the same region is observed another variety of disease, described by Waren Tay and Hutchinson as Central Senile Guttate Choroiditis, marked by the appearance of numerous white, glistening dots, somewhat resembling the earlier stages of albu- minuric retinitis, and always symmetrical, though sometimes an interval of time elapses before the implication of the second eye. In the two last-named varieties of choroidal disease, treatment appears to have no influence. Absorption-crescents at the outer side of the disk call for enforced rest to the eyes, with correction of the refraction error, local depletion, and counter-irritation ; if the disease be rapidly progressive the administration of bichloride of mercury, as advised by Lawson, is a useful measure. Purulent Choroiditis is referred to under Panophthalmitis (page 762). Beside the diseases of the choroid which have been described, others appear which cannot be definitely classified : large patches of atrophy, not located in special portions of the choroid, and resulting probably from the absorption of former hemorrhages ; hemorrhagic choroiditis, especially occurring, as pointed out by Hutchinson, in young men, and resulting in numerous spots of atrophy which are not readily distinguished from those 752 DISEASES OF THE EYE. of the syphilitic variety; congestion of the choroid, seen in myopic and asthenopic eyes as the result of exposure to prolonged bright light and heat; the so-called " woolly choroid," particularly that form which is seen associated with immature cataract, and which, as insisted upon by Bislcy, should be looked upon as one of the causes of degeneration of the len9; anaemia of the choroid, characterized by paleness of the fundus oculi, and often accompanied by contraction of the retinal vessels; and rupture of the choroid, the result of a blow upon the eye, which after absorption of the effused blood shows itself in the form of a long line of atrophy situated in the central region (see page 362.) Bony Deposits are occasionally found in the choroid, ajijiarently result- ing from osseous change in previously formed inflammatory lymph; cal- careous deposits are in the same cases often found in the lens and cornea. Tubercles of the Choroid are met with in cases of acute tuberculosis; the coexistence of the choroidal affection with tuberculosis of the lungs is, according to Steffen, more constant than with the same condition of the pia mater. Tumors of the Choroid.—By far the most common growth met with in this situation is the sarcoma, which is always primary ; much more rarely carcinoma appears, and is a metastatic affection, the original growth having usually occurred in the breast, as in a case recently described by Scha- pringer. In either variety the tumor is apt to contain a certain amount of melanotic deposit. The only treatment to be recommended is excision of the globe, which should, if possible, be performed before the tumor has made its way- through the external coats of the eye. Wilson, of Dublin, records a case in which a cyst containing crystals of cholestearine was developed between the choroid and retina, simulating glioma of the latter structure. Other rare forms of tumor found in the choroid are the sar- coma carcinomatosum, the osteosarcoma and the cavernous angeioma, an example of which has recently been reported by Schiess-Gemuseus. Congenital Defects of the Choroid.— Coloboma of the choroid is a con- genital deficiency of the lower jiart of this membrane, and apjiears as a large white patch due to exposure of the sclerotic coat, often embracing the disk, and not infrequently associated with a similar defect in the iris. This solution of continuity is said always to occur in the lower part of the eye-ground, except in the case of macular coloboma, but De Schweinitz and Randall have described and figured a nasal coloboma of the choroid. Albinism is that condition in which there is congenital want of pigment in the whole uveal tract, and is associated with imperfect pigmentation of the hair of the body. The eyes of albinotic subjects are always defective in visual acuity, and usually exhibit marked ny*stagmus. Changes in the Retina__Hyperaemia of the Retina, when active or arterial, is marked by increased vascularity of the disk, and is caused by over-exertion of the eyes under hurtful conditions and exposure to dazzling light; when passive or venous, it is characterized by great distention and tortuosity of the veins, and results from affections of the general circula- tion, or from cerebral disease or tumor, which mechanically obstruct the central vein or venous sinuses ; if severe, it is associated with serous exu- dation along the course of the vessels. Mere capillary congestion, how- ever, does not change the appearance of the retina itself, and is not always easily recognized in the disk. The treatment consists in removal of the cause, with rest of the organ, the use of local depletion, counter-irrita- tion, and the cold douche, the administration of tonics, etc. The iodide and bromide of potassium are also recommended. Anaemia of the retina may accompany anaemia of the choroid, and be associated with chlorosis, CHANGES IN THE RETINA. 753 or may result from disturbances of the circulation as the result of pressure on the orbit; the' pernicious forms of anamiia produce oedema of the retina and hemorrhages. Pallor of the disks has been observed by Clifford Allbutt, Hughlings Jackson, and Arlidge, during epileptiform seizures, and De Wecker has seen diminution in the size of the arteries during the stage of pallor. Raynaud has observed anaemia of the retina causing amblyopia, increased by external heat and diminished by cold. Retinal Anaesthesia (Neurasthenic asthenopia) is seen among children about the age of jiuberty*, and among hysterical and chlorotic women, esjiecially if the subjects of uterine disorders. It is characterized by fluc- tuating visual acuity, attacks of dim sight, the rapid disajipearance of ob- jects from view, and apparent contraction of the field of vision. The treatment consists in improving the general health, the use of strychnia, correction of errors of refraction, and securing perfect rest for the eye. Hyperaesthesia of the retina appears in hysterical subjects, and in those who have over-exerted the eyes when improjierly focussed; it causes dread of light, pain, and blepharospasm. It may be associated with neu- rasthenic asthenopia. It calls for functional rest, with the use of suitable glasses and of tonics. Retinitis is very often associated with choroiditis, and not infrequently with iritis. The distinguishing characteristic of retinitis is loss of trans- parency in the retina, either diffused or in more or less circumscribed patches, and associated at a later period with serous effusion, in many instances with hemorrhages, and in certain varieties with the dejiosit of pigment—either as a symptom of the special type of the disease, or as the result of the ab- sorption of effused blood. Slight retinitis or choroido-retinitis has been observed in the macular region, following prolonged gazing at the sun, usually during an eclipse. It is convenient to recognize the following varie- ties of the disease:— Syphilitic Retinitis sets in from six to eighteen months after the incep- tion of the primary affection. It occurs also in hereditary syphilis, and usually attacks both eyes. It is frequently associated with choroiditis and with opacities in the vitreous. The ophthalmoscope reveals diffuse haziness, tortuosity- of the retinal vessels, increased vascularity of the optic disk with imjierfect differentiation of its margins, and sometimes hemorrhages. Amblyopia, night blindness, micropsia, and annular defects in the field of vision, are prominent symptoms. The disease is chronic in its nature, and tends to frequent relapses. Mercury is the best medicinal agent, and disuse of the eyes, with local depletion, is indicated. Retinitis Pigmentosa is characterized by* a deposit of pigment matter in the fibrous layer of the retina, beginning in the periphery, and, because arranged in stellate spots with intercommunicating processes, often compared to the so-called "bone-corpuscles." Jsight blindness is one of the most prominent symptoms, and is accompanied by progressive contrac- tion of the field of vision, which goes on until the disease, which is incura- ble, produces total blindness; though, as the course of the affection is very slow, old age may be attained before this consummation is reached. Strychnia may be given in the treatment of this affection, and temporary improvement in vision has followed the use of the continuous current, in the hands of Standish and Derby, in this country, and of Gunn, in Eng- land. Professor Arlt, of Vienna, has given the name Retinitis Nyctalo- pica to certain cases of inflammation of the retina in which the patients see better in the evening than in ordinary daylight. The treatment which he recommends is functional rest, with the use of colored glasses and the administration of mercury. 48 754 DISEASES OF THE EYE. Albuminuric Retinitis apjiears usually with the chronic types of renal affection, esjieciallv with that variety known as interstitial nejdiritis, but is seen also with the albuminuria of jiregnaney. It begins usually witha grouping of yellowish dots, somewhat radially arranged, around the macula, and goes on to extensive involvement of the retina, with the occur- rence of fatty degeneration, hemorrhages, and implication of the optic disk, producing a picture of the highest grade of papillo-retinilis. Some- times the retinal lesions predominate; in other instances the optic disk suffers severely, its appearance resembling that seen in the neuritis which follows cerebral disease. The prognosis is grave, Bull's statistics showing the occurrence of death within a year in more than half of the cases. The treatment is that adopted to ameliorate the renal disease by which the retinitis is caused ; the muriated tincture of iron and small doses of bichlo- ride of mercury* answer a useful purpose. In the neuro-retinitis of pregnancy, Pooley, Risley, and other surgeons have recommended the in- duction of premature labor. Diabetic Retinitis is one of the ocular affections which sometimes occur during the course of saccharine diabetes. The visual disturbances in this affection, of which a number have been recognized and described, have been esjiecially discussed by Hirschberg, in Germany, and by Moore, in this country. Leucocythsemic Retinitis is a rare affection which, according to Leber, apjiears in not more than one-fourth of all cases of leucocytlaemia, and generally with the splenic variety of the affection. When fully developed, this disorder jiresents a striking ophthalmoscopic picture: an orange-col- ored fundus; broad, pale, often tortuous retinal veins; numerous hemor- rhages ; and yellowish spots due to extravasated leucocytes. Hemorrhagic Retinitis.—Hemorrhages may occur in any form of reti- nitis, more particularly in the nephritic, or may appear in the form of nu- merous linear hemorrhages from other causes, such as heart-disease, gout, atheroma of the retinal vessels, thrombosis of the trunk of the central vein, or suppressed menstruation. Apoplexy of the retina is a name given to cases of extensive extravasation, often of obscure origin, but sometimes related to senile changes in the vessels. Occasionally single large hemor- rhages occur in the macular region, jirobably from rupture of an artery, and cause great defect in vision. The treatment consists in obviating a recurrence of the hemorrhage by endeavoring to remove the cause, if this can be ascertained. Advantage may perhajts be derived from the u>c of iodide of potassium in hastening the absorjition of the effused clots. Detachment of the Retina may occur in cases of extreme j>osterior staphyloma, or may be due to loss of vitreous, to hemorrhage or serous effusion, or to the growth of tumors of the choroid. .Nordenson's re- searches have confirmed Leber's theory that spontaneous detachment is due to shrinking and traction of a diseased vitreous. Retinal detachment is more frequent in men than in women, and myopia is the most frequently associated error of refraction. An attempt may lie made to evacuate the subretinal fluid (as originally suggested by Sichel) by puncturing the scle- rotic with one or two needles, passed through the sclerotic and vitreous, as advised by Von Graefe and Bowman; or with a delicate trocar, as recom- mended by De Wecker, who has also suggested drainage of the subretinal space by the introduction of a gold or catgut thread; Galezowski prefers aspiration without drainage. Sutphen, of Newark, has practised punc- ture of the retina after the manner of De Wecker. Wolfe and Abadie have employed sclerotomy, and the latter surgeon intentionally produces slight local irritation at the point of puncture. McKeown, of Belfast, has sue- CHANGES IN THE OPTIC PAPILLA. 755 cessfully operated by excising sub-conjunctivally a portion of both scle- rotic and choroid. Iridectomy has been employed in cases of retinal detach- ment, but is condemned by Landolt. Dianoux and Green have derived advantage from hypodermic injections of pilocarpine, and Guaita records amelioration from instillations of eserine. The dorsal position and a com- pressing bandage have sometimes proved useful. Embolism of the Central Artery of the Retina jiroduces contraction of both sets of retinal vessels, but particularly of the arteries, and is often accompanied with sub-retinal effusion and the characteristic cherry-red sjiot in the neighborhood of the macula lutea. Embolism of the retinal artery often dejiends upon the existence of cardiac valvular disease of the left side. It produces sudden and total blindness, and is rarely recovered from.1 In recent cases, massage of the eyeball is recommended by Mules, Hirschberg, and others, and has been employed with good results. Tumors of the Retina.— Cystic degeneration of the retina is occasion- ally observed in an eye which has long been blind, and may require exci- sion of the globe, if the disease should produce pain and threaten the integrity of the other eye. The most common retinal tumor, however, is the Glioma, which runs an almost malignant course, and was indeed formerly- considered to be of an encephaloid character. It is a disease of early childhood, and may be congenital. The growth begins in the granular layer of the retina, which is usually early detached ; it often fills the eyeball and spreads by contact to the choroid, or passes along the optic nerve to the brain ; or it may burst forth at the corneo-scleral margin, and form a rapidly growing fungous mass. The only treatment to be recom- mended is early excision, which may be required in the case of both eyes, if both be affected. The disease often recurs in the orbit. In y*oung chil- dren, inflammatory and purulent changes in the vitreous, the result of arrested irido-choroiditis, occasionally* simulate glioma closely, and have received the unfortunate name of pseudo-glioma. In any case of doubt, the eye should be excised. Changes in the Optic Papilla. Optic Neuritis.—Two forms have been recognized, distinguished by* Von Graefe as ',' descending neuritis" and " choked disk;" but inasmuch as these names refer to a distinction the pathological basis of which is unsettled, Leber has suggested the general term "papillitis," which describes the appearances of the con- gested or inflamed disk, without reference to its etiology. This name is employed also by Govvers, Nettleship, Swanzv, and Deutschmann. The optic papilla is at first swollen and congested, afterwards assuming a peculiar " woolly" appearance; the veins are distended and tortuous ; the arteries grow smaller and are hidden in the grayish swelling, the stria? of which extend from the disk into the surrounding retina, while on or near the papilla, flame-shaped hemorrhages may* appear. When the changes are not confined strictly* to the optic nerve, but involve the surrounding retina, the term neuro-retinitis, or papillo-retinitis, is suitable. Vision, as origi- nally pointed out by Hughlings Jackson, may* be retained until a late period of the affection. Tumor of the brain is the most common cause of optic neuritis, and usually originates a high grade of the affection—the " choked disk" of the older nomenclature. Tubercular meningitis is the next most usual cause, but the condition arises also under the influence of abscess of the brain, inflammatory and other changes in the orbit, exposure to cold, suppression of the menstrual flow (under which circumstances the 1 According to Loring, Magnus, and Zehender, many cases of sudden blindness which are ordinarily attributed to embolism are really due to other conditions, such as hemorrhage or serous effusion within the sheath or amid the fibres of the optic nerve. 756 DISEASES OF THE EYE. neuritis may be monocular) anauuia, syjihilis, uramiia, lead-poisoning, etc. The relation of brain tumor to optic neuritis has been the subject of much study. According to some observers, the increased intra-cranial pressure causes dropsy of the intersheath of the optic nerve (which is nearly always found on careful examination) by forcing the subarachnoid fluid along this subvaginal lymph space. Deutschmann's theory (Inn7) is that the inflammation is due to certain " irritating elements," which find their way from the neighborhood of the growth to the bulbar end of* the nerve, and there set up a neuritis which travels upwards—the "choked disk" depending not ujion compression, but the compression upon the jiapillitis. The ascending course of the neuritis has been denied by Edmunds and Lawford, who with Govvers, Brailey, and other observers, maintain that in the majority of instances a cerebritis or meningitis—only discoverable perhaps with the microscope—is present, and that this originates an in- flammatory* process which descends through the optic nerve. The old view of Von Graefe, which assumed a venous obstruction and impeded outflow of blood, has been abandoned. The prognosis depends upon the cause ; in many instances it is unfavorable. Mercury, iodide and bromide of potassium, and pilocarpine, with local blood-letting, are the remedies com- monly employed. Neurotomy, or slitting the sheath of the optic nerve, has been advantageously resorted to by Wecker, Power, and Brudenell Carter. Excavation, or Cupping of the Optic Papilla.—A slight depression in the centre of the optic disk may exist in the normal state, constituting what is known as the physiological cup. In glaucoma, and in some ca>cs of advanced myojiia, a much more marked and abrupt form of cupjiing is observed; the most distinctive characteristic of this condition is the bend- ing of the retinal vessels at the margin of the optic disk, the whole of which is occupied by the glaucomatous cup; if the excavation be very deep, the retinal and papillary portions of the vessels may be seemingly quite disconnected. A third form of cupping often accompanies atrophy of the optic nerve, a condition which may result from the pressure of intra- orbital tumors, from disease of the brain or spinal cord, or from the abuse of tobacco, etc. Tumors of the Optic Nerve.—Various forms of morbid growth are met with in this situation, as myxoma, glioma, and myxo-sarcoma; there are usually in these cases double vision and protrusion of the eyeball, with diminution of the field of vision, or amblyopia; the treatment consists in removal of the tumor, which Knapp has succeeded in effecting in one case without removal of the eyeball. Tumors in this region have been well studied by Frothingham. Optic Atrophy.—This is divided by systematic writers into primary, secondary, and consecutive or posl-papillitic atrophy, by which is meant that form which results from an antecedent neuritis. Atrophy, with impairment or loss of vision, and without any recognizable primary lesion of the eye, may result from disease of the brain or spinal cord; from sudden suppression of the menses or other uterine disturbance (even from preg- nancy); from profuse hemorrhage; from reflex irritation, as from a carious tooth ; from compression of the optic nerve or tract; from the toxic influence of tobacco, alcohol (described also as retro-ocular neuritis or central am- blyopia), lead, quinia, or bisulphide of carbon ; from uraemic poisoning, diabetes, etc. Primary atrophy may also appear without known cause. Sometimes it is distinctly hereditary, as in cases described by Leber, Norris, and Habershon ; and in rare cases it has been associated with persistent drojiping of watery fluid from the nose, as recorded by Nettleship, Priestley NYCTALOPIA, OR NIGHT-BLINDNESS. 757 Smith, Ermys-Jones, Leber and others. In all cases, the immediate cause of the loss of sight is interference with the circulation of the nervous struc- tures concerned in vision, or, in permanent cases, atrophy- of the fibres of the ojitic nerve. In advanced atrophy from cerebral disease the pupils are usually dilated; in spinal disease, especially in locomotor ataxia, even though the degeneration of the nerve fibres may be in an early stage, the pupil is commonly* contracted (spinal myosis), does not react to light and shade, but contracts in the effort of accommodation (Argyll-Robertson pupil). The field of vision is differently affected in different cases ; thus the centre, or the periphery, of the field may- be chiefly involved, or the loss of sight mav involve just half of the field (hemiopia), vision being perfect on one side of a vertical line and absent on the other. I have seen a well-marked case of hemiopia following a fracture of the base of the skull. In tobacco amblyopia the defect in the field of vision consists in a central dark area (scotoma), usually oval in shape, in which particularly* the jierception for red and green is lost. Similar scotomata are found associated with retro- bulbar neuritis, and have been observed in locomotor ataxia. The treatment of optic atrophy consists in endeavoring to remove the cause, when that can be ascertained: when resulting from disease of the central nervous system, the prognosis is extremely unfavorable. Nagel, of Tubingen; Chisolm, of Baltimore; Bull, of New York; and Harlan, of this city, have derived advantage in some of these cases from the use of strychnia. The drug may be administered hypodermically, or, which Chisolm now prefers, may be given by the mouth in quantities varying from ^ to I grain daily, in divided doses. Quaglino and Bull speak favor- ably of the use of bromide of potassium in cases of alcoholic amblyopia. Inhalations of nitrite of amvl have been successfully used by Swanzy. Parnard has stretched both optic nerves, but with little if any benefit. Galvanism has also been employed, but without much avail. Amblyopia from Extra-ocular Causes and Functional Disturbances op Vision. Nyctalopia,1 or Night-Blindness, is a functional condition, consist- ing in a diminished sensibility of the retina, due apparently to excessive exjiosure of the eves to light, together with a debilitated and especially a scorbutic condition of the system. It is most common among residents in tropical countries, soldiers and sailors, etc., and has been occasionally- ob- served in large schools, usually in the sjiring or early summer, as noted by Snell and Nettleship. Martel regards it as simply the first stage of sleep. Endemic Nyctalopia prevails in certain countries, especially in Russia, during the Lenten fasts. The affection is usually associated with the appearance upon the conjunctiva of small scales which are composed of sebaceous matter and epithelium. This affection must not be confounded with Retinitis Pigmentosa, in which night-blindness is a frequent sy*mptom ; in true nyctalopia no morbid changes whatever are revealed by the ophthal- moscope. The treatment consists in the administration of tonics, especially cod-liver oil, with the use of dark-colored glasses to protect the ey*es. If the disease can be traced to scurvy, or to malarial fever, remedies suitable 1 From the Greek word vvirraXi»4. (vu£ dxao'c Sit), signifying literally "night-blind- eye," or one who cannot see at night. Hetneralopia is the opposite condition, signify- ing an inability to see during the day. These terms have been commonly misapplied by ophthalmic writers, their proper meanings being reversed. (See interesting papers by Dr. Greenhill and Prof. Tweedy in the Ophthalmic Hospital Reports, vol. x., pp. 284, 413.) 758 DISEASES OF THE EYE. to those affections must be employed. Inst illation of a solution of strychnia (gr. i-f.^j) is recommended by Walker, of Liverpool. Snow-Blindness, or Ice-Blindness, is a condition analogous to nyctalopia, resulting from exposure to the dazzling reflection from snow or ice, and accompanied by pain, dread of light, and occasionally hemor- rhages into the conjunctiva; the eyes should be shielded by colored glasses, and tonics administered if the jiatient's general condition demands their use. A similar affection has been observed as the result of exposure to the electric light. Hemeralopia, or Day-Blindness, is a rare affection, which has been observed in certain cases of congenital amblyopia. Color-Blindness, or, as Dixon more accurately terms it, Acritoch.ro- macy, is a defect of vision in which the power of distinguishing one or more colors is lost. Usually red and green are the two colors which are confused together, but in some cases vision is achromatic, all colors alike ajipearing as white, black, or grey. Color-blindness is usually congenital, but may result from disease ; achromatic vision existed, as a temporary condition, in a case of optic neuritis observed by Chisolm. When con- genital, the affection is probably incurable. Examination for color per- ception has been especially studied in this city by W. Thomson and by C. A. Oliver. Erythropsia, or Red-Vision, is an interesting and rare condition which, in most instances, has been noted after the extraction of senile cata- ract. Bromide of potassium has been recommended as a remedy. Micropsia, or that condition in which objects appear too small, and Megalopsia, the opposite condition, in which they apjiear too large, have been seen in hysterical cases, and the former is not infrequently caused by syjihilitic retinitis. Accommodation and Refraction. Accommodation is the power of self-adjustment which an eye pos- sesses, by means of which objects at various distances are equally well seen. This adjustment is accomplished by a muscular effort (on the part of the ciliary muscle), of which the individual is, however, usually unconscious. Refraction is the passive power by which, when the eye is at rest, rays of light are brought to a focus on the retina; it is a purely physical property, depending upon the shape of the eye and of its various refracting media, as the cornea, lens, etc. The various anomalies of refraction and defects of accommodation, to which the human eye is subject, have received of late years a great deal of attention from ophthalmologists, and the means by which these anomalies and defects may be recognized and corrected have been thoroughly studied and systematized; for information on these topics, I must, however, refer the student to special treatises on the subject, contenting myself with men- tioning and exjilaining the jirincipal terms employed. Emmetropia.—This is the normal condition ; an eye is emmetropic when parallel rays are converged to a focus on the retina by the refractive power of the eye itself, without any effort of accommodation. Myopia or Brachymetropia (Short Sight).—In this condition, dis- tant rays are brought to a focus in front of the retina, the image formed upon which is therefore indistinct. Myopia is usually due to an elongation of the antero-posterior diameter of the eye, and commonly results from a prolongation of the posterior half of the eye, often accompanied with thin- ning of the sclerotic and partial atrophy "of the choroid, constituting pes- APHAKIA. 759 terior staphyloma. This condition requires the use of concave glasses. As sjiasm of the ciliary muscle is present in many cases, the methodical use of atropia, as recommended by Schiess, Windsor, and Derby, is advisable. Hypermetropia, or Hyperopia, is a condition exactly the reverse of the {(receding; here, distinct rays come to a focus behind the retina, the image on the latter being of course indistinct as in the previous case. A hypermetropic is usually smaller than an emmetropic eye, particularly in its antero-posterior diameter, whence it has a flattened appearance. Ac- cording to Stevens, hvjiermetropia and inijierfect equipoise of the external eve muscles are often associated with nervous disorders, particularly chorea and epilepsy. Hypermetropia requires the use of convex glasses. The local use of Calabar bean is recommended by Magnus. Ametropia1 is a general term embracing both the preceding conditions ; it is therefore the opposite of emmetropia. For its intelligent correction by suitable glasses, atropia, or some other mydriatic,2 should first be em- ployed. Astigmatism is a condition in which the refracting power varies in different meridians of the eye, and it may be regular or irregular. In regular astigmatism, one principal meridian may be emmetropic, and the other ametropic (simple astiamatism); or both principal meridians may be ametropic, but of the same character (compound astigmatism) ; or one principal meridian may be hypermetropic and the other myopic (mixed astigmatism). Irregular astigmatism consists in a difference of curvature in the different parts of the same meridian, and may have its seat in either the cornea or the lens. It is often caused by ulcerated and conical cornea. The remedy for regular astigmatism is the use of cylindrical glasses, meas- ured after the ciliary muscle has been completely* paralyzed by a suitable mydriatic. Many persons have slightly astigmatic vision without know- ing it, and it is only* when the want of symmetry* is marked that the affec- tion excites attention. Anisometropia is the term which designates the state in which the refraction of the two ey*es is unequal. Aphakia is an anomalous state of refraction caused by the absence of the crystalline lens, as after cataract operations. Aphakia renders the nor- mal eye markedly hypermetropic, while it diminishes myopia, and may even make a myopic eye emmetropic. The remedy for aphakia (which is accom- panied by loss of accommodation) is the use of powerful convex lenses. 1 For a convenient mode of determining the degree of ametropia, see an able paper by Dr. W. Thomson, in the American Journal of the Medical Sciences, for October, 1870. Dr. Thomson has invented an ingenious instrument, which he calls an ametrometer, for measuring the refraction of the eye without the use of lenses. A convenient mode of estimating the refractive condition of the eye is known as the shadow-test; if a lamp be placed above the patient's head, and the fundus oculi be illuminated by an oph- thalmoscopic mirror of 10-inch focal length (25 cin.), held at a distance of four feet (120 cm.), there is seen a bright area of the retina, with a dark border which is the shadow of the iris. By tilting the mirror, the light area will be displaced in the opposite direction (" against" the mirror) in emmetropia, hypermetropia, and low myopia ; in cases of myopia of more than one dioptric, the shadow will move in the same direction as the mirror ("with" the mirror). In retinoscopy practised with a plane mirror, which has been especially well-studied in this country by Edward Jackson, these movements are exactly reversed. By ascertaining the strength of tlie glass, concave or convex, which will just reverse the movement of the shadow, the degree of ametropia can be estimated with sufficient accuracy for ordinary purposes. 2 As a mydriatic for use in correcting errors of refraction, Risley prefers a two-grain solution of sulphate of hyoscyamia, or a six-grain solution of homatropine hydrobrom- ate. Jackson recommends cumulative instillations of homatropine, and De Schweinitz and Hare have further proved its value both clinically and experimentally. 760 DISEASES OF THE EYE. Presbyopia is a diminution of the range of accommodation, interfering with vision of near objects, while distant vision remains unimjiaired. Pres- byojna is an almost constant attendant upon old age, and can scarcely he looked ujion as abnormal: the treatment consists in the \\>r of con vex glasses. Paralysis, and Spasm of the Ciliary Muscles may each be a cause of loss of accommodation. The Calabar bean may be used for the former, and atropia for the latter, condition. Asthenopia, or Weak Sight, may depend upon exhaustion of the power of accommodation in cases of hypermetropia, or upon insufficiency of the internal recti muscles, by which the necessary convergence of the eyes for near vision cannot be long maintained. The former (which is called accom- modative asthenopia) requires the use of convex glasses, while the latter (muscular asthenopia) may demand division of one or both external recti, or the use of appropriate prisms. As jiointed out by S. W'. Mitchell, Iliggens, Carter, Piorry, and other writers, asthenopia may give rise to cerebral symptoms, such as headache, giddiness, etc., and may thus be mis- taken for intracranial disease. Insufficiency of the vertical muscles (hyper- phoria) has been especially studied as a cause of functional nervous dis- orders by Stevens, Ranney, and Webster. Glaucoma. Glaucoma is the term which was formerly apjilied to all cases of impaired vision accompanied by a greenish hue of the pupil, and not manifestly due to lesions situated in front of the iris. The affection was variously sup- jiosed to consist in an abnormal condition of the vitreous, retina, optic nerve, or choroid, but its pathology was not well understood until quite recently. Von Graefe, who showed that all the symptoms of this formidable dii-easc were due to increased intraocular tension, believed that this was due to the augmented volume of the vitreous and aqueous humors, probably origina- ting in an irido-choroiditis. It is impossible to discuss in this jdace the numerous theories which have been brought forward to exjilain the mechan- ism of glaucoma, or the numerous investigations which have of late been undertaken to elucidate the jiathology of this serious disease. The labors of Max Knies, Adolph Weber, Brailey, and Priestley Smith, have been especially productive of good results. As the latter observer has said, it appears that hypersecretion is sometimes concerned in the onset of glaucoma; serositv of the fluids plays an imjiortant part in those forms which j>rescnt a deep anterior chamber and a wide "filtration angle;" and obstruction at the " filtration angle"—or angle of the anterior chamber—is a jiart of the glaucomatous process in the vast majority- of cases. The distinctive Symptoms of glaucoma are increased hardness or tension of the eyeball ; diminished sensibility, and, at a later period, haziness of the cornea ; distention of the ciliary vessels ; diminution in the size of the anterior chamber; sluggishness and dilatation of the pupil (which has a green hue) ; partial atrophy of the iris ; and lastly opacity of the crystalline lens. By* the ophthalmoscope, the retinal arteries are seen to pulsate; the optic pajiilla presents the characteristic glaucomatous cup (page 7oil); the vitreous apjiears cloudy; and hemorrhages into the deep structures of the eye may be observed. Vision is hypermetropic and presbyopic ; the Held of vision becomes contracted, especially in its nasal half; amblyopia, at first periodic, ends in complete amaurosis; halos or prismatic sjiectra are seen on looking at the flame of a candle ; and pain, more or less intense, i-* felt in the eyeball, and along the course of the optic nerve. Glaucoma is usually met with in jiersons past the middle period of life, GLAUCOMA. 761 and is especially frequent between the ages of 55 and 65 ; it is rather more frequent in women, except the very chronic form, which is said to be com- moner in men. It may arise spontaneously*, or may be due to some injury, or antecedent inflammation or disturbance of the general circulation, result- ing in ocular congestion in an eye predisposed to the disorder by changes in the ciliary region. It is said to be occasionally traceable to the shock of mental or moral emotions, and has been seen in association with neural- gia of the fifth nerve. Theobald, of Baltimore, argues in favor of astigma- tism, where the meridian of least refraction is vertical, or nearly* so, as a factor in the production of glaucoma ; and obstruction of the circumlental space and consequent rise of pressure may follow the increased size of the lens due to advancing years, unusual smallness of the ciliary* area in hy*per- metropia, or abnormal enlargement of the ciliary processes—facts especially dwelt upon by Priestley Smith. Various forms of the disease are recog- nized by systematic writers, as glaucoma fulminans, in which the symptoms may be fully developed in a few days or even hours ; the acute, sub-acute, and chronic, or simple glaucoma, which progresses very slowly, unassociated with any of the so-called inflammatory symptoms—pain, lachrymation, and discoloration of the iris—but which steadily advances with increased failure of central sight and contraction of the field of vision ; the consecu- tive or secondary glaucoma, caused by intraocular tumors, dislocation of the lens, serous iritis, and extensive posterior synechia?; and, finally*, the so- called hemorrhagic glaucoma, in which the earliest symptom is the occur- rence of hemorrhages into the retina. Diagnosis.—It is of the utmost importance that glaucoma should be recognized, if possible, in its very incipiency. The most usual premonitory symptoms are failure in the amplitude of accommodation and frequent desire to change the reading glasses, periods of temporary obscuration of vision, and the appearance of halos surrounding the lamp lights. The glaucomatous attack itself has frequently been mistaken for a " cold in the eye," for iritis—when the disease has been aggravated by the instillation of atropia,which under all circumstances iscontraindicated—and for rheumatic ophthalmia. The condition of the pupil, the depth of the anterior chamber, the anaesthesia of the cornea, and, above all, the increased tension of the globe, demonstrated by palpation with the fingers, are the symptoms which should prevent so fatal an error. The Treatment of glaucoma consists essentially in the adoption of means to lessen the intraocular tension. In mild cases, advantage may no doubt be derived from the assiduous use of eserine or pilocarpine, and a few attacks have certainly been cured by their use, while they are of the greatest service in cases in which it is necessary to defer operation. Leeches, hot compresses, purgation, and analgesics are indicated to relieve the pain; Greenway advises the application of ice. In the majority of instances no time should be lost in resorting to iridectomy, which, under these circum- stances, should be jierformed as directed at page 736. The benefits to be ex]>ected from this operation, for the introduction of which we are indebted to Von Graefe, are in inverse proportion to the duration of the disease; thus, if employed during the forming stage of the affection, a perfect cure may be reasonably* hoped for; an early operation, even in fully developed acute glaucoma, will probably at least arrest the course of the disease, and prevent further deterioration of sight; while in chronic glaucoma, if the structural changes are far advanced before the nature of the case is recog- nized, comparatively little can be expected from any mode of treatment. Nettleship believes that the state of the pupil and its reaction to eserine furnish a good prognostic guide for operative interference in chronic 762 DISEASES OF THE EYE. glaucoma. Here also, as elsewhere, an early ojieration, before much eon- traction of the field has occurred, is greatly to be desired. Other operations for the relief of glaucoma have been practised, and with alleged good results. Thus rejieated paracentesis of the cornea is highly recommended by Sjierino; trephining the cornea has been tried by Argyll Robertson; stretching the external nasal nerve by Badal, Trousseau, and W. (J. Moore; cylicotomy, or division of the ciliary muscle, by Hancock; and puncture or incision of the sclerotic (sclerotomy) by Quaglino, Wecker, Lefort, Spencer Watson, Bader, Mauthner, and other surgeons. Sclerotomy is performed by passing a Graefe's cataract knife through the sclerotic, one millimetre (half a line) from the margin of the clear cornea in front of the iris, and bringing it out at a corresponding point on the other side, so as to include nearly one-third of the circumference; the puncture and counter- puncture are then enlarged, but the central quarter of the sclerotic flap, and the whole of the conjunctiva, excejit where punctured, are left undivi- ded. The weight of testimony in favor of iridectomy is, however, such that the surgeon will usually hesitate to delay the latter operation while experimenting with any other mode of treatment. Affections of the Entire Eyeball. Panophthalmitis, or Inflammation of the Eyeball, may result from traumatic causes, occasionally, though rarely, following operations; may be idiojtathic; may follow perforation of the cornea from deep ulcers, esj>ee- ially those associated with smallpox; or may be an incident of jiyaMiiia, and occur as a further stage of purulent choroiditis, when this is metastatic, or as seen associated with epidemic cerebro-spinal meningitis and other diseases. The symptoms are those of deeji-seated inflammation generally, with such sjiecial jihenomena as are traceable to the implication of the various ocular tissues. The disease usually terminates in supjmration and rupture of the globe, or in sloughing of the cornea. The treatment during the early stages consists in the use of cold ajiplications to allay jiain, with local depletion, scarification of the conjunctiva, and instillation of atropia. If there be much teuton, the cornea may be tapjied with advantage. Spencer Watson recommends, under the name of keratectomy, the estab- lishment of a corneal fistula. When suppuration has occurred, warm should be substituted for cold applications, and a free incision should be made into the sclerotic as soon as the jiresence of pus is detected, while quinine may be exhibited internally, and morjihia, if there be much jiain. If the eye- ball be totally disorganized, excision may be required. Opinion differs among surgeons in regard to the advisability of enucleating the globe during the acute stages of a purulent inflammation, some ojierators declin- ing to perform excision under such circumstances, in the belief that menin- gitis is liable to follow, while others do not recognize such a danger, and do not hesitate to operate. Sympathetic Irritation and Sympathetic Ophthalmitis, affections in which one eye is implicated as the result of disease or injury of the other, are especially apt to occur in consequence of wounds involving the ciliary region, particularly if complicated by the presence of a foreign body. According to C. Iliggens, they often follow the ojieration of sclero- tomy, and Gunn has shown that symjiathetic ojdithalinitis may follow perforation of the cornea with ini|ilication of the iris, rujiture of the ciliary region with blunt instruments, old corneal ulceration, cataract extraction, and the needle ojieration, when associated with iritis. Sympathetic Irri- tation is a functional disturbance, and is characterized by weakness of the EXCISION OR ENUCLEATION OF THE EYEBALL. 763 sympathizing eye, failure of accommodation, temporary obscurations of sight photophobia, and subjective sensations of dark and colored spots, flashes of light, etc. It should be treated by the prompt removal of the exciting eye. Sympathetic Ophthalmitis is usually* developed five or six weeks after the reception of an injury, though sometimes not until a much later period; in Gunn's collection the shortest interval was 14 days, while the longest interval was 39 years. In its common form it apjiears as a severe iridocyclitis, though it may occur as a serous iritis, or as a retino- choroiditis. In some cases the sympathetic irritation, though so great as to render the eye practically* useless, does not reach the point of structural change, constituting then what Donders has described as a Sympathetic Neurosis. While sympathetic ophthalmitis may originate in an attack of irritation, such is not necessarily the case, as it more usually begins with- out such antecedent symptoms. Gunn, as quoted by Nettleship, has observed a marked oscillation of the iris when sympathetic irritation is about to develop into inflammation. The exact nature of this grave malady is not perfectly known, nor is the jiath of the morbid changes which jire- cede the inflammation fully mapped out. The old hypothesis of transmis- sion by the ciliary* nerves has largely been abandoned for the theory of infection, which has received much support from the researches of Deutsch- mann, in Germany, and of Gifford, in this country. Deutschmann's view that the route of the micro-organisms is by* the way of the sheaths of both optic nerves, has not been confirmed by all observers, although all are in accord in the theory of infection. The belief that sympathetic inflamma- tion arises from a propagation to the sympathizing eye by direct continuity through the optic nerves and chiasm from the exciting eye, has led to the adoption by some writers of the term Migratory Ophthalmitis. The treatment of sympathetic ophthalmia, as regards the eye originally affected, depends upon the stage of the disease, and the amount of vision possessed by the injured organ. Foreign bodies should be extracted before the development of any* sympathetic symptoms, and if the lesion of the ey*e be so great as to render it useless, excision should be unhesitatingly performed. The same operation would, of course, be indicated, should the case be first seen when the second eye is becoming involved. If the injured eye still retains some sight, at the time of the occurrence of sympathetic symptoms, the course to be pursued is more doubtful; for it has sometimes happened, under these circumstances, that the eye first affected has in the end proved more useful than the other. If the case be seen at a very early jieriod, an iridectomy on the sympathetically affected eye may occasionally prove serviceable, but in most instances it is better to wait until the subsi- dence of acute symptoms, and then, if necessary*, extract the lens and make an artificial pupil. Sclerotomy is preferred to iridectomy, in these cases, by Mr. Lawson. The general treatment of sympathetic ophthalmia con- sists in the enforcement of functional rest, with the administration of tonics, especially* quinia, the cautious use of mercurial inunction, and the free instillation of atropia. Von Graefe has suggested, in some cases, the for- mation of a seton through the vitreous, as a substitute for enucleation of the injured globe; while, in the comparatively mild cases of sympathetic neurosis, division of the nerves of the ciliary region has been successfully practised by Meyer, Secondi, and Laurence. Excision or Enucleation of the Eyeball is thus performed: The patient being fully etherized, the lids are held apart with a stop-speculum, while the surgeon divides the conjunctiva and adjacent fascia with scissors, in a circle as close as possible to the margin of the cornea. The tendons of the ocular muscles are then successively raised upon a strabismus hook 764 DISEASES OF THE EVE. and divided, when, the eye being drawn forwards and outwards, the optic nerve can be cut with long and narrow scissors, curved on the flat. The eye being removed, hemorrhage is to be checked by the ajijilication of cold, when, if thought jiroper, the conjunctival wound may be closed with a silk suture. This, however, should not be done when the ojieration is jierforiued upon an inflamed eye, as a free vent should then be provided for the dis- charges. Careful antiseptic precautions, especially irrigation with a bichloride solution, should be employed in connection with enucleation. The after- dressing may consist in (lusting the interior of the orbit with powdered iodoform, jilacing, if thought necessary, a drainage tube in the outer can- thus, and applying a firm antiseptic bandage. There is rarely any serious bleeding; if such should occur, firm pressure before the adjustment of the final bandage will suffice to control it. When cicatrization is complete, and all inflammatory symptoms have subsided, an artificial eye may be adajited. Chibret, Terrier (two cases), Rohnier, May, and Bradford have supple- mented enucleation by the insertion of an eye transplanted from a rabbit, or, as in Rohmer's case, from a dog; in all six cases, however, the operation apjiears to have been a failure. Various substitutes for enucleation have been suggested : (1) Abscission, as in staphyloma, has already been described on page 730; (2) Eviscera- tion, or Exenteration, an operation revived and advocated about the sune time by Graefe, in Halle, and by Mules, in Manchester, and adopted in this country by Michel, of Charleston, consists in an evacuation of the contents of the eye from within the sclerotic, and the closure of the sclero- conjunctival wound with sutures, thus forming a movable stumji for an artificial eye. Mules has further modified the method by inserting into the scleral cavity* a hollow glass ball, best done with a special instrument designed for the purpose, then carefully stitching the sjilit sclerotic over the ball, and sewing the conjunctiva separately. Graefe advocates this operation as less likely than enucleation to provoke meningitis, and Mules defends it as furnishing equally good protection against sympathetic inflam- mation, while yielding a better stump. Frost and Lang have projiosed the introduction of Mules's sjihere into Tenon's capsule, after ordinary enucleation, closing the muscles and conjunctiva over it in the usual way. (3) Optico-ciliary Neurotomy, or division of the optic as well as the ciliary nerves, has been advised by J. A. White, Xoyes, Burnett, C. B. Taylor, and H. W. Williams; Knapp and Roosa, however, condemn the operation, which, in their opinion, is less safe than enucleation, and which has provoked sympathetic inflammation, and is said to have caused death in tbree or four cases. In some eases of malignant disease, it may be necessary to extirpate the whole contents of the orbit. This may be done by dividing the exter- nal commissure of the lids, incising the conjunctiva, severing the levator pal|)ebrae, attachments of the oblique muscles, and all other orbital con- nections of the eye, and then, drawing the globe inwards, cutting the optic nerve with curved scissors, introduced on the outer side. The lachrymal gland should be also removed, if it be diseased. Strabismus. Strabismus, or Squint, is defined by Donders as a "deviation in the direction of the eyes, inconsequence of which the two yellow spots receive images from different objects." The squint is concomitant, in contradis- tinction to paralytic, when the squinting eye accompanies the straight in all its movements to an equal extent; and, when convergent, presents ^ev- STRABISMUS. 765 eral varieties, as periodic, persistent, alternating, and monocular. Stra- bismus is usually convergent (cross-eyes), or divergent—the former being commonly associated with hy*permetropia, and the latter with myopia. Squinting may be brought on by* various forms of reflex irritation, but usually depends on some anomaly of refraction, or on defective vision in one eye. In the majority of cases of concomitant convergent strabismus, the squint- ing eye is amblyopic, generally*, it has been believed, from want of use (amblyopia ex anopsia). Certain observers teach, however, that this am- blyopia is congenital, and actually one of the factors in the production of the strabismus. Treatment.—If the affection be periodic, an attempt may be made to effect a cure by suitable constitutional treatment, by the coutinued use of atropia or duboisia, as advised by Boucheron, by the use of glasses to remedy the defect in refraction, etc. If the strabismus be persistent, and not dependent on mechanical causes, such as the contraction of a cicatrix, or of the pressure of a tumor, an ojieration may be resorted to, one or both internal or ex- ternal recti muscles being di- vided, according to the nature and extent of the squint. Be- fore having recourse to an operation, the surgeon should (in case of concomitant squint) determine which eye is primarily affected, and the degree of convergence or di- vergence, as the case may be; the former point may conve- veniently be ascertained by* repeatedly* causing the patient to close both eyes and suddenly open them, that eye which constantly or habitually de- viates from the straight position being the one primarily affected. The degree of squinting can be ascertained by using the strabisinometer devised by Laurens, or that of Galezowski, but, in the absence of these instru- ments, may be simply determined by marking on the lower lid points cor- responding to the centre of the pupil, when the eye is fixed, and when it is squinting. A more accurate procedure is that introduced by Landolt— the angular method—in which, with the help of a perimeter, the observer measures the size of the angle made by the visual axis of the squinting eye with the direction it should naturally have. If the degree of strabismus be moderate, less than three lines, for instance, the primarily affected eye alone need be submitted to operation ; but in case of greater deviation, a better result will be obtained by dividing the operation between both eves. The object to be accomplished, in an ojieration for strabismus, is to alter the point of attachment of the divided tendon, and thus diminish the range of motion which it can impart to the eye: hence the importance of ascer- taining the degree of deviation, that the separation of the tendon from its attachment may be more or less complete, according to the exigencies of the particular case. The operation for Division of the Internal Rectus Tendon is thus per- formed : The eyelids being separated with a stop-speculum, the surgeon catches with fine-toothed forceps a fold of the conjunctiva and subjacent fascia, on a level with the lower border of the tendon, and with delicate probe-pointed scissors makes an opening just large enough to admit the strabismus hook ; the latter is then insinuated behind the tendon, which Fio. 443.—Galezowski's strabisniometer. 766 DISEASES OF THE EYE. it renders tense by drawing it forwards and outwards; the scissors are next introduced closed, and then ojiened, so as to j>laee one blade behind, and the latter in front of the tendon, which is subsequently divided sub- conjunctivally, close to its sclerotic attachment, by a number of slight cuts. To prevent the slipping of the tendon, which is apt to occur with the ordinary strabismus hook, an ingenious instrument known as the "crotchet hook" has been recently introduced by Dr. Theobald, of Baltimore. A counter-oj>ening in the conjunctiva, to , ,, __ ^..•^s^f allow the escape of blood, may be made, if" s^^"^ as is done by Bowman, by cutting I with the scissors on the jioint of the no. 444.—strabismus hook. hook before this is withdrawn. The above is known as the sub-conjunctival operation, and was introduced by Critchett. Other surgeons, as in the Graefe method, prefer to divide the conjunctiva more freely, afterwards bringing the edges of the wound together with a suture. The surgeon ean regulate the effect of the operation by sejiarating more or less freely the sub-conjunctival fascia from the tendon to be divided, thus allowing the greater or less retraction of the latter. The ajijilication of a suture also serves to lessen the effect of the operation. Snellen makes the conjunctival incision in a direction parallel to and immediately over the muscle, which he then seizes with forcejis and divides with sharp-pointed scissors. Dr. Frank, of Baltimore, effects the division of the tendon with an instrument similar to the knife-hook used by Purves in cases of aural polypi. The External Rectus Tendon may be divided by an ojieration analogous to that above described. Considerable difference of opinion exists among surgeons as to whether both eyes should be operated on simultaneously (when both require operation), or whether the second operation should be postponed until after an interval of several days. Probably a safe rule is that given by Wells, to wait and observe the effect of the first ojieration, in cases of deviation of less than five lines; by this precaution the surgeon can form an estimate as to how much remains to be accomplished in the second operation. Stevens, of New York, has esjieciallv develojied a sys- tem of operations, in which graduated tenotomies are performed for the purpose of correcting those conditions which are usually denominated in- sufficiencies of the ocular muscles, but for which he proposes the generic name heterophoria, and by the correction of which he has reported bril- liant successes in the treatment of numerous functional nervous disturb- ances ascribed to these anomalous conditions. With a pair of small, narrow-bladed scissors, a transverse incision is made through the conjunc- tiva, exactly* corresponding to the line of insertion of the tendon. This is seized behind, but near its insertion, and a small opening is made dividing the centre of the tendinous expansion exactly on the sclera. This ojicning is then enlarged by* careful cuts with the scissors toward each edge, keep- ing carefully on the sclera as the border of the tendon is approached ; the amount to be cut depends upon the judgment of the operator and the na- ture of the case. General Anaesthesia is, as a rule, undesirable in squint operations, though it may be employed in cases of children, or in tho.-c of nervous adults; it is in these cases that the local use of cocaine has gained some of its most brilliant successes. The after-treatment in cases of stra- bismus consists (if both eyes have been operated on) in simply bathing the parts with cold water ; if one eye only has been submitted to ojieration, the other should be closed with a bandage, so as to force the patient to use that of which the tendon has been divided. Suitably adjusted glares, fully correcting the error of refraction, must be worn after strabotomv, and PARALYSIS OF THE OCULAR MUSCLES. 767 these mav indeed, sometimes combined with prisms, suffice to effect a cure without operation, in cases of periodic squint. An attempt may be made to cure slight cases of strabismus by the orthoptic treatment of Javal, and good results follow this method in cases in which strabismus has been par- tially overcome by operative procedures. Among complications of squint operations have been noted hemorrhage beneath the capsule of Tenon, orbital cellulitis, and even perforation of the sclera. Instead of dividing the contracted tendon in cases of strabismus, Dr. Noyes advises that the opposing or elongated tendon should be shortened, bv cutting it near its insertion into the eyeball, bringing the posterior under the anterior portion, and securing it there with sutures. Advancement, or Readjustment, is an operation in which the tendon of a rectus muscle, usually the internal, but sometimes the external, which by a too free division has become adherent too far back, is brought forward to a new attachment. The same operation is applicable to cases in which the tendon has become weakened, as for instance in my-opia, or to those instances of convergent strabismus in which it is desirable to combine advancement of the external rectus with tenotomy of the internus. The insertion of the tendon is exposed, and the strip of conjunctiva between the opening and the cornea detached from the sclera, A hook is then inserted beneath the tendon and brought well up to its insertion. A needle, threaded with fine catgut or silk, is next inserted from the upper margin of the tendon between this and the sclera, and passed through the tendon at its middle line. Similarly, another suture is passed behind the tendon from its lower margin, close to the first. Each of these is firmly- knotted, a long end being left. The tendon is now separated with scissors, and the sutures are passed through the conjunctival flap in the direction of the muscle, and are tied with their own ends. Numerous methods have been devised for performing the operation of advancement, among the most ingenious being those of the late C. R. Agnew, of New York, and of A. E. Prince, of Jacksonville, who secures an unyielding anterior fixation-point by utilizing the dense episcleral tissue, securing the muscle and regulating the effect by a skilfully devised " pulley-suture." Advance- ment of the capsule, of Tenon, the tendon being folded on itself, has been advised and practised by De Wecker, and has been followed by good results in the hands of many operators; it is especially recommended by Knajip, of New York. The operation of advancement is tedious and painful, and general anaesthesia is necessary* for its satisfactory performance. Paralysis of the Ocular Muscles (Paralytic Strabismus) may- result from disease in the orbit or within the cranium, often syphilitic, from injuries to the head, or from exposure to cold; it is sometimes associated with locomotor ataxia, and may occasionally* be functional, as in hysterical cases. The symptoms common to palsies of the external muscles are (1) limitation of movement and strabismus; (2) double vision, either "crossed" or " homogeneous," but determined by the use of a red glass before the affected eye; (3) erroneous projection of the field of vision; and (4) secondary deviation or excessive movement of the sound eye, when this is prevented from seeing an object which the affected eye "fixes." A simple rule formulated by Gower, in regard to diplopia, is that when the jiro- longed axes of the eyes would cross, the images are not crossed ; when the prolonged axes would not cross, the images are crossed. (For the symptoms of palsies of the several muscles, the reader is respectfully referred to special works on ophthalmology.) 768 DISEASES OF THE EYE. Treatment.—This must be directed to removing the cause of the paralysis, and, as in many instances syjihilis is present, mercury and iodide of potassium deserve extended trial. At a later period the use of strychnia is indicated, while in rheumatic jialsies the salicylates may be exhibited; faradization has been resorted to. by R. B. Carter. According to Alfred Graefe, very few cases of paralytic squint are suitable for surgical inter- ference. He thus classifies the operations : Advancement of the |>araly\sed muscle (substituting operation); tenotomy of the antagonist (equilibrating operation) ; and tenotomy of the associated antagonistic muscle of the sound eye (compensating operation). Preference should be given to that operation which in each case seems best adajited to restore binocular vision. Ophthalmoplegia Externa (Nuclear Paralysis).—Hutchinson has described under this name cases of partial symmetrical immobility of the eyes, with ptosis, due to syphilis, either congenital or acquired, and suscep- tible of improvement from the use of iodide of potassium. The intra- ocular muscles are not involved. Syphilis is not the cause in all cases of this affection, which dejiends upon degenerative changes affecting the nuclei of origin of the inijilicated nerves, in the floor of the fourth ventricle. Conjugate Deviation is the involuntary turning of the two eyes in the same direction. It is sometimes the result of paralysis affecting certain associated movements of the two eyes, and not the muscles supplied by a particular nerve. These cases are probably* due to lesions of the centres of combined movements. Paralysis of the Iris or Ciliary Muscle ajipears in the following forms: (1) Pujiil alone affected (paralytic myosis and mydriasis); {!) paralysis of the iris (iridoplegia) ; (3) paralysis of accommodation (cyclo- plegia), often seen after diphtheria; (4) jiaralysis of the ciliary muscle and iris (cycloplegia with mydriasis). Hutchinson has given the name of ophthalmoplegia interna to cases of complete paralysis of the internal muscles of the eye, which he believes to be due to disease (jirobably syphi- litic) of the lenticular ganglion. Diseases of the Eyelids. Blepharitis (Ophthalmia 1'arsi, Tinea Tarsi, Blepharitis ciliaris, B. squamosa, B. ulcerosa) is the name given to a subacute or chronic form of inflammation, affecting the edges of the eyelids and the follicles of the lashes, which become loosened and fall out. The palpebral edges are red, thickened, and sometimes ulcerated, and become glued together by the drying of the accumulating secretion. In its severer forms, the affection gives rise to the condition known as Lippitudo or Blear-eye. The punvta lachrymalia are often everted or obliterated, giving rise to a constant stilli- cidium of tears, which excoriate the skin and add to the patient's discom- fort. This affection is, according to Roosa, often dependent on the ex- istence of ametropia. The treatment consists in removing the dried secretion by warm alkaline fomentations, and smearing the edges of the lids with dilute citrine ointment,1 or that of the yellow oxide of mercury. In severer cases the local application of nitrate of silver will be of service, and, if the puncta be everted or obliterated, the canaliculi should be freely slit up, the incision being directed inwards. As this affection commonly occurs in scrofulous children, cod-liver oil may be properly admini>tered in most cases. If the patient be ametropic, relief may be afforded by the in- 1 Ung. hydrargyri nitrat. 3j ; Ung. aq. rosae 3vij. M. TRICHIASIS AND DISTICHIASIS. 769 stillation of atropia and the use of suitable glasses. Oliver recommends tattooing the edges of the lids with India ink, as a cosmetic remedy in in- veterate cases. Blepharitis Pediculosa (Phtheirasis Palpebrarum) appears, as a rare affection, when the pediculus pubis invades the eye-lashes. The cilise have the appearance of being dusted over witha dark-brown powder. The affection gives rise to intense itching. The parasites may be destroyed bv the use of a mercurial ointment. Hordeolum or Stye is a small boil occurring at the edge of the lid, and often originating in the follicle of an eyelash ; it is met with usually in debilitated persons, and occasionally as the result of over-exertion of the ey-es, or of exposure to too bright a light, as to the glare reflected from snow. When situated just within the edge of the lid, it produces pain by pressing on the globe; relief may be sometimes afforded under these cir- cumstances by fixing the lid in a position of slight eversion by* means of collodion. The treatment consists in the use of warm fomentations, with a puncture if required, the induration which remains being dispersed by the use of dilute citrine ointment. Tonics are usually indicated as con- stitutional remedies, and sulphide of calcium has proved useful. Trichiasis and Distichiasis___The former term signifies an irregu- lar displacement of the eyelashes, some of which, stunted and inverted, jiroduce great irritation by friction on the conjunctiva and cornea, the latter becoming in extreme cases cloudy and vascular. In distichiasis a complete double row of lashes exists, the inner row being inverted, and producing great irritation as in the previous case. The treatment of either affection consists in carefully extracting with cilia forceps the offending lashes, or, if only* a few hairs, situated close together, are involved, they may be excised with the corresponding portion of the border of the lid. Excision of the whole row of cilia (Flarer's operation) by making parallel incisions on either side of the lashes, splitting the tarsal cartilage and re- moving a wedge-shajied strip bearing the cilia, is objectionable as depriving the eye of its natural means of protection, and as leading to cicatricial contraction. Herzenstein applies a subcutaneous ligature around the roots of the lashes, while Hayes, of Dublin, induces sloughing of the follicles by the hypodermic injection of the perchloride of iron. If but one or two lashes are involved, an old operation (illaqueatio) revived by Snellen, Watson, and Robertson, may be resorted to. This consists in drawing the displaced eyelash, by means of a fine ligature (Watson employs human hair) under the skin of the eyelid, and thus mechanically altering the direction of the lash's growth. Electrolysis has been proposed as a remedy for this condition by Mitchell, Benson, and Taylor. For complete dis- tichiasis, Transplantation should be employed, one of the best forms of this procedure being the Jaesche-Arlt ojieration, in which, after the lid is fixed with a Knapp's or Snellen's clamp (Pig. 445), its intermarginal portion is split by a first incision into two layers, the anterior containing all the hair bulbs. A second incision is made 5 millimetres (2^ lines) from the margin of the lid, while a third is carried in a curve from one end of the second to the other, and the intervening integument is dissected away. The margins of the gap are drawn together with fine sutures, and the bridge of tissue containing the hair follicles is thus shifted away from the cornea. Double transplantation ojierations have been proposed by Spencer Watson, Gayet, Dianoux, and other surgeons. In the method of Dianoux, support is given to the cilia by transplanting a strip of skin to the intermarginal space. The fine cutaneous hairs on the transplanted flap often irritate the cornea, an objection which E. Van Millingen has 49 770 DISEASES OF THE EYE. sought to obviate by the introduction of his tarso-cheilojdaslic ojieration In this, after splitting the lid in the usual manner, a strip of mucous mem- brane from the patient's under lip is transplanted into the gap in the inter- Fio. 415.—Snellen's clamp. marginal space. The treatment of trichiasis and entropion by the trans- plantation of buccal mucous membrane is advocated and largely practised by A. II. Benson. In the case of the lower lid, it will usually be sufficient to remove an elliptical strip of skin with the subjacent fibres of the orbi- cularis muscle, thus producing eversion as in the operation for entropion. Entropion, or Inversion of the Lids, may result simply from sj>as- modic action of the orbicularis palpebrarum (blepharospasm), as in the entropion after cataract operations in old persons, or from long-continued conjunctival inflammation, the injudicious use of caustics, etc The irrita- tion produced by the friction of the inverted lashes is very great, and sometimes induces opacity of the cornea. The treatment of the spasmodic cases1 consists in restoring the lid to its projier position by* traction with the fingers, and then fixing it by the application of collodion, the contractile property of which serves to obviate the tendency to inversion. Chronic cases of entropion may be remedied by various ojierations, such as (1) pinching up, with entropion forceps, and excising a small strip of skin, with the subjacent fibres of the orbicular muscle, parallel to the ciliary border of the lid—the wound being subsequently closed or not with sutures,2 (2) " grooving the tarsal cartilage," as recommended by Streat- * feild, the operation consisting in the removal of a transverse strip of the cartilage by means of two parallel incisions meeting at the apex of a V—tne skin wound being subsequently closed with stitches; (3) excising a narrow 1 Dr. Harlan reports an obstinate case of blepharospasm cured by inhalations of nitrite of amyl. 2 Schneller has modified this operation by circumscribing, without excising, an elliptical strip of skin, and having loosened the lateral portions, uniting them with sutures above the central portion, which is thus covered in and serves as a splint to give firmness to the part. ECTROPION. 771 oval piece extending the whole length of the cartilage, as advised by Ber- lin ; (4) making a linear incision, cutting away a portion of the orbicular muscle, and stitching the skin of the lid to the distal edge of the tarsal cartilage, as practised by Hotz, of Chicago; (5) the introduction of two or three threads in a longitudinal direction through the cutaneous surface of the lid, the ligatures em- bracing the ciliary margin and being allowed to cut their way out by ulceration, as advised by Pagenstecher, or embracing the skin and muscle of the lid only, as recommended by Laurence ;* (6) the excision of a triangular portion of skin, with or without a part of the subjacent cartilage, as recommended by Von Graefe ; (7) the removal of the whole row of cilia, as described in speaking of trichiasis; (8) transplantation of the cilia to a better position on the lid, as practised in various way's by Arlt, Jsesche, Warlomontand McKeown; or (9) splitting- the lid into an anterior and poste- rior layer, and inserting a strip of mucous mem- brane taken from the patient's lip, as advised by Van Millingen. As a preliminary to any of these operations, it will often be advisable to slit up the external canthus (canlhoplasty), re-adhesion being prevented by uniting the skin and mucous mem- brane on either side by a stitch. Ectropion, or Eversion of the Lids, may be of an acute character, resulting from spasm of the inner fibres of the orbicularis palpebrarum in cases of purulent conjunctivitis, in which case its treatment is that of the disease which it ac- companies, or may* appear as a chronic affec- tion, resulting from ophthalmia tarsi, chronic conjunctivitis, etc. Under these circumstances, the treatment consists in the application of nitrate of silver to the mucous membrane just within the line of eversion, with slitting of the canali- culi if the puncta be everted or occluded. If the ectropion be aided by relaxation of the tissues, as in old jieople, excision of a V-shaPed piece of the whole thickness of the lid (Figs. 447 and 448), or of a horizontal strip of the most everted por- F,°- ^.—Entropion forceps. tion of the conjunctiva, may be practised. The operation of Snellen, by which the everted mucous membrane is returned into place by a suture entered at two points, one-third of an inch apart, passed deeply, and brought out upon the cheek where the ends are tied over a piece of drainage-tube, is useful, as is also the ingenious procedure of Argyll Robertson, in which a piece of sheet lead, shaped to resemble the normal tarsus, is placed beneath ligatures in the conjunctival cul-de-sac. Ectrojiion from the contraction of cicatrices, abscesses, etc, usually requires aplastic operation (blepharoplasty),2 w*hich consists in embracing the vicious 1 A somewhat similar operation is employed by Solomon, and is said to have been devised by Snellen, of Utrecht. 2 C. S. Bull advises kneading and traction of the cicatrix, as a preliminary to any operation of blepharoplasty. 772 DISEASES OF THE EYE. cicatrix, if small, in a V-snal),i(i incision, sejiarating the flap, and |>ushing it up into jilace while the lower part of the wound is drawn together with sutures, thus converting the V into a Y; or, if extensive, in dissecting out the scar and filling the gap by transplanting a flap of skin, from the Figs. 447 and 443 —Adams's operation for ectropion. (Lawson.) forehead in the case of the ujiper, and from the nose or cheek in case of the lower lid. Many operations of this nature have been devised; the site and character of the lesion will, in each instance, determine the best method of procedure. The disadvantages of these blepharoplastic operations are obviated by the plan introduced by Lefort and Wolfe, and successfully practised by Wadsworth, Von Zehender, Aub, Reeve, Abbott, Noyes, Mathewson, Ely, E. Smith, Tosswill, and other surgeons, which consists in transplanting skin without a pedicle from a distant part, the flap being shaved down so as to assimilate the ojieration to Reverdin's transplanta- tion of cuticle. Preputial grafts are suggested by Jeffries, of Boston. The Taliacotian method has succeeded in the hands of R. II. Derby. Ptosis, or Falling of the Upper Lid, may be congenital, or may re- sult from the increased weight of the part due to inflammatory thickening or to fatty deposit (Schell), from wounds dividing the levator paljiebrae or its nerve, or from paralysis of the third nerve. The treatment (in cases of sufficient severity to justify operation) consists in removing an elliptical portion of the skin and subjacent muscle of the lid, the edges of the wound being then ajiproximated transversely, so as to place the part under con- trol of the occipito-frontalis muscle, which sends fibres to the upper |>ortion of the orbicularis—or in the introduction of ligatures (Pagenstecher) as described in sjieaking of entropion. In paralytic cases, the endermic appli- cation of strychnia has been occasionally resorted to with advantage. Dr. Van Bidder, of Xew York, recommends the employment of a delicate India- rubber band, fastened with collodion and isinglass plaster to the edge of the lid and to the forehead, so as to supplement the jniralyzed muscle, as in Barwell's and Sayre's method of treating club-foot. Dr. Mathewson has employed a similar plan in the treatment of spasm of the orbicularis (ble- pharospasm). Lagophthalmos, or Hare-eye, denotes an inability to close the eye- lids; it may result from the contraction of cicatrices, when its treatment is that directed for ectropion, but more often dejiends on paralysis of the orbicular muscle from some local affection of the portio dura, or from intra- cranial causes. If the affection appear to result from the pressure of a tumor on the portio dura, the offending growth should, of course, be re- moved ; a blister to the temple may be of service in cases resulting from TUMORS OF THE EYELIDS. 773 exposure to cold; while, if a syphilitic origin be suspected, the iodide of potassium should be administered. If the lagophthalmos results from mechanical causes, such as exophthalmic goitre, and the exposure causes dryness and ulceration of the cornea, the operation of tarsorraphy may be necessary. This consists in freshening and uniting with sutures the mar- gins of the upper and lower lids in the neighborhood of the external com- missure. Symblepharon is a morbid adhesion of the eyelid to the eyeball, re- sulting usually from the cicatrization of burns, ulcers, etc. The treatment consists in (lj dividing the adhesions, and uniting the cut edges of conjunctiva with sutures (Wilde); (2) covering the raw sur- face, left after severing the adhesions, with flaps of healthy conjunctiva taken from un- affected parts of the ey*eball (Teale),1 with a flap from the skin of the eyelid itself, passed through a slit in the tarsal cartilage (C. B. Taylor), or with a strip of mucous membrane from thelip (Meighan); (3) dis- secting back the symblepharon as far as the retrotarsal fold, doubling it upon itself so as to oppose a mucous surface to the globe, and fixing it in this position by Fio. 449.—Symblepharon. (Mackenzie.) means of a ligature which is armed with two needles and passed through the lid from within outwards (Arlt) ; or (4) emjiloying delicate flaps taken from the cheek or forehead, and in- verted so as to turn the cutaneous surface toward the eyeball, as success- fully done by Dr. G. E. Post, of Beirut, Syria. Dr. MacFarlan, of New York, succeeded in one case by simjily dissecting out the symblepharon and keeping the lid drawn away from the globe, until cicatrization oc- curred, by attaching the lid to the cheek with pins and ligatures. Anehyloblepharon is an abnormal adhesion of the free edges of the upper and lower lids, either congenital or the result of injury, etc. The treatment consists in severing the adhesions with a small knife and grooved director, reunion being prevented by touching the cut edges with collodion. Blepharophimosis, or a contraction of the external commissure and conse- quent narrowing of the palpebral fissure, requires the operation of can- thoplasty. Tumors of the Eyelids.—Sebaceous, Vascular, and other Tumors occur on the eyelids, and are to be treated as similar growths in other situations. The Chalazion, or common tarsal tumor, appears to originate in a distended state of a Meibomian follicle, and often suppurates ; the treatment consists in making an incision on the conjunctival surface and squeezing out the contents of the mass. If the tumor is firm and does not point toward the mucous surface, it should be removed by a cutaneous incision, care being taken not to button-hole the conjunctiva. The lid must be fixed with a Snellen's or Knapp's clamp. Ray has modified the late Dr. C. R. Agnew's method, by seeking for the duct of the involved Meibomian gland, injecting a few drops of a solution of cocaine into its mouth, incising the tumor in the course of the injection, and evacuating the contents with a sharp curette. The injection of cocaine in the neigh- borhood of tumors of the lids, greatly facilitates their removal. Sarcoma 1 Wolfe, Dufour, Calhoun, Noyes, Callan, Brown, Little, and Parker, have operated successfully by transplanting portions of conjunctiva from rabbits. 774 DISEASES OF THE EYE. of the lid sometimes closely simulates chalazion, as in a case recorded by Randall. Chisolm recommends, in all cases of paljiebral cyst, simjtle puncture followed by the evacuation of the cyst contents, and subsequent cauterization of the cavity* with a silver probe dipped in nitric acid. Epicanthus is a congenital affection in which a crescentic fold of skin overlaps the inner canthus of the eye, producing considerable deformity ; the treatment consists in excising a longitudinal fold of skin and bringing .the edges of the wound together with sutures, so that the subsequent con- traction may expose the jneviously hidden canthus. Coloboma of the Lids is a congenital fissure, Avhich may be treated by paring the edges of the gap and uniting them with sutures. Congeni- tal Absence of the Eyelids and Abnormal Shortness of the Lids have occasionally been noticed. Diseases of the Lachrymal Apparatus. Diseases of the Lachrymal Gland.—This organ may be inflamed (Dacryo-adenitis), or may be the seat of hypertrophy, or of various morbid, growths. These affections are, however, rare, and their treatment presents no features calling for special comment. iSoyes has recently re- moved the gland for spontaneous prolapsus. Fistula of the Lachrymal Gland may result from abscess or wound of this jiart; it may be treated by paring the edges and introducing a suture, by the application of caus- tic or the galvanic cautery, or by* establishing a free communication with the conjunctival surface by the use of a seton. as has been successfully done by Bowman. Excision of the Lachrymal Gland is recommended by Laurence in cases of obstruction of the canaliculi, in which it is found impossible to restore their permeability ; the operation consists in making an incision below the upjier and outer third of the orbital ridge, cautiously opening the orbit, seizing the gland with a double hook, and carefully dissecting it from its attachments; hemorrhage having ceased, the wound is closed with sutures. To avoid the risk of ptosis, which occasionally follows the operation, Mr. Laurence suggests that an internal incision should be made through the upper sinus of the palpebral conjunctiva, with an external division of the outer canthus ; the substance of the lid would not thus be involved in the operation. De Wecker has successfully excised the jialpe- bral portion of the gland in several cases of persistent epiphora. Epiphora, strictly speaking, signifies an excessive secretion of tears, but the term is often used as equivalent to Stil/icidium Lacrymarum, which is the overflow from obstruction of the canaliculi or nasal duct. Excessive lachrymation may be a symptom of various inflammatory con- ditions of the eye, or may result from the presence of foreign bodies, entro- pion, etc., under which circumstances its treatment requires, of course, the removal of the cause to which the epiphora is due. Obstruction of the Canaliculi1 may occasionally be remedied by dilatation of the passage with probes of gradually increasing size, but it will usually be necessary to slit up the canal with a delicate grooved direc- tor and cataract knife, with scissors, or with a delicate beaked knife, which is perhapsthe most convenient instrument. The same operation is required in cases of eversion or obliteration of the puncta lacrymalia. The lower canaliculus is the one usually slit, the incision being made towards the con- 1 The canaliculus is sometimes plugged by a fungus, which may undergo calcifica- tion and form a ducryolite, or tear-stone. FISTULA LACRYMALIS. 775 junctival surface, so as to open a passage for the tears. Reunion is to be prevented by* the daily introduction of a probe, by the application of nitrate of silver, or by excising a small portion of the mucous membrane. Jessop and Steavenson recommend electrolysis for this purpose. If the jiunctum be indistinguishable, the lachrymal sac may be opened beneath the tendo oculi, and the canaliculus slit from below upwards, as recommended by 11 *'P=== ~ Fig. 450.—Bowman's canaliculus knife. Bowman, or a bent director may* be introduced through the upper punctum and brought around in the lower canaliculus, or vice versa, as advised.by Streatfeild. Obstruction of the Nasal Duct usually results from thickening of its mucous lining, as the consequence of chronic inflammation. It may follow periostitis or necrosis, caused by syphilis or by certain of the exan- themata. As especially pointed out by Harrison Allen, the change in the mucous lining is often a part of chronic disease of the naso-pharynx. It occurs at all ages, but more frequently in the female than in the male. The treatment consists in effecting gradual dilatation by means of probes, in- troduced through the punctum, the canaliculus being, if necessary, pre- viously slit. In passing probes through the canaliculi and nasal duct, the position of the instrument is at first longitudinal, then transverse, and then somewhat longitudinal again, with a slight inclination inwards and back- wards in correspondence with the anatomical disposition of the parts, which must be borne in mind. Metal probes, Bowman's or Williams's, are com- monly to be preferred for dilatation of the lachrymal passages, though bougies of the laminaria digitata have been successfully emjiloyed by sev- eral surgeons. Tansley recommends a modification of Weber's probe, which in turn embodies the ideas of Theobald, who advises aluminium for the manufacture of these instruments. Other modes of treatment are the introduction of a style through the slit canaliculus into the nasal duct, the instrument being allowed to remain several days (Bowman), the internal division of the strictured part by nicking the seat of obstruction in several directions with a suitable knife (Stilling), and the forcible dilatation or rupture of the stricture, as in Holt's method of treating stricture of the urethra (Herzenstein). The old plan of introducing a style through an external excision, is now generally abandoned, except with refractory pa- tients, or with children in whom frequent passage of the lachrymal probe is attended with difficulty. Inflammation of the Lachrymal Sac may be acute (Dacryo- cystitis) or chronic (Blennorrhcea, Mucocele). The former variety of the affection is to be treated with warm fomentations, and an early puncture from the conjunctival surface, or an incision through the skin, if suppura- tion occur; and the latter by the use of astringent lotions, by splitting the canaliculus and dilating any stricture that may be found, and by washing out the sac with astringent injections introduced by means of a canula and syringe. In obstinate cases it may be necessary to excise the anterior wall of the sac (Von Amnion, Bowman, Lawson, Monoyer), or to oblite- rate the sac itself by the use of caustic or the galvanic cautery, applied through an incision, which is best made, as advised by Agnew, of New York, through the conjunctiva. Supjiuration in the region of the lachry- mal sac may, as pointed out by Parinaud, be due to dental disease. Fistula Lacrymalis, or fistula of the lachrymal sac, is occasionally congenital, but usually results from either acute or chronic inflammation 776 DISEASES OF THE EYE. of the part; the treatment consists in the removal of any obstruction to the natural course of the tears, and in the use of astringent injections; if necessary, the sinus may be laid open with a cataract knife, or its edges may* be pared and a suture introduced. Syphilitic Affections of the lachrymal ajqiaratus, both secondary and tertiary, are described by R. W. Taylor, of New York. Diseases of the Orbit. Abscess of the Orbit may be acute or chronic; the symptoms of the former are those of abscess in general—deep-seated and constantly increas- ing pain, aggravated by motion or pressure, with a swollen, glazed, and cedematous state of the eyelids (particularly the upper), chemosis of the conjunctiva, and protrusion of the eye, the displacement being usually some- what downwards and inwards, as well as forwards. Imjiairment of sight results from pressure on and stretching of the optic nerve. Fluctuation is finally developed, and pointing usually occurs below the inner portion of the supra-orbital ridge. The symptoms of chronic abscess are much less distinctive, the diagnosis from encephaloid or other soft tumor being often impossible without the aid of the exjiloring needle. The treatment of either form of abscess consists in making an incision with a knife introduced flat- wise at the point of greatest fluctuation, the subsequent management of the case being conducted on general principles. If a sinus persist after the evacuation of an orbital abscess, it may be stimulated to heal by the use of astringent injections. Periostitis, Caries, and Necrosis of the orbital walls are occasion- ally* observed, usually* as the result of constitutional syphilis. According to Mraeek, of Vienna, syphilitic periostitis is sometimes a manifestation of the secondary, but usually of the later tertiary period, and most frequently attacks the orbital margins, rarely the orbital walls behind Tenon's cap- sule. It may occur either as a gummatous or as a sclerosing or osteoplastic periostitis. The treatment of these affections presents no features re- quiring sjiecial comment. Tumors of the Orbit.—Various forms of morbid growth are met with in this region, as the cystic, cartilaginous, osseous, fibrous, sarcoma- tous, vascular, and cancerous. The treatment of these different affections has been sufficiently considered in Chajiter XXVI. ; in dealing with non- malignant grow*ths, the eyeball should, if uninvolved, be, if possible, allowed to remain; but in the case of cancerous tumors of the orbit, it must com- monly be removed, to allow space for complete excision of the morbid growth. Lawson recommends that, after the removal of a malignant tumor from the orbit, lint spread with a paste of chloride of zinc should be carefully applied to the whole surface from which the growth sprang. Hydatids of the orbit have been observed by Lawson, Higgins, and others. Aneurisms of the Orbit__The orbit may be the seat of ordinary aneurism, affecting the ophthalmic artery, of traumatic aneurism, or of aneurism by anastomosis. In either of the two first-named condition?* there would be exophthalmos, with more or less pulsation, but according to Terrier and Rivington, who have ably investigated the literature of the subject, the same symptoms may be equally due to an extra-orbital aneu- rism of the ophthalmic artery, to an aneurism of the internal carotid, to an extra-orbital aneurismal varix involving the internal carotid and the cavernous sinus, or to dilatation from obstruction of the ophthalmic vein. Aneurism by anastomosis appears to involve the orbit only by spreading from neighboring parts, and is not accompanied by exophthalmos. Vascu- DISEASES OF THE AURICLE. 777 lar protrusion without pulsation may result also from hypertrophy and hvperaemia of the adipose tissue of the orbit, as in the jieculiar affection known as Exophthalmic Goitre, or Graves's, or Basedow's Disease, an affection which Barie and Joffroy have found in some instances associated with locomotor ataxia, and which will be again referred to in the chapter on Diseases of the Neck. The surgical treatment of orbital aneurisms has already been considered. (See pages 577, 608.) Distention of the Frontal Sinus, by the accumulation of pent-up fluid, mav, by forming a tumor at the upper and inner portion of the orbit, cause disjilacement of the ey*eball, and entail great disfiguration on the patient. The treatment consists in evacuating the fluid by perforating the thinned wall of the sinus and then establishing a free communication with the nose, re-accumulation being prevented by the introduction of a drain- age-tube. CHAPTER XXXVI. DISEASES OF THE EAR. As in dealing with Diseases of the Eye, it is not my intention in the following pages to discuss all those subjects which properly belong to the domain of aural surgery, but to refer only- to those more common affec- tions of the ear which the general practitioner may at any time be called upon to treat, and to describe those ojierations upon the organ of hearing which every surgeon should be competent to perform. Diseases of the Auricle. Malformations of the Auricle are occasionally* met with, usually in conjunction with other congenital defects; if the malformation consists in contraction of the orifice of the meatus, from undue projection of the tragus or antitragus, advantage may be derived from the employment of dilatation, or from excision of a portion of the cartilage. Congenital closure, of the meatus by an abnormal membrane is not infrequently* associated with grave defects of the deeper structures; and hearing must be proved by the tuning-fork and other tests to be present, before operative interfer- ence is permissible. The auricle may* be displaced, so that careful explora- tion is necessary to find the deeper part of the meatus. This condition, like accidental closure, may be treated by incision and the subsequent use of tents. Supernumerary auricles in the form of cartilaginous or fatty nodules, usually in front of the ear, are sometimes met with, and may be treated by excision, as in cases reported by Birkett and Gross. They may be associated with branchial fissure or congenital aural fistula, generally situated in front of the auricle, and due to incomplete closure of the first branchial cleft. The sinus rarely communicates with either the meatus or the tympanic cavity, but usually discharges periodically a watery or puru- lent fluid, which may call for efforts to close the opening by cauterization or incision. Acute Inflammation of the Auricle may be at times erysipe- latous, but is usually* either an acute eczema or the rarer herpes. Frost-bite, and burns, caused by exposure to the sun or otherwise, may give rise to a similar condition. Emollient and protective apjilications are at first indi- 778 DISEASES OF THE EAR. cated, followed by painting with nitrate of silver or other astringents. Vesicles or bullae may* form, and go on to sujijuiration and the formation of crusts. Pain may be very severe in erysijielas and herpes; in the latter, sometimes preceding by several days any visible lesion. In eczema the itching is usually* extreme, and the constitutional disturbance may be very marked. Internal medication by tonics is called for, full doses of the muriated tincture of iron being probably the best in doubtful cases, and quinia in the herpetic. Chronic Inflammation may be left after an acute attack. It is attended with great thickening, induration, itching, and tenderness, and is chiefly observed in debilitated women who have passed the middle jieriod of life. It is usually eczematous in its nature, and in such cases there is almost always an unusual rigidity of the auricle and meatus, which serves as an easily* recognized diagnostic sign. Gouty individuals are esjtecially prone to a dry, scaly eczema, affecting more particularly the meatus; while a moist form, with vesicles, fissures, and crusts, is common in strumous children, particularly* those who have a purulent discharge from the tymjianic cavity*. Roosa recommends the warm douche as especially useful in sub- acute cases involving the meatus, but often water and soap are jiarticularly to be avoided, and cleansing with cosmoline and oily applications are more efficacious. An ointment of calomel in cosmoline generally gives good results, or slightly stimulating substances, sUch as the dilute citrine oint- ment, may be used. Tumors of the Auricle.—These may be cystic, fatty, fibrous, vas- cular, malignant, etc. Those particularly deserving mention are the cysts, and the fibrous, cheloid-looking growths which occasionally follow the use of ear-rings, especially in the negro. A cyst of the auricle may contain serous or sanguineous fluid, in the latter case constituting the Othematoma or Heematoma Auris. Traumatism is a frequent cause in the sane, but the cyst may occur without it, and while usually of the nature of a peri- chondritis of the pinna, may, in spite of an acute onset, be wholly lacking in the ordinary symptoms of inflammation. The spontaneous form is more common in the insane, and its occurrence in others, without jiersonal or family history of mental disease, is sometimes prodromal. It is most common on the left side. Recovery of the reason has taken jilace in insane patients who have had cysts of the auricle, but it is rare, and they are generally of unfavorable prognostic meaning. They have been very care- fully studied by Virchow, and by Hun, of Albany. Brown-Sequard is quoted by Roosa as having demonstrated that section of the restiform bodies will produce othaematoma in the lower animals, generally on the same side as the lesion, and there is considerable evidence that the sjionta- neous form in man is due to a lesion at the base of the brain. The treat- ment by evacuation, pressure, and massage (Blake), is probably the best, although under any circumstances considerable deformity of the auricle may result. Hearder recommends the application of a blistering fluid to the inner surface of the pinna. The cheloid-like growth, which usually affects the lobule alone, may be treated by excision, but the disease is apt to return. Diseases or the External Meatus. In some cases it is possible to obtain a satisfactory view of the meatus by simply placing the patient in a good light and drawing the ear slightly backwards and upwards, while the tragus is pressed in the opposite direc- tion, so that the light passing by the observer's temple may fall into the ACCUMULATIONS OF CERUMEN OR EAR-WAX. 779 depths of the canal. Usually, however, the light is reflected into the ear by a concave brow mirror, and it is often necessary to employ a speculum to dilate and straighten the tortuous canal (Fig. 451), and to press aside the hairs which line its outer portion; the best for general use are Wilde's, Toynbee's (Fig. 452), and Gruber's. The speculum may be of silver or Fiq. 451.—Vertical section of the external auditory canal, membrana tym- pani, and tympanic cavity, viewed from in front.—A. Upper osseous wall of the canal. -V. Lower osseous wall of the same. B. Tegmen tympani. C. Entrance to Eustachian tube. D. Tympanic cavity. E. Membrana tym- pani. F. Head of malleus and body of incus. G. Cochlea. H. Facial nerve. I. Acoustic nerve. J. Stapes in the oval window. K. Semi- circular canals. L. Isthmus tuba:. M. Glandular orifices in the skin of the cartilaginous canal. 0. Short process of the malleus. P. Eu- stachian tube. (After Poi.itzer.) of vulcanite, the latter being the lighter and the pleasanter to use, while the metal instrument may be more conveniently and thoroughly cleansed by brief boiling. Several sizes are generally required, and the lumen may be slightly greater if oval in section, as is the canal itself. For special cases other instruments may be emjiloy-ed, such as Hassenstein's (which is provided with a tube containing a lens and a perforated mirror), or, for ojierating, the ingenious prism speculum of Dr. Blake, of Boston, who also employs small reflectors, shaped like laryngeal mirrors, which can be introduced through perforations in the membrana tympani. Any* good source of light may* be employed, artificial light being jireferable to poor daylight. Direct sunlight is usually too dazzling and too uncertain; it should be reflected by a plane mirror, since its concentration may burn. Using the brow-mirror, so that both hands are free, will often enable the observer to dispense with a speculum, but this should be used whenever the view without it is not entirely satisfactory, being introduced gently and under full illumination. Accumulations of Cerumen or Ear-Wax, mingled with short hairs and flakes of cuticle, are often met with, and furnish 14 per cent, of the work of ear-dispensaries. They are a frequent cause of deafness, often sudden in its onset, and due to occlusion of the canal. The treatment con- sists in the removal of the hardened mass by syringing, as directed for foreign bodies in the ear (page 365), aided, when necessary, by the gentle use of instruments under full illumination. Excoriated areas are often Fia. 4r)2.—Toynbee s speculum. 780 DISEASES OF THE EAR. present on the walls beneath the plug, and the drum-membrane will often give evidence of the truth of the claim that cerumen rarely becomes im- pacted in a healthy- ear. The meatus should be gently dried with absorbent cotton after syringing, and any denuded surfaces should be lightly dusted with impalpably powdered boric acid. Vegetable Parasites have been met with in the meatus, causing generally* a marked inflammatory* condition, with accumulation of dense white, or at times blackish, flakes of thickened cuticle. Pain, deafness, and a sense of fullness, are generally present, and may be extreme. Wreden, of St. Petersburg, who has contributed much to the knowledge of this affection, advises the use of parasiticide fluids, but Roosa claims that the free use of warm water is equally efficacious. Thorough cleansing is essential, and the promptness of recovery dejiends principally ujion this. Burnett recommends insufflations of the salicylate of chinoline, 1 jiart to 16 of powdered boric acid. Specula and other instruments used should be thoroughly disinfected, lest they should communicate the disease to other patients. Follicular Abscesses or Furuncles occur in the meatus, constitu- ting an extremely painful and annoying affection ; they are chiefly met with in those of debilitated constitution, and may* be multiple, or may occur in series. Lowenberg lays stress upon the parasitic character of furuncles, and claims especially good results from antiseptic measures, both in con- trolling the lesion and preventing recurrence by auto-infection. The treat- ment consists in the use of hot anodyne fomentations, irrigations with warm water, and the evacuation of pus as soon as its presence is detected, followed by the use of dilute citrine or other stimulating ointment to re- move any indurations which may be left. Weber-Liel employs, as an abortive measure, interstitial injections of a five per cent, solution of carbolic acid, and Grosch advises repeated applications of a solution of acetate of aluminium. The preparations of iron may be administered internally, if a tendency to recurrence is observed. Sexton and others highly* praise calcium sulphide, in frequent small doses, as checking promptly this and other suppurative affections; but the drug, as sold, is often inert. Diffuse Inflammation of the External Meatus is a term which may be used for all the inflammations not of a furuncular character. Many forms have been differentiated, but with doubtful advantage, as the dividing lines are generally* arbitrary. If considered and treated as various jdiases of eczema, dry or moist, acute or chronic, they can generally be satisfac- torily* managed. Exudation may be rapid enough to cause an actual dis- charge of watery or purulent matter from the ear, but the great majority of otorrhceas come from the middle ear. The presence of mucus in the flow proves that the discharge has its source, in part at least, in the tym- panum or the accessory cavities, since all mucous surfaces are shut off' by the drum-membrane, and an opening must exist through this partition, or through the adjacent wall of the meatus, to allow mucus to enter the external canal. Perforations at the upper and anterior part of the tym- panic membrane—in Shrapnell's "flaccid membrane"—are not very un- common, but they are often extremely difficult to recognize. Air will rather rarely pass through them when the tympanum is inflated; and these unrecognized perforations are the source of many enigmatical discharges. In the treatment, as in the diagnosis, thorough cleansing is essential, though often difficult and tedious ; and the insufflation of powdered boric acid in the moist cases, and the use of emollient or stimulant ointments in the dry cases, will generally secure prompt improvement. Relapses are common, and entire cure difficult; internal medication, especially in the strumous AURAL POLYPI. 781 and the gouty, being usually requisite, as well as a series of topical appli- cations as in chronic eczema. Dr. T. G. Morton, of this city, has employed with advantage in the moist cases a "styptic-cotton," prepared by soaking absorbent-cotton in a dilute solution of subsulphate of iron. Chisolm recommends insufflation of alum. Counter-irritation over the region of the mastoid process may at times be advantageously employed. The presence of a diphtheritic membrane in the external ear has been noted by Gruber, Callan, and other surgeons. Polypi frequently arise from the deeper portions of the meatus, although their most common seat is the mucous membrane of the tym- jianum. On the walls of the meatus, they may in rare instances arise from overgrowth of the papilla? of the macerated and inflamed cutis, or as granu- lations about the opening of a furuncle, especially* if poulticing has been used to excess; but their presence should always lead to a careful exjilora- tion of the wall which forms the point of origin, and in the majority of cases a sinus will be found leading into one of the adjacent cavities. Polypi arise at times from the outer surface of the tympanic membrane, or from the margin of a perforation, but in the great majority* of cases they have their origin from the tympanic mucous membrane, and protrude through a perforation in the drumhead. They are usually met with in neglected cases of chronic suppuration of the tympanum, but sometimes form behind the intact drum-membrane, distending and finally rujituring it. They generally consist of granulation tissue, but may often be included in the fibro-cellular variety of tumor (p. 515). They produce, when large, a feeling of distention, and may, if of the fibrous form, lead by pressure to considerable absorption of the meatus-walls. Ordinarily they present no sjiecial symptoms, but are apt to give rise to hemorrhage, the presence of which in an otorrhoea often points to their jiresence. They may cause serious impediment to the exit of discharge, and thus give rise to grave cerebral symptoms. The treatment should begin by removing the growths, from whatever position they spring. The removal of an aural polypus is usually best effected by the "snare" of Sir W. Wilde (Fig. 453), or Blake's Fig 453.—Wilde's snare. modification of the same, or by delicate forceps, of which a good form is exhibited in Fig. 454. Purves, of London, employs a sickle-shaped "poly- pus knife-hook." The wire employed in the snare should be very fine and annealed, or, as Hinton recommends, the instrument may be armed with the gimp employed by anglers, instead of wire. The probe should be care- fully used, after cleansing, in order to determine the location and size of the root of the polypus before any attempt is made to seize it; and when the growth has a small neck it may at times be twisted off or strangulated by simple torsion with the probe—a point of importance when an operation is objected to. Great care must be exercised not to injure the ossicles and other delicate structures to which polypi may be attached, and but little traction is permissible in their removal The"roots must be treated with 782 DISEASES OF THE EAR. caustic applications, such as chromic acid, tincture of the chloride of iron (Politzer), or burnt alum—to jirevent recurrence—astringent lotions or Fio. 434.—Forceps for aural polypus. powders being used at the same time. Politzer and MacBride recommend instillations of alcohol when removal is not permitted. Tumprs of the Meatus.—Exostoses and hyperostoses are occasion- ally met with in the walls of the meatus, and, if large, may encroach so much on the canal as to cause deafness. According to Cumberbatch, they are often of gouty origin, but most writers note that they have been gene- rally* preceded by long-continued suppuration, and incline to ascribe their occurrence to the irritation thus produced. They may be multijile, and, growing until they meet, will sometimes coalesce; yet their growth often seems to be self-limited, and, after attaining a size that almost entirely closes the canal, they may show no further tendency to enlarge. The treat- ment, in the early stage, consists in the ajiplication of tincture of iodine to the surface of the growth, and jierhaps behind the ear, and by a jiersevc- rance in this plan the increase of the tumor may sometimes be arrested. At a later period little can be done beyond the prevention of the accumu- lation of wax, cuticle, or other matter behind the growth, by frequent syringing, though they have been removed with the chisel (Politzer), for- cejis (Burnett), or snare (Cocks), and have been perforated with file (Bonnafont), or drill (Mathewson and Field). Cumberbatch has seen benefit from the application of nitric acid. Bagroff employs the gouge and galvano-cautery. If suppuration is present, operative interference may be imperative to relieve obstruction. The growth is generally of ivory hardness, but its point of origin may often be more readily attacked than the tumor itself. The occlusion may be caused only by the swelling of the soft tissues, and dilatation, cauterization, or removal of these will at times afford all necessary room. Sebaceous or molluscous tumors result from the enlargement of sebaceous follicles, and when laid open are found to consist of a cyst-wall containing layers of epidermis. If neglected, they are apt to cause absorption of the bone, and grave or even fatal cerebral complications. The treatment consists in laying ojien the cyst, evacuating its contents by sy*ringing, and then drawing out the cyst-wall with forceps. Malignant tumors of the meatus are rarely pri- mary, being commonly extensions from growths in the tympanum. Diseases op the Membrana Tympani. The membrana tympani, being covered on its outer surface by the cutaneous lining of the external meatus, and on its inner by the mucous membrane of the tympanic cavity, is usually involved in affections of these parts, and is but rarely the seat of strictly local lesions, other than trau- matic. Clinically, however, there is at times a preponderance of the local manifestations, which may make the lesions appear independent, and these are sufficiently distinct to merit notice. Inflammation of the Drum-membrane, or Myringitis, may be acute or chronic, and its causes, beside traumatism, may be " cold-taking," the entrance of cold water to the ear while bathing, etc. Pain is generally present, usually of a shooting character, with some dulness of hearing; DISEASES OF THE MEMBRANA TYMPANI. 783 but any considerable loss of function is more often due to associated disease of the deeper structures. Inspection shows in the early stages a network of injected vessels upon the dull sur- rf « J / Fig. 415.—Enlarged representation of normal membrana tympani.—a. Short process of mal- leus. 6. Posterior suspensory ligament, c. An- terior suspensory ligament, d. Shrapnell's membrane, or membrana flaccida. e. Anterior fold. g. Posterior fold. /. Descending process of incus, h. Tendon of stapedius muscle, i. Umbo and tip of malleus handle, k. Niche of round window. I. Promontory, m. Light spot or cone of light, n. Annulus tendinosus. face of the drum-head, an appearance which is apt to give place subse- quently to a more general redness, or which may be hidden by infiltration or desquamation. Vesicles, "blood- blisters," or even miliary abscesses may form, and, bursting, may give rise to ulcers; but the latter are rare. Resolution is usually prompt and comjilete in acute cases, but in chronic cases recovery is slower, and when these are neglected the excoriated or granulating surfaces which are present may give rise to considerable serous or purulent discharge, and the granu- lations may become polypi. Rup- ture of the drum-membrane may be caused by pneumatic pressure, as in explosions or by blows upon the ear, by wounds from peuetrating bodies, generally introduced to relieve itching or to remove wax, or by violence to the whole head with or without fracture of the cranial bones. Bleeding, followed by serous discharge (which although copious may not be cerebro-spinal fluid), is the most con- stant symptom; and more or less deafness and tinnitus are usual. Non- interference will usually* be followed by recovery, with healing of the torn membrane ; and the hearing will be recovered unless the labyrinth has been injured. The treatment of inflammation of the tympanic membrane, in acute cases, is by jirotection, with depletion and cleansing when called for, and the use of moist or dry* heat when the pain is not relieved by leeching. If the drum-membrane have been ruptured, the meddlesome use of syringing or of fluid applications may seriously complicate and retard the cure. In chronic myringitis expectancy avails little, and the employ- ment of astringents in powder or solution must be added to the other measures, with counter-irritation. Depletion should be effected by means of the natural or artificial leech, placed in front of the tragus, as most of the veins of the middle ear pass out along the front wall of the meatus. The Fibrous Lamina, or membrana propria, is frequently affected as a result of chronic inflammation of the tympanum, being at times thickened by infiltration or calcareous degeneration, or else stretched and atrophied almost beyond recognition. The latter condition, the " collapse" of Wilde, is usually- due to obstruction of the Eustachian tube, and, even if the cause can be overcome, is hardly remediable in extreme cases. Re- peated incisions, or the application of collodion, as suggested by McKeown, of Belfast, may lessen the laxity of the membrane, which usually causes great interference with hearing by enveloping the stapes in elastic tissue. An artificial drum-head may also improve the hearing by securing the tension of the chain of ossicles which the relaxed tympanic membrane no longer affords. Thickening is a common result of long-continued inflammation, and gives rise to opacity and to some rigidity of the membrane ; but this rigidity is wholly secondary in importance to that of the chain of ossicles not infrequently associated with it, and topical applications are of little 784 DISEASES OF THE EAR. Fia. t.->6.—Siegle's pneumatic speculum. value. Calcareous deitosits, consisting chiefly of phosphate of lime, may occur in the infiltrated tissues, and even flakes of true bone may form (Politzer) ; but they do not appear to interfere jiarticularly- with the power of hearing, and no treatment is likely to jirove of much service. The jineumatic sju'culuni of Siegle (Fig. 45(!) may be of considerable therapeutic as well as diag-- no.-tic value, since with it not only can the mobility of the tympanic membrane and of the malleus be investigated, but a sort of massage of the ossicular chain, which probably constitutes the princijial value of inflation of the tympanum hi such cases, can be very gently, yet thoroughly jiractised. The mobility of the apjiaratus may be increased, with the result of improved hearing, lessened subjective noise, and a distinct sense of relief. Pressure of the finger ujion the tragus, rapidly repeated (Hoinniel), or better still, alternate pressure and withdrawal of the linger, closing the meatus, forms a good substitute. Attention to the nares and jiharynx is generally requisite in these cases, with inflation through the Eustachian tube; but the latter measure must be used cautiously, as it sometimes increases the atrophy of a relaxed membrane. Incision of the Membrana Tympani or even excision of a jiortion or the whole of the membrane, with the malleus, is sometimes advised in the management of the various affections which have been described. Where alterations of the drum membrane or the ossicular chain offer great ob- struction to proper conduction of aerial vibrations, hearing may be greatly improved by making an ojiening in the drum-head. The chief objection to the treatment by incision is the temporary nature of the improvement, owing to the rapid healing of the wound ; to obviate this, surgeons have exercised much ingenuity, but with little avail, and the eyelet of Politzer, and such means, are now rarely* used. The simple excision of a flap in little better; the turning down of such a flap, without excision, has been suggested by McKeown. Wreden, of St. Petersburg, advises the excision of part of the malleus-handle with two-thirds of the membrane—an oj>eration which has been followed by dangerous inflammation, as has that of inclos- ing the tip of the handle in a tubular ring. Total excision, with removal of the malleus and often the incus, has been practised by Schvvartze, Sexton, and others, with moderate reaction and occasional good results, but has generally been limited in its apjilication to sujipurative cases, with caries which was otherwise inaccessible. Perforation by add (Simrock), actual cautery (Bonnafont), or the galvanic cautery (Voltolini and Purves) seem to have little advantage over incision—the reaction is apt to be much greater, and the opening very slightly more persistent. In the same con- nection may be cited Weber's tenotomy of the tensor tympani, and the division of the posterior fold (Politzer, Lucae), which may give very good results at first, with relapse as soon as the opening in the tympanic mem- brane heals. Perforation of the Membrana Tympani may result from trau- matic causes, from ulceration of this structure itself, or, more commonly, as a consequence of intra-tympanic inflammation, the mucus or pus which accumulates within the cavity* gradually making its way through the mem- brane, and being discharged" externally. The opening is usually single; PERFORATION OF THE MEMBRANA TYMPANI. 785 but in rare cases, from two to five openings, or more, may be simulta- neously present. One of these may be in the flaccid membrane. When multiple jierforations occur, tubercular ulceration is the most frequent cause. The opening can commonly be seen through the speculum, and may be of any size from that of a pin-hole to a total destruction of the membrane; and the patient can, if the Eustachian tube be pervious, blow air through the meatus by making a forcible expiration (or, as suggested by Dr. Schell, yawning) with the mouth and nostrils closed (Valsalva's experiment). The surgeon may do the same by the use of the Eustachian catheter, or by Politzer's method, which consists in blowing air through the nostril while the patient swallows—the Eustachian tube being opened during this act, and the soft palate raised so as to shut off the naso-pharynx, by the action of the palatal muscles. The surgeon may simply blow through a flexible tube, or, which is far preferable, may use an India-rubber bag provided with a well-fitting nozzle. The nozzle of Politzer's original apparatus was like a Eustachian catheter ; but one of olive-shape is now more often employed, as less likely to injure the nasal mucous membrane. Gruber has modified Politzer's method by directing the patient, instead of swallowing, to pronounce the syllable "huck" or "hck;" and the same effect may be obtained by causing him to puff out his cheeks. If swal- lowing be employed, the larynx should be watched, and the infla- tion made just as the larynx is seen to rise. In using Politzer's method, Hinton advises that the bag should be applied to the nostril of the opposite side to that of the ear which it is intended to inflate, and that the meatus of the sound ear should be firmly closed with the finger, so as to guard its membrane from the ef- fect of pressure. The passage of air through a perforation will generally give rise to a sound, which maybe shrill, if the opening be small, or bubbling, if fluid be present. The treatment of perforation of the tympanic membrane should be directed in the first place to securing the cessation of any discharge, the free opening of the Eustachian tube, and the restoration of the parts to their normal condition. Spontaneous healing will generally follow, even in long-standing cases ; if not, attempts may be made to secure closure of the opening by stimulating its margins with applications of nitrate of silver, etc., by covering it with a disk of paper (Blake), one of adhesive plaster (Tange- man), or a piece of the lining membrane of an egg shell, or by inserting an artificial drum-head. As the main value of such treatment is merely to 50 J Fiu 457.—Politzer's method of inflating panum. the tym- 786 DISEASES OF THE EAR. protect the tympanic cavity from external influences, it is well to determine that hearing will not be made worse, by closing temporarily the jierlbra- tion before going further. When there is reason to susjieet loosening of the connections of the ossicula, great benefit may sometimes bo derived from the adajitation of an artificial membrana tympani, which may consistsimjdy of a plug of cotton- wool dipped in glycerin (Vearsley), ^ an India-rubber di>k or globe, as're- commended by Toynbee (Fig. 45s), or any other body which will excr- F.o. 458-Toynbee'. artificial membrana tym- (.jse tjle ,.,.,,„jsjto amount of pressure pani. * . , ■ to restore tension, and vet not act as an irritating foreign body*. Considerable care is requisite in placing the apparatus so as to secure the best result ; and the adajitation of the a|)jili- ance in each individual case may necessitate a series of exj>eriments with its various forms. The cotton-pellet is usually the simplest and the best. Diseases of tiik Cavity of the Tympanum. Inflammation of the Mucous Membrane of the Tympanum, or Otitis Media, is not infrequently jiresent in Its milder forms in eases of common " cold in the head and sore throat," giving rise to deej>-seated jmin in the ear, with buzzing noises and slight impairment of hearing; inflation of the tympanum is painful, and inspection shows the membrana tymjiani to be more vascular than in its normal state. This affection, which constitutes the ordinary transient " earache" of children, is very apt to recur at inter- vals, giving rise ultimately to tissue changes leading to permanent deafne-> Sexton, of New York, lays much stress ujion the fact that, in some cases, disea>e of the middle ear is dependent upon affections of the teeth, in adult life as well as during dentition—a point which should be duly considered, but which should not at all lead to neglect of the aural condition. The treatment consists in the use of soothing applications (such as the warm douche, or warm solutions of atropia or morphia) with leeching if necessary, and counter-irritation over the region of the mastoid j>rocess during the attacks—followed by attention to the hygienic state of the jiatient, and to the condition of the nose and throat, during the intervals, so- as to obviate recurrence. Hinton recommends that the tympanum should be inflated with warm vapor every evening for a few days after each attack. In its severer forms inflammation of the mucous lining of the tympanum is an extremely painful affection, attended by much constitutional disturb- ance, and sometimes by delirium. The symptoms of the milder variety are all aggravated, and there is, besides, often great tenderness over the mastoid process and in front of the ear. To distinguish between the catarrhal and the purulent form is not possible at first, although the latter is apt to have severer symptoms; yet the two affections are quite distinct, and the catarrhal rarely jiasses into the suppurative form. I iisper- tion will generally show intense congestion of the tympanic membrane, and often of the adjacent walls of the meatus ; and all landmarks may he hidden by the infiltration of the tissues. Bulging of a part or the whole of the drumhead is generally present, most easily recognizable at the superior and posterior part; and the yellowish or greenish color of the exudate, which fills the tympanum, may be perceptible through the stretched and bagging membrane. The Eustachian tube is usually so far involved as to render inflation of the tympanum, if at all possible, very PERIOSTITIS OF THE MASTOID PROCESS. 787 difficult and painful; yet inflation may give great relief, either by estab- lishing drainage through the normal outlet, or by rupturing the distended tympanic membrane, and thus relieving the painful pressure. If it fails, paracentesis of the tyinjianum may be done, under full illumination, with a long-shanked needle, the ojieration giving rise to but brief pain, and being generally followed by much relief from evacuation of the secretion and depletion of the congested vessels; the most bulging portion of the membrane is generally the best position for the incision. The further treatment consists in local depletion, with the use of the hot douche, and perhaps warm anodyne instillations of atropia and morphia. It is a good rule, as to the latter, not to use more of these drugs in the ear than would constitute a full dose by* the mouth, since they may be absorbed, or may pass through a perforation and reach the fauces. Laxatives, diapho- retics, and tonics may be given internally, as indicated ; but the use of quinia is strongly condemned by Roosa and others, as increasing the congestion. The catarrhal form of otitis media is often termed the non-perforating, as in it the occurrence, and still more the persistence, of perforation is rare, any opening, whether natural or artificial, quickly* tending to close. In the purulent or perforating form an opening is unavoidable, and may persist after the discharge has ceased ; it may, on the other hand, contract or close prematurely, and give rise to retention of the secretion, calling for incision. Thorough cleansing is necessary, rejieated as frequently* as the amount of the discharge may demand, warm syringing with boric acid or other astringent solutions being jirobably the best means of securing the object. The use of imjialjiably powdered boric acid, as recommended by Bezold, of Munich, has now been very generally- adopted for the treat- ment of sujipurating cases, after the subsidence of the most painful stage ; and the "dry* treatment" of this affection (including numerous modifica- tions, rarely for the better) has established itself as the simplest and best for most cases. The accessible cavities are dried with absorbent cotton, after a scrupulous cleansing either with the cotton carrier or the syringe, and the powdered boric acid is dusted in upon the inflamed tissues until the bottom of the meatus is filled. Numerous powder-blowers are in use, but a quill or small speculum, filled by thrusting it into the powder, and blown empty by a puff of the Politzer bag, can hardly be surjiassed for effectiveness. The cleansing and insufflation must be rejieated as often as demanded by the recurrence of discharge ; when it remains dry, the powder may be left undisturbed, unless indications arise for its removal. Insoluble jiovvders, such as talc (Hinton) and iodoform (Rankin) are dangerous, and are less valuable in every respect. Neglect of these cases often gives rise to chronic suppuration; and the groundless fear of checking a chronic discharge restrains the patient, or even his attendant, from endeavoring to secure its cessation. The fallacy of such a fear requires no proof; and the rules of all insurance companies indicate most clearly that a " running ear" is not a trivial matter. Unless the bone be involved, such cases usually yield promptly to dry treatment. Periostitis of the Mastoid Process, or Inflammation of the Mastoid Cells, may accompany a similar condition of the tympanum, or may apparently- arise independently. Even in infancy a large air-cell, the antrum, communicates with the posterior part of the tympanum ; and a large part of the fully-developed mastoid is filled with a series of such cells, all continuous with the tympanic cavity, and lined with an extension of its mucous membrane, which takes the place of periosteum. Pain, tender- ness, and swelling behind the auricle are usually marked in mastoid 788 DISEASES OF THE EAR. inflammation, and redness and fluctuation may indicate either that the affection is primarily superficial, or that it has reached the surface of the bone from within. Dejiletion, heat, cold, or counter-irritation, mav at times abort a threatened attack; but the most imjiortant measure is to make a free and early* incision down to the bone in a longitudinal direc- tion, three-quarters of an inch behind the ear, and extending almost the whole length of the mastoid jirocess (Wilde's incision). Marked relief may* follow, even if no pus is evacuated; but in some cases it is necessirv to open the mastoid cells and wash out the affected cavities. In children, the thin soft bone may be broken through with any hard instrument; but in the adult, the trephine, drill, or chisel is requisite. The j>erforation is usually carried into the antrum; and as the lateral sinus may be nearly in the field of operation, the surgeon must jirocood cautiously, and keep close behind the external meatus. Carious bone may be scrajted away, and anv necrosed portions may be detached and removed ; yet, in view of the important structures which might be injured, it is more common to await the spontaneous separation of the disorganized tissues, after estab- lishing a free ojiening with drainage. Almost the entire temporal bone may be sejiarated by exfoliation. Fatal Consequences of Inflammatory Affections of the Ear. —Inflammation attacking any of the deejuT-seated structures of the ear may occasionally lead to a fatal result by implication of the brain or lateral sinus, the immediate cause of death being in the former case meningitis or cerebral abscess, and, in the latter, thrombosis of the lateral sinus, and perhajis of the jugular vein, giving rise to pyaemia, or to secondary jineti- monia, or even sloughing of the lung. Little can be done as a rule to avert the fatal i.-sue when these lesions are actually jiresent, but already quite a series of cases of cerebral abscess, secondary to otitis, have been success- fully treated by trephining and evacuation, especially by Macewen, of Glasgow. The abscess is most frequently situated in the spheno-temporal lobe, over the roof of the tympanum ; but may, especially in mastoid sup- puration, be in the cerebellum. The point of election for trephining, when an exploration is made in the absence of localizing symjitoms, is from one to one and a half inches behind, and from one to one and a half inches above, the ujiper wall of the auditory- meatus. Chronic Catarrhal Inflammation of the Tympanum, or Scle- rotic Catarrh, deserves separate consideration. It is usually a most in- sidious affection, and may be wholly unassociated with even sub-acute attacks of otitis media. Its starting-point is almost always an inflamma- tion of the nares, which extends up the Kustachian tubes; and the dis- tinct hereditary character often observed in the affection, is probably explained by the inherited configuration of the nasal chambers. Pharyn- geal involvement is generally present also, but the tendency is now to regard this as not causative, but as only another consequence of the nasal condition. The atrophic state of the mucous membrane of the nose, and the dry, glazed condition of the pharynx, have probably their counterpart in the condition of the lining of the whole middle ear; and the external auditory meatus, unless blocked by a plug of altered ear-wax, is generally destitute of secretion. Little abnormality of the drum-membrane may be visible, but it usually shows depression, and localized thickenings or calci- fication ; and bands of adhesion between the ossicula or the tympanic walls can sometimes be discerned through it. The Eustachian tube is rarely patulous in the normal state, and the inflation sounds, as heard through the auscultation tube (the otoscope of Wilde and Toynbee), may be shrill, indicating stenosis, or crackling from the presence of tenacious CHRONIC CATARRHAL INFLAMMATION OF TYMPANUM. 789 mucus. When attempts to inflate by the Valsalva and Politzer methods fail, catheterization may be required. This is effected simply by passing Fig. 459 —Application of the otoscope. (Toy.nbee.) the Eustachian catheter (Fig. 460), with its point turned downwards, along the floor of the nostril until the posterior pharyngeal wall is reached, and then drawing the instrument about half an inch forward, while its point is turned gently outward and upward, when it will usually readily Fiu. 460.—Catheter for the Eustachian tube. enter the orifice of the Eustachian tube. Pomeroy, of New York, uses a "jiharyngeal catheter," which is introduced through the mouth, as was the instrument of Guyot, the pioneer in this field. Air may be forced through the catheter with the Politzer bag, when the surgeon can recog- nize its passage by means of the auscultation tube, the air seeming to im- pinge upon his own drum-membrane. The vapor of chloroform or ether will sometimes pass when air will not, and numerous other vapors have been used, but with doubtful benefit; various fluids, too, have been forced into the tube, and bougies passed through it, to dilate it, or to convey med- icaments or apply electricity; many of those, however, who have used these measures, have abandoned them as not free from risks outweighing their probable value. The treatment of chronic catarrh of the tympanum should consist primarily in remedying as far as practicable the nasal affec- tion, in rendering the Eustachian tube patulous, and in restoring, if pos- sible, the normal ventilation of the tympanic cavity. Its success will depend largely upon the stage of the disease. If taken early, in the phase of " Eustachian catarrh," when the tubal obstruction is the main lesion, and the tympanum not seriously involved, the restoration of hearing may be prompt and gratifying. If, in the stage of sclerosis, with profound alteration of the mucous membrane, thickening of the joints of the ossicles, anchylosis of the stajies, and perhaps secondary degeneration of the inter- 790 DISEASES OF THE EAR. nal ear, no treatment may succeed even in arresting the downward pro- gress. Between these two extremes, all varieties of eases are met with. Accumulation of Mucous or Serous Exudation -within the Tympanum is, according to Hinton, a frequent cause of deafness, and when occurring in children, may give rise to convulsions, or, as in the otorrhcea of scarlet fever, etc., may prove the immediate cause of death. It is not infrequently present in sub-acute and chronic catarrh; and in some cases the curved surface-line of the fluid may be seen through the drum membrane. The patient may have the sensation of something being present in the ear and moving with the movements of the head, and change of jiosition may increase or lessen the interference with the hear- ing. The exudation may become insjiissated, and form bands and adhe- sions, as damaging to the hearing as organized new tissues; or calcareous degeneration, or jxissibly organization of these deposits, may occur. The treatment consists in the removal, if jiossible, of the exudate. If it be in a fluid condition, it may sometimes be evacuated through the Eustachian tube, by simply placing the patient in such a position that the fluid will esca|»e by gravity while the tympanic cavity is inflated by Politzer's method or through the catheter. The elastic catheter of Weber-Liel may be used to remove the exudation by aspiration, solvent alkaline fluids having been first injected, if necessary ; but the method of incising the membrana tym- pani, and, if inflation fail to remove the secretion, syringing through the opening, either through the Eustachian catheter, or, as advocated by Hin- ton, injecting first alkaline and then astringent fluids from the meatus through to the fauces, is more thorough and efficient. The entrance of fluid into the Eustachian tube or tymjianum, when in apjiroximately nor- mal condition, by- the use of the nasal douche or by nasal syringing, has frequently given rise to severe jiurulent otitis; and thjs must be borne in mind in the use of any infra-tympanic injection, though the diseased tissues seem far more tolerant of interference than the normal. As there is no doubt that convulsions in children are sometimes connected with, and probably dependent upon, the jiresenee of mucus or other exudation in the tymjianum, Hinton judiciously advises that in cases of cerebral irri- tation in the young, the ears should be examined as regularly as the gums; and mere inflation of the tympanum, or incision of the drum membrane, may* dissijmte promptly what appears to be dangerous implication of the brain or menniyos. Nervous Deafness.—The researches of modern aural surgeons have shown that most of the cases formerly classified under this head arc really instances of some of the affections of the conducting media, which hav« already been described. Thus the deafness in cases of anchylosis of th« stapes and other lesions of sclerotic catarrh, may be almost total, and only by careful tests can the unaffected condition of the internal ear be demon- strated. The diagnosis between deafness from tympanic lesions and nervous deafness may commonly be made by the use of the tuning-fork, the following rules for the employ*ment of which are given by Hinton:— 1. In a normal state a tuning-fork is heard before the meatus after it has ceased to be heard on the vertex. 2. When placed on the vertex, it is heard more plainly when the external meatus i« closed. 3. Consequently, when one meatus alone is closed, the tuning-fork is heard n>'*t plainly in the closed ear. Hence, 4. In cases of one sided deafness, if the tuning-fork, when placed on the vertex, i* heard most plainly in the deaf, or more deaf, ear, the cause is seated in thf conducting apparatus; if it is heard loudest iu the better ear, the cause u probably in some part of the nervous apparatus. PARALYSIS OF THE TYMPANIC MUSCLES. 791 '). If on closing the meatus, the tuning-fork is heard decidedly louder, there is no considerable impediment to the passage of sound through the tympanum. 6. If the tuning-fork is heard longer on the vertex than when placed close before the meatus, the cause of the deafness is in the conducting media. 7. However imperfectly the tuning-fork may be heard when placed on the vertex, it gives reason for suspecting only, and is not proof of, a nerve affection. The first rule isthe basis of "Rinne's test," which measures the relation of aerial to bone conduction, and expresses the normally greater duration of the former as +, the less duration as —, the number of seconds that the tuning- fork is heard in the better place after it has ceased to sound in the other. It is thus found that in some cases of middle-ear deafness, bone-conduction is actually, as well as relatively*, better than in the normal ear. Rules 3 and 4 constitute " Weber's test" as to the lateralization of the sound, which should normally seem to be on neither side, but above. Roosa simplifies the test greatly by studying merely whether the sounding tuning-fork is heard louder in front of the meatus, or when resting on the mastoid. In a deaf ear louder bone-conduction means tympanic lesion ; louder air-con- duction means nerve lesion. Gelid claims that rarefaction or condensation of the air in one auditory meatus reduces the hearing of the other ear for a.tuning-fork sounding before it, if the stapes be movable; but has no effect when the stapes is anchylosed. Electrical stimulation will probably afford us a means of testing the healthy* condition of the acoustic nerve ; but the question of a "normal formula" (Brenner) is still in dispute, and no gen- erally accepted conclusion on the subject has yet been reached. True " nervous deafness" is rare, jirobably not furnishing more than 5 per cent, of the cases met with in jiractice; and in but a part of these will it be found indejiendent of other lesions. It may result from concussion or apoplexy of the auditory nerve, from effusion of blood or serum into the labyrinth, from cerebral affections, from syphilis, etc., while it may also occur as a reflex phenomenon, dependent upon disease of the fifth nerve, or upon the irritation produced by intestinal parasites—or even a's a func- tional affection, the result of anaemia and general nervous exhaustion. The deafness may be only for certain parts of the musical scale, usually the higher tones, but may on the other hand be absolute Total deafness is not possible except when the nervous apparatus is seriously involved, no lesion of the conducting apparatus being sufficient to cause it; but in the aged, bone-conduction is greatly lessened, and a tympanic lesion may leave very* little hearing. Labyrinthine involvement may result from dis- ease of the middle ear. Tinnitus and vertigo are generally associated with the deafness, when the labyrinth is involved, and may be extreme— the sudden onset of such a group of symptoms (Meniere's disease) being generally due to extravasation into the semicircular canals. Treatment cannot be expected to accomplish much in case of organic lesion of the brain or auditory* nerve, but when the deafness is dependent upon syphilis, or is a reflex or functional condition, the iodide of potassium, mercury, anthelmintics, or such other remedies should be given, as may* seem to be indicated in each case. Politzer has obtained good results from the hypo- dermic use of a two-per-cent. solution of pilocarpine (mjv-x), and Hagen, of Leipsic, from strychnine; and in cases of Meniere's disease large doses of quinine have been advantageously resorted to by Charcot. Except jierhaps in syphilis, recent lesions only prove as a rule amenable to treat- ment. Galvanism may be tried, but its usefulness is rarely very great. Paralysis of the Tympanic Muscles may occur, but the recogni- tion of the particular muscle involved is difficult, since their function in health is not certain. The stapedius is implicated in paralysis of the 792 DISEASES OF THE FACE AND NECK. facial nerve, such as not infrequently takes place, esjieciallv in otitis media with caries ; and the tensor tympani is generally jiaralysed with the palatal muscles. Roosa calls senile loss of hearing presbycusis, and con- siders it a loss of accommodation. If so, it may be due to a j>aretic con- dition of the muscles. Neuralgia of the Ear (Otalgia) is rare in the absence of inflamma- tory conditions, pain being often referred to the ear from carious teeth, ulcerated tonsils, or lesions at the mouth of the Kustachian tube. Tinnitus Aurium, or subjective noise in the ear, sometimes exists as an isolated symptom, and cannot be referred to any discoverable disease. It is usually of a hissing, ticking, or chirjiing character, though at times becoming a roar which the patient can hardly believe to be inaudible to others. It commonly originates in the- blood circulation in the neighbor- hood of the ear, as pointed out by Theobald, of Baltimore ; but may be due to increased pressure in the labyrinth, as is usually* the case when tinnitus occurs in tympanic affections. Eree inflation of the tymjianic cavity with air or stimulating vajiors, the use of the pneumatic sjieculum, electricity (esjiecially the constant current), and internal medication, will each succeed in some cases ; but a subjective noise, once heard, is rarely so comjiletely lost again, that it cannot be heard when listened for in a still jilace. C. H. Burnett advises, in extreme cases, perforation of the membrana tympani; Key-burn has obtained a cure by ligation of the occipital artery on the affected side; and Seiss has had admirable results from freezing the mas- toid with a sjiravofrhigolene. Michael and S. M. Burnett recommend inhala- tions of nitrite of amyl, and Woakes commends the internal use of hydro- bromic acid ; nitroglycerine has also been used with success. The large number of the remedies proposed indicates their very limited efficiency, and some cases seem wholly rebellious to treatment. CHAPTER XXXVII. DISEASES OF THE FACE AND NECK. Diseases of the Nose. Lipoma (Acne Rosacea sive Hypertrophica.) is a hyjiertrophied con- dition of the cutaneous and subjacent cellular tissues of the nose, forming a red or purple, soft, lobulated mass, and causing great deformity. Ana- tomically the disease should be classed as a fibro-cellular outgrowth. The sebaceous follicles of the nose often appear to be the parts principally in- volved. The treatment consists in excision, the only jioint in the operation requiring any particular attention being not to lay* open the nostril; the occurrence of this accident may be avoided by causing an assistant to dis- tend the part with a forefinger, that he may warn the surgeon if the knife enetrate too deeply. There is usually a good deal of hemorrhage which may be checked by* the application of cold. Healing takes jdace by granu- lation and cicatrization. To avoid bleeding, Oilier recommends the em- ployment of the galvanic cautery. Imperforate Nostril___This is occasionally, though rarely, met with as a congenital deformity; if the obstruction be not too deejdy seated, it may- be removed by incision and subsequent dilatation with bougie-. Epistaxis, Hemorrhage from the Nostrils, is in many ca-cs. jiarticu- larly when occurring in young persons, an effort of nature to relieve internal EPISTAXIS. 793 Fio. 461.—Lipoma. (Liston.) congestion, and may be looked upon under such circumstances as rather salutary than otherwise. It is, however, even when not injurious, often annoy- ing and inconvenient, and an attempt should therefore be made to prevent its oc- currence, in persons liable to it, by administering laxa- tives to relieve visceral con- gestion, by attention to the menstrual function, etc. In most cases no further local treatment will be re- quired than the application of cold to the nucha and forehead, or compression of the facial artery (as advised by Marin) over the superior maxillary bone, but in some instances if the flow of blood be profuse and exhausting, more active measures must be adopted. The jiatient should, under these circumstances, be kept quiet in bed, with the head and shoulders slightly elevated; the cold applications should be continued, and opium and gallic acid, ergot, or the acetate of lead, may be administered internally. An efficient local remedy is the muriated tinc- ture of iron, which may be applied to the mucous surface of the nostril by means of a camel's-hair brush. An ingenious nostril-clamp has been de- vised by Dr. Caro, of New York, for treating hemorrhage from the ante- rior nares by compression. As a last resort, it may be necessary to plug the nostrils; the anterior nares may be readily plugged with a piece of compressed sponge, or with a pledget of lint, introduced with slender forceps, and having a ligature attached to facilitate withdrawal; if the blood continues to flow backwards into the pharynx, the posterior nares must also be plugged__this being most conveniently accomplished by the use of Bellocq's sound, though, in the absence of this instrument, a double canula, or even a flexible catheter, may be used instead. The sound, previously armed with a strong ligature^ is passed along the floor of the nostrils till it reaches the pharynx, when' the sj)ring being protruded, the ligature may easily be brought out of the mouth and furnished with a plug of the required size. Bv withdrawing the instrument, the plug is now brought into position, the end of the liga- ture being allowed to hang out of the mouth to facilitate removal. Instead of merely plugging the posterior nares, it is often better to apply pressure to the whole floor of the nostril from behind forwards; this may readily be done by attaching to the ligature a series of moderate-sized plugs, which, as the instrument is withdrawn, are successively brought into position, or by using instruments1 described by Kuchenmeister and Closset under the name of rhineurynters, which consist of bags or sacs, to be inflated after introduction, like the colpeurynter of the accoucheur. The operation of 1 Similar contrivances have been suggested by Dr. Taaffe, Mr. Godrich, and Dr. %>nistrom, of Upsala. 794 DISEASES OF THE FACE AND NECK. plugging the jiosterior nares ajijioars to be not entirely free from risk, Crequv and Gelle having recorded cases in which it was followed by sup. puration of the middle ear. In a case of Verneuil's, in which ejiistaxis Fia. 462.—Plugging the nostrils with Bellocq's sound. (Feruusson ) appeared to be due to cirrhosis of the liver, all other means failing, a cure was effected by the apjilication of a blister to the hejiatic region. Chronic inflammation -with Thickening of the Schneid- erian Membrane is not infrequent, especially among strumous children, though by no means confined to them. I have observed it in an adult, an the result of the mechanical congestion produced by constant vomiting during pregnancy. The portion of mucous membrane which lines the turbinated bones is that which is chiefly affected, ajipearing as a projecting ridge, or mass, of a red color and velvety ajipearance, sometimes covered with muco-purulent secretion. Respiration is obstructed, jiarticularly in wet \yeather, the tone of the voice being altered, and a constant dis|>osition to snuffling induced. The treatment consists in the a|i|ilieation of astrin- gents, frequent syringing with cold water, and (in a strumous jiatient) the administration of cod-liver oil, iodide of iron, etc. No operative treat- ment, except perhaps scarification, is admissible. Change of air is often beneficial. Rhinorrhoea or Ozaena (the latter term referring to the fetid nature of the discharge) signifies a flow of muco-purulent matter from the nostril.-', one or both of which may be affected. This condition is a symptom rather than a disease, and may be due to a simple catarrhal affection, to the presence of a foreign body, to scrofulous inflammation of the various nasal tissues, or to constitutional syphilis. In children it sometimes ajipears to be a reflex condition, dependent upon the irritation of teething. Scrofu- lous and syphilitic ozaena are often accompanied by ulceration, which may lead to caries or necrosis of the nasal bones, producing eventually great deformity. In the treatment of ozaena, such constitutional means must be adopted as are indicated by the general condition of the patient; before resorting to local treatment, it may be necessary to explore the nasal cavity, the anterior portion of which may be readily inspected by means of a small RHIN0RRH03A OR OZtENA. 795 bivalve speculum,1 or the ingenious spring speculum devised by Wimmer, but the deeper portions of which can only be examined bv the cautious introduction of a female catheter, Bellocq's sound, or Zaufal's sjieculum, or by a resort to Rhinoscopy. This mode of inspection requires the use of a small mirror which can be introduced into the pharynx, and of a reflector, if artificial light is to be employed. The ordinary mirror employed in laryngoscopy will commonly answer every purpose, or two mirrors, as advised by Voltolini, or the ingenious instrument devised by Dr. Simrock, of New York, may be used instead ; this ajiparatus is pro- vided with a movable spatula by which the soft palate may be raised, so as not to obstruct the surgeon's view. Dr. White, of Richmond, Va., em- ploys a palate-hook furnished with an attachment which is fixed over the upper lip, so as to hold the retractor in position. The most important point in the local treatment of ozaena is to secure cleanliness, by the use of a so- lution of the permanganate of potassium, or other disinfectant lotion, which may be applied with a large syringe, or by means of Weber's or Thudi- churn's douche. This consists of a reservoir containing the disinfectant, which is placed a little above the level of the patient's head, and is provided with a flexible tube which is introduced into the nostril. If the patient be now directed to breathe through the mouth, the soft palate closes the com- munication between the nose and pharynx, and a continuous stream is made to flow by atmospheric pressure into one nostril and out by the other. The force of the stream can be regulated by varying the elevation of the reservoir. If one nostril only be affected, the stream should pass from the healthy to the diseased side; while if both be affected, the direction of the stream may be alternated from one to the other. A posterior nasal syringe with long curved nozzle (Fig. 463), introduced by the mouth and Fig 463.—Posterior nasal syringe. made to inject fluids through the posterior nares, is preferred by many surgeons, and is probably a safer instrument, numerous cases having been reported by Roosa and others in which suppuration of the middle ear has followed the use of 'the ordinary douche, probably from entrance of the injected fluid through the Eustachian tube; a similar nozzle may be used with the ordinary douche, as recommended by Dr. George Thompson, of New York. Any ulcers that are detected should be touched with nitrate of silver, and to prevent the formation of scabs, dilute citrine ointment may be applied at night by means of a camel's-hair brush. Letzel recommends the use of iodoform as a snuff, in the proportion of one part to five of pow- dered acacia, while H. Allen employs iodoform with carbolic and tannic acids, held in suspension in gelatine. R. W. Seiss speaks favorably of thymol. The hypertrophied condition of the mucous membrane covering the turbinated bones may be treated by cauterization with nitrate of silver or chromic acid, as recommended by A. H. Smith, of New York, or, as preferred by Bosworth, with glacial acetic acid or the galvanic cautery. The same surgeon, with Dr. Jarvis and Dr. F. L. Knight, advises, in some eases, removal of the protruding part with a wire ecraseur. Bucklin em- ploys a small saw. Medicated nasal bougies, made with gelatine, have been Dr. H. Allen recommends a vulcanite speculu n with an elliptical opening. 796 DISEASES OF THE FACE AND NECK. recently employed in Germany*. If necrosis occur, the sequestra should be removed as soon as they have become loose, access to the part being facili- tated, if necessary*, by llouge's method of turning up the nose ami liji by an incision through the mouth. Adenoid Vegetations__This name is given by Meyer, of Cojicn- hagen, to certain growths met with in the naso-jiharyngeal cavity, which appear to be identical in structure with the closed follicles of the mucous membrane from which they arise. The most prominent symptom is an interference with speech, the jiatient being unable to pronounce the nasal consonants m and n, and the voice being deficient in resonance ; breathing through the nose is prevented, and the mouth is consequently kejit ojmii ; there is, moreover, a feeling of obstruction at the back of the throat, with a copious flow of mucus, and sometimes slight hemorrhage; the patient frequently* is deaf, and often suffers from otorrheea or annoying tinnitus. The growths themselves have a velvety appearance, and a deep red or sometimes yellowish hue. The diagnosis may be made by the aid of rhinoscojiv, or by digital examination. The treatment consists in cauteri- zation with nitrate of silver, or, as preferred by Lincoln and Roe, with the galvanic cautery, or in excision ; this may be done with a knife, composed of a ring-shaped blade with a slender shaft, with a sharp spoon, or, which Lbwenberg and Curtis prefer, with cutting forcejis; and the operation should be followed by injections of saline or alkaline solutions. Polypi___The term polypus has been applied to a variety* of nasal tumors, which have in common merely their locality and their peduncu- lated character. 1. The ordinary Soft, Mucous, or Gelatinous Nasal Polypus belongs to the fibro-cellular variety of tumor (myxoma), and may sjiring from any part of the nasal cavity* except the septum, though its more usual point of origin is one of the turbinated bones; occasionally polypi project into the nose from the frontal sinus or antrum. These growths are usually mul- tiple, of a soft, semi-gelatinous consistence, and of a grayish-yellow color while in the nasal cavity, becoming shrivelled and brown when they pro- trude externally. They produce a feeling of distention, and by obstructing the nostril, impede respiration, alter the tone of the voice, and give rise to a disagreeable habit of snuffling; all the symptoms are aggravated in damp weather. As the polyjii grow, they press upon and displace the neighbor- ing bones, producing great deformity, obstructing the nasal duct, and thus causing a stillicidium of tears, and eventually leading to caries of the turbinated bones. They sometimes protrude into the pharynx, where they may be seen, or at least felt by* the finger introduced behind the soft palate. Treatment.—Nasal polypi have occasionally been successfully treated by the use of astringent injections,1 but in the large majority of eases it is better to resort at once to an operation, which may consist in avulsion, in strangulation with the ligature, or in the use of the galvanic cautery; before attempting removal by any of these methods, the position of the pedicle of the tumor must be ascertained by exploration with a probe. (1) Avulsion is effected with delicate but strong forcejis made for the purpose, with serrated blades and a longitudinal groove so as to afford a firm grasp. The patient being seated with the head thrown backwards, one blade of the forceps is introduced on either side of the neck of the 1 Caro recommends interstitial injections of acetic acid, and Duplay and Bartheleiny advise those of chloride of zinc, while Reginald Harrison practises puncture with a nn.tdleor fine trocar and canula, followed by the local use of carbolic acid and glycerine: B. W. Richardson employs the ethylate of sodium, applied on a pellet of cotton, and Miller, of Edinburgh, uses a spray of alcohol. NASAL POLYPI. 797 tumor, and the latter is then torn away by a combined process of twisting and pulling. The hemorrhage, though free, is seldom troublesome. Several polypi usually require removal, and the process has generally to be repeated at intervals. Insufflation of powdered alum has been recommended, with a view of preventing a recurrence of the disease. Mackenzie removes the polypus with " punch forceps" and cauterizes the base with the galvano- cautery. In some cases he removes also the portion of turbinated bone from which the polypus springs, and Banks, of Liverpool, recommends that this should be done in all cases. When the posterior naris is the seat of the polypus, this may sometimes be conveniently removed by thrusting it backwards with one finger intro- duced into the nostril (the patient being etherized), and seizing it with a finger of the other hand introduced behind the soft palate. (2) Ligation is particularly adapted to large polypi with a broad base, or to such as project into the pharynx; the ligature, or, which Fergusson prefers, a loop of silver wire, is passed along the floor of the nostril by means of a double canula (Fig. 464), and slipped around the tumor by the Fig. 464.—Gooch's double canula. aid of the finger introduced behind the soft palate. The loop being then tightened, the mass may be left to slough, or may* be cut through, as by an 'ecraseur. Sometimes the polypus may be thus withdrawn through the nostril, but it will commonly* fall backwards into the throat—when it should be instantly removed with forceps, lest by falling on the glottis it should cause suffocation. (3) Perhaps the neatest, as well as the most expeditious, way of removing nasal polypi, however, is by means of the platinum wire-loop ecraseur and galvanic cautery. The loop being adjusted around the base of the growth, is heated by connecting the instrument with the poles of the bat- tery, when the mass is severed with a slight hissing noise; the operation is both painless and bloodless. In some rare cases, in which the growth is very large, it is necessary in order to expose the polypus sufficiently for the ajijilication of any means of removal, to lay open the cavity of the nose by an incision along the junction of the ala with the cheek. 2. The Hard or Firm Polypi of the nose belong to the class of fibrous tumors; they usually sjiring from the superior turbinated bone, or posterior part of the septum, project into the pharynx, and occasionally find their way into the antrum, through the ptery*go-maxillary fissure, or even into the orbit. On the other hand, fibrous or fibro-nucleated tumors, originating in the antrum, or from the periosteum at the base of the skull (Naso- pharyngeal Polypi), may project into the nostril and be mistaken for intra- nasal tumors. Hence it may be, in some cases, an extremely difficult matter to decide, whether a particular growth should be called a tumor of the antrum, a nasal, or a naso-pharyngeal, polypus. The fibrous polypus is usually single, very vascular, and is apt by displacing the walls of the nose to produce the deformity known as frog-face. The symptoms are pretty much those of the soft polypus, but the fibrous growth may be distinguished by its consistence, by its color (a deep modena red), by its tendency to bleed, and by its not possessing hygrometric properties. 798 DISEASES OF THE FACE AND NECK. The treatment consists in avulsion or ligation, if the tumor be so small as to render these operations applicable, or in excision. In order to expose the growth sufficiently to render its comjilete removal jio»ib|<>, the surgeon may lay ojien the cavity of the nose, removing with cutting-pliers the nasal bone and the ascending jirocess of the superior maxillary; may turn down the nose over the mouth by means of a f|-sliiiped incision, as recommended by Oilier, the bridge of the nose being sawn through in the line of the external cut; may turn the nose to one side by cutting through its bony attachments with saw and chisel, as practised by Von Brims and MacConnac, and by myself in the case from which Fig. 465 is taken; may cut through the hard and soft palate, as advised by Nelaton; or, finally, may resort to pre- liminary excision of the upjier jaw. Either of the last-named operations may be employed in cases of true naso-pharyngeal polypus, the latter, which appears to have been first practised by Flaubert, in 1840, being probably the best procedure. The operation is certainly justifiable, in view of the hopeless nature of the affection which it is designed to remedy (these cases, according to Nelaton, always proving fatal, either by hemorrhage, or by the obstruction to breathing and swallowing), but should not be too lightly undertaken, as it may prove immediately fatal by shock and profuse bleeding,1 or may cause death at a later period by pyaemia or consecutive inflammation of the brain. It should be added that Gosselin advises delay and a resort to partial removal in cases of naso-pharyngeal polypus in young persons, believing that the disease manifests a tendency to self-limitation on the aji|iroach of adult life. The galvanic cautery has been successfully employed by A Ibertini. J. D. Bryant ligates both external carotid arteries, and finds that the consequent shrinkage and retrocession of the growth afford a practical cure. Duplay and Rochard advise injections of chloride of zinc, and Anger those of perchloride of iron; Koonig lays open the nostril of the affected side and removes the growth with the sharp spoon or curette; Verneuil divides the soft palate, removes the projecting part of the growth with the icraseur, and makes repeated applications of chromic acid to the remainder; Annandale raises the upper lip and nose, as in Bouge's ope- ration, divides the bony septum of the nose, the alveolus and hard palate, and, if necessary, the soft palate, forcibly separates the jaws, and removes the growth with forceps, curette, ecraseur, or galvanic cautery. Osteoplastic Resection of the Upper Jaw.—This is the name given to an eration which appears to have been suggested by Iiuguier in lx.riand Fig. 465.—Fibrous polypus of nose, producing frog face (From a patient in the University Hospital.) operati i Weir has recorded a case treated by Ndlaton's method, which proved fatal almost immediately after the operation, and Shrady and myself have had equally unfortu- nate cases after preliminary excision of the upper jaw. DISEASES OF THE NASAL SEPTUM. 799 1854, which was first practised about seven years afterwards simultaneously by himself and by Langenbeck, and by which it is proposed to remove tumors lying behind the upper maxilla, without the extirpation of that bone. The necessary incisions being made, the saw is applied in such a way as to sever the connections of the jaw except at its nasal side (Lan- genbeck), where it is left attached; it is then forcibly turned inwards, to be replaced after removal of the growth from behind it. Cheever, of Bos- ton, reviving Huguier's method, leaves the jaw attached by its palatal instead of its nasal connections, and has thus operated twice successfully on the same individual. In another case, the same surgeon displaced simultaneously both upper maxillary bones downwards, to facilitate the removal of a naso-pharyngeal polypus occupying a median position, but the patient never fairly reacted from the operation, and died on the fifth day. A similar operation, in the hands of Tiffany, of Maryland, however, proved entirely* successful. Cooper Forster has further modified this ope- ration by displacing the jaw in an outward direction. Burow has success- fully operated by Langenbeck's method, but, on the other hand, fatal cases have occurred in the bands of several surgeons, including Esmarch, Hill, and Verneuil. In a case recorded by Prof. Agnew, the displaced jaw became spontaneously separated nine days after the operation, and was removed through the mouth as a sequestrum. Malignant Tumors of the nostrils usually belong to the Sarcomatous or Epitheliomatous varieties. They may be recognized by their rapid growth ; by their involving the neighboring bones, forming an elastic swelling; by their tendency to ulcerate and bleed; by the pain which attends their progress, and by the early implication of the neighboring lymphatic glands. In most cases, palliative treatment only is justifiable— complete extirpation being rarely practicable, while a partial removal could but aggravate the disease. If, however, the nature of the tumor be recog- nized at a very early period, and it appear that the growth actually origi- nates in the nose, and does not (as sometimes happens) spring from the sphenoid or ethmoid cells, or even from within the skull, excision may perhaps be attempted by the following method. An incision carried from the inner angle of the eye downwards, alongside of the nose, lays open the nostril, while another incision across the cheek forms a flap which is to be dissected up. The superior maxilla is divided above its alveolar border, with saw and cutting pliers, a second section passing from the outer ex- tremity of the first into the orbit; the nasal process and nasal bone are then similarly severed, when a considerable part of the upper maxillary may be removed ; the tumor is then to be extirpated, bleeding being checked by the use of the actual cautery, and by stuffing the cavity with lint soaked in Monsel's solution, or in the muriated tincture of iron. In cases not admitting of any attempt at excision, tracheotomy may sometimes be required to avert death from suffocation. Rhinolites, or Nasal Calculi, are sometimes met with in the cavity of the nostril, when they may be extracted with forceps, etc., as other foreign bodies; or they may be found beneath the mucous membrane, when thev must be removed by careful dissection. They consist of phosphates, and carbonates of lime and magnesium, with inspissated mucus, and are usually formed around a nucleus of some extraneous substance. Diseases of the Septum—The septum nasi may be the seat of hematoma or thrombus (the result of injury), of abscess, or of cvstic or cartilaginous growths. The treatment of thrombus in this situation con- sists in the adoption of measures to promote absorption, while on the other hand, an early- incision is indicated in cases of abscess. Cystic tumors may 800 DISEASES OF THE FACE AND NECK. be treated by cutting away a portion of the wall and applying nitrate of silver, while the cartilaginous growths require excision by the use of the knife and gouge. If perforation of the septum occur, in any of these affec- tions, a plastic operation may be required to relieve the consequent defor- mity. Casabianca mentions two cases of chronic thickening of the nasal septum which had been mistaken for epithelioma. Schrotter and Lefferts have observed cases of double septum occurring as a congenital deformity. Displacements of the septum, resulting from injury, have already been referred to on page 252. Rhinoplasty. The whole, or a portion merely, of the nose may be destroyed by injury, by ulceration with or without caries or necrosis, or by the ravages of lupus or of constitutional syphilis. Under these circumstances various rhino- plastic operations may be employed to relieve the deformity, it being, how- ever, an invariable rule, that no operation is to be performed until the destructive process has been completely and permanently arrested. Operation for Partial Restoration of Nose.—If the columna and jiart of the septum only be destroyed, a new columna should be fashioned from the upper lip, by making incisions on either side of the median line, so as to detach a strip of tissue about four lines wide and embracing the entire thickness of the lip ; this strip, with its end suitably pared, is then turned upwards, and attached by means of the twisted suture to the lower surface of the nasal tip, which is previously freshened for the pur- pose. The wound of the lip is united with harelip pins, a few narrow strips of adhesive plaster serving to support the new columna in its jilace until firm union has occurred. The size of the newly formed nostrils must be maintained by the occasional introduction of gutta-percha or silver tubes. If one ala of the nose only be deficient, the surgeon may, if the loss of tissue be but slight, take a flap from the upper part of the nose itself, and, freshening the edges of the border of the gap, attach the transplanted por- tion by a few points of suture. Under other circumstances the flap may be taken from the cheek (as I did successfully in the case of a woman whose husband, moved by jealousy, bit a piece from her nose), or, if the loss of substance be very considerable, from the forehead ; in the latter case, the pedicle of the flap must be twisted upon itself, and, to prevent its sloughing, a groove may be cut for its reception on the dorsum of the nose. When union of the transplanted flap is complete, the pedicle may be raised and cut away, the groove being then closed with sutures. Fsmarch has suc- ceeded by transplanting skin-flaps from distant parts without leaving any pedicle, as in Wolfe's operation for ectropion. ' A nose which is too short may be lengthened by Weir's method, which consists in cutting the organ across transversely, depressing the tip to the required extent, and filling up the gap with flaps taken from the cheeks, Kbnig employes an inverted, periosteal, median flap, and superimposed, cutaneous, lateral flaps, all taken from the forehead. Fistulous Openings through the nasal bones occasionally result from necrosis following scarlet fever, etc. Under such circumstances, a flap may be raised from the cheek or forehead, and attached by sutures to the freshened edges of the gap. . Operations for Restoration of the Entire Nose.—The whole nose may be restored by several methods, those best known being desig- nated respectively as the Taliacotian and the Indian operation. RHINOPLASTY. 801 1. The Taliacotian Operation (so called from Taliacotius, a dis- tinguished.Italian surgeon of the sixteenth century), consists in fashioning a nose from the fleshy tissues of the arm.1 A flap of sufficient size of skin and areolar tissue is first marked out, and partially detached, being left in this condition for a fortnight to become vascular and thickened by- the pro- cess of granulation; the remains of the original nose are then pared, and the flap reduced to a proper shape and attached in its new position by numerous points of suture, the arm being approximated to the head, and fixed by a complicated system of bandages. After about ten days, when union may be supposed to be complete, the attachment of the flap to the arm is severed, and any trimming of the new organ which may be necessary is effected. A columna is subsequently made from the upper lip. This process is so tedious and unsatisfactory that it is seldom resorted to at the present day, though it has been successfully emjiloyed by MacCormac and Stokes. It has been modified by Warren and others, by taking the flap from the forearm, and by* shortening the time during which the head and arm are fastened together. In order to supply a bony support for the new nose, Dr. Hardie, an English surgeon, transplanted the ungual phalanx of a finger, keeping his patient's arm fastened up to her face for three months, and a similar procedure is said to have been employed by Dr. Sabine, of Now York. 2. The Indian Method, which was introduced into England by Carpue, in 1816, is that which is now generally* preferred. In this pro- cedure, a flap is taken from the forehead to form the greater part of the nose, the columna being subsequently made from the upper lip, though in some cases it is possible to derive the columna from the forehead also. The operation, as usually performed, may be divided into three stages. (1) The first stage consists in the formation and attachmentofthe/rojitoZ flap. A piece of thin gutta-percha should be first modelled to the size and shape of the organ which it is desired to reconstruct, and then should be flat- tened out and laid upon the forehead, so as to form a guide for the incisions, as shown in Fig 466. As the flap— which may be taken from the middle or from either side of the forehead— is sure to shrink after its formation, a margin of a quarter of an inch should be allowed on all sides of the pattern, and it is convenient to mark out the lines in which it is designed to cut, with the tincture of iodine. If the patient have a very high forehead, the central portion of the flap may be pro- longed, so as to form a columna, but under ordinary circumstances, it is better to leave this part of the operation until a subsequent occasion. In raising the frontal flap, the surgeon should 1 It is scarcely necessary to say that the well-known Hudibrastic legend which represents Taliacotius as making noses for his patients from the gluteal regions of other persons, is &fa.cetia merely, without any foundation in fact. 51 Fig. 466.—Rhinoplasty by Iudian method. (Feroosson.) 802 DISEASES OF THE FACE AND NECK. Fio. 467.—Tongue and groove suture. cut fairly down to the periosteum, beginning at the root, which should be made long, so that its circulation may not be interfered with when it is twisted. The flap should embrace all the soft tissues of the forehead down to the periosteum; and indeed, it has been suggested that even this tissue should be included, in hojie that osseous matter would be developed in the structure of the new nose.1 It does uot apjiear, however, that such a result would be attended by any particular benefit, while the removal of the periosteum from the frontal bone exjioses that part to the risk of necrosis. The flap, having been raised, is laid back upon a piece of wet lint, while the stump of the nose is pared and made ready for its recejition. The integument should be dissected up in such a way as to form a groove for the reception of the frontal flap, the edges of which should themselves be shaved, so as to furnish two raw surfaces. All hemorrhage having been checked (if possible, without the use of ligatures), the flap is to be twisted upon its root and adjusted, being held in jilace by means of the interrupted suture, or, which is better, the " tongue and groove suture" emjiloyed by the late Prof. J. J'ancoast, of this city, the mechanism of which can be readily understood from the annexed dia- gram (Fig. 4(57.) The flaj> should be suji- ported by gently introducing beneath it a plug of carbolized gauze, or, if the columna have been made at the same time, two small plugs, one corresponding to each nostril. The extent of raw surface left ujion the fore- head may be diminished by the use of harelip pins. The patient is then put to bed in a warm room, with light dressing over the part to preserve its temperature. The dressing should not he disturbed for several days, when it will usually be necessary to renew the plug, the sutures being allowed to remain until union has occurred. (2) The second stage of the operation consists in the formation of a columna, if this has not already been done in the previous part of the proceeding. The columna may be formed from the upper lip in the way directed at jm C D, when, by slitting the cheek trans- versely in the line B K, enough tissue was brought forward, as in Serres's ojieration, to close the gap in the lip, a new jirolabium above and below being formed by stitching together the skin and mucous membrane. The result is shown in Fig. 480. Fig. 470.—Diagram of operation for resto- Fig. 480.—Result of operation for restoration of the ration of the upper lip and angle of the upper lip and angle of the mouth. (From a patient mouth. in the Episcopal Hospital.) Ingenious operations for the restoration of large portions of the upper lip have been performed by* Sedillot, Gurdon Buck, and other surgeons. Figs. 481, 482.—Restoration of upper lip. (S£i>im.ot.) The annexed cuts show the general plan and result of such an operation (Figs. 481, 482). Harelip—This term is used to signify a congenital deformity, con- sisting of one or more fissures in the upper lip, resulting from an arrest of development. The fissure in harelip does not occujiv the median line, aa in the lip of the animal which has given the disease its name, but cor- HARELIP. 809 responds to the line of junction between the intermaxillary and superior maxillary bones, this line of junction being itself often deficient. When one side only- is involved, the harelip is said to be single; in double harelip the intermaxillary portion is often displaced forwards, and may even be attached to the base of the nose, giving a peculiar, snout-like appearance. In these cases one or both fissures may extend into the nostril, and the affection is not unfrequently uncomjilicated with cleft palate. Age for Operation.—As the deformity of harelip can only be remedied bv operative interference,1 the age at which this should be attempted becomes an important matter for consideration. Some surgeons have de- precated early operations, and have even advised that all treatment should be jiostponed until adult life; while others, going to the opposite extreme, have ojierated within a few hours of birth. Although it is impossible to give any positive rule upon this subject, it may be said, in general terms, that from six weeks to three months after birth is, in most instances, the period during which this operation should be by preference performed. If, however, the deformity* interfere with the nutrition of the child, by pre- venting suckling, or by allowing regurgitation of food, the surgeon should not hesitate to operate at a much earlier period. The popular opinion that operations in infants are apt to be followed by convulsions, though sanc- tioned by the authority* of Sir Astley Cooper, is, according to Butcher and Fergusson, incorrect; shock was, however, the cause of death in two cases of harelip operated on by the last-named surgeon. Operation.—The operation for harelip consists essentially in paring the Under the name of preventive treatment of harelip, Mr. Tuckey, an Irish surgeon, recommends the administration to the mother, during pregnancy, of a mixture of the phosphates of calcium and sodium, carbonate of calcium, bicarbonate of magnesium, chloride of sodium, gelatine, and gum, and reports several cases in support of his sug- gestion. ^r ° 810 DISEASES OF THE FACE AND NECK. own knees. The lip should be first freely sejiarated from the upjier jaw bv dividing the frtenum and any membranous adhesions; a Xunneley's clip (Fig. 293) is then adjusted on either side so as to control the labial artery, while the surgeon, seizing with toothed forcejis the ex- tremity of one side of the fissure, transfixes the jiart near the summit of the gaj), vyith a small straight bistoury, and cuts downwards in a slightly curvilinear direction, concave inwards, so as to insure sufficient length to the cicatrix when the parts are brought together. The ojijtosile side of the fissure is then pared in a similar manner, the incisions being evenly united above the summit of the gap, and extending far enough outwards to cut away the rounded edges of the jirolabium at the base of the fissure. The cut surfaces are then accurately- adjusted and held together with two or more harelip pins, the lowest of which is made to acujuess the cut labial artery on either side. These pins should enter and leave the tissues at least a quarter of an inch from the lines of incision, and should embrace the whole thickness of the lip including its mucous lining. The more accu- rate adjustment of the prolabium may be effected by inserting an inter- rupted suture of fine silk through the mucous membrane, just behind the edge of the lip, and another may be jilaced superficially between the jiins. In apjilying the twisted suture" over the harelip pins, a sejiarate thread should be emjiloyed for each ; the points of the pins being cut off, a piece of adhesive jilaster is placed beneath them to protect the skin, and the dressing is completed by supporting the tissues on either side with narrow strips of the same. Tension may be still further lessened by the use of Dewar's or Hainsby's cheek-comjiressor (Fig. 484), or by simjily ally- ing a long strip of adhesive plaster across the wound and around the head, as recommended by Coote. The pins may commonly be removed on the fourth, and the interrupted sutures on the sixth day, but the parts should be supported with adhesive jilaster for at least a week or ten days longer. The above description will suffice for what may be considered the sim- plest form of operation in a typical case of single harelip. Various modifications are required under different cir- cumstances; thus, if, as often hajipens, the sides of the fissure be of different lengths, the red edge jiared from the shorter side may be left attached at its base to the lower border of the lip, and fastened to the jireviously sloped border on the other side, as advised by Langenbeck and Holmes; or a flap may be taken from the longer, and attached to the" base of the shorter F.o. 4So.-Malgaigne>s opera- .^ T obvjate the nQt(.h which jH a](t t0 he tion The dotted lines mark the ,„,,,,, -, ■, c . i • t •„ /i|/>1„rtt'a flBSUre. left at the lower border of the cicatrix, ( leinot 8 and Malgaigne's plan may be followed, the in- cisions being made as shown in the annexed cut, or Xelaton's method may be adojited; this consists in surrounding the fissure with an inverted /\-shaped cut, and bringing down the flap, which is left attached at both sides, so as to convert the wound into one of a diamond 0 form. Many othervervingeniousoperationshavebeen devised by (iiraldes, Collis, Stoke-, Wolff, Pheljis, and other surgeons, but, while more complicated than tliOM- in common use, have not, as far as I am aware, been proved to possess any practical superioritv. Butcher, Wheeler, and others, operate with scissors instead of the knife, while the use of harelip pins has been abandoned hy Mr. Erichsen in favor of the simple interrupted suture, a> was likewise done by the late Mr. Collis; the latter surgeon used horsehair as a material for his sutures, while the former gives the preference to fine silver wire. HARELIP. 811 Fio. 486—Double harelip; pro- jecting intermaxillary portion. (Holmes.) Should the approximation of the cut surfaces be hindered by the projection of the intermaxillary bone, this may* be cut away, as advised by Fergus- son, with gouge or bone-forceps. Double Harelip.—The treatment of double harelip is conducted on the same principles as that of the simpler form of the affection, both fissures being pared, and pins inserted so as to transfix the middle flap, and close both gaps at once; Coote, however, advises that the fissures should be operated upon on different occasions. In some instances, it is better to cut away the median portion, or to carry it upwards and Jj ,;$ backwards, so as to increase the length of the columna of the nose. The chief difficulty* in cases of double harelip is in the management of the intermaxillary bone, if, as often hap- pens, this interferes with the operation by its anterior projection. If it be small, the inter- maxillary bone may be cut away (and indeed Fergusson recommends thatthis should always be done, and such has been my own practice), but some surgeons prefer to fracture its base, and bend it backwards into its proper position, with broad forceps covered with vulcanized India-rubber; this proceeding may be some- times facilitated by dividing the attachment of the projecting bone to the septum with cutting forceps, as advised by Blandin and others, or by grooving its base with ingenious forceps devised for the purpose by Butcher, of Dublin ; in case the intermaxillary portion should be found too large for the gap which it is meant to fill, its sides may be cut away with forceps, when the edges of the superior maxillary bones should be similarly freshened at the same time. In making these bone-sections, particularly in dividing the attachment of the projecting intermaxillary bone to the nasal sejttum, there is often free hemorrhage, which may require the use of the actual cautery. Should it be thought necessary, the intermaxillary bone may be fastened by means of silver sutures to the adjoining maxilla?, as advised by Sims and Whitehead. Primary- union is usually obtained without difficulty* in cases of harelip operation, but if it should fail (which may happen from too early with- drawal of the pins, or from a depressed state of health in the patient), the surgeon should not despair, but should re-approximate the parts in hope that union of the granulating surfaces will occur; in this way I have ob- tained a much more satisfactory result than might at first have been anticipated. If it be necessary to repeat the entire operation, an interval of at least a month should be allowed to elapse, in order that the parts may have time to return to a healthy condition. After the operation for harelip, the child, if an infant, mav be allowed immediately to take the breast, the action of sucking tend- *'*■ ™--*™™»™> »r «»*«- • , ' o »"^"va ital fissure at the angle of the mouth- ing rather to keep the parts together than (From a patient under Dr. Harlan's to separate them ; if already weaned, abund- care, at the children's Hospital.) 812 DISEASES OF THE FACE AND NECK. ant nutriment in a fluid form should be supplied, and may be most conve- niently administered with a sjioon. For further information with regard to the treatment of harelip, the reader is respectfully invited to refer to the chapter on this subject in Mr. Holmes's well-known work on the Surgical Treatment of Children's Dis- eases, where will be found an excellent account of the more eoni|>licated forms of the affection, and of the special ojierations required for each. Congenital Fissure of the lower lip is occasionally met with, as is the same deformity at the angle of the mouth, where it constitutes the affection known as Macrostoma, of which I have seen one case under the care of Dr. Harlan, of this city ; these rare conditions require to be treated on jirecisely the same princijiles as those which have been laid down for the management of ordinary harelip. Mr. J. II. Morgan and Mr. F. Mason have called attention to the coexistence of macrostoma, and the deformity of the ear which is marked by the jiresence of the so-called auri- cular appendages. As may be seen from the annexed cut (Fig. 487), the same peculiarity was noticed in the case of Dr. Harlan's patient. Diseases of the Xkck. Bronchocele or Goitre is a hyjiertrophied state of the thyroid gland, and may exist in an indejiendent condition, or in connection with anamiia and protrusion of the eyeballs, as in the affection known as Graves's or Basedow's disease (Exophthalmic Goitre). Other varieties are recog- nized by systematic writers, such as the Fibrous Bronchocele, the Cystic Bronchocele,1 in which cysts are develojied in the structure of the thyroid, with or without hypertrophy of the gland tissue itself, and the Pulsating Bronchocele (an affection which may be mistaken for carotid aneurism), in which the tumor has a distinct, expanding pulsation, synchronous with the cardiac systole, and evidently depending ujion the intrinsic vascularity of the growth itself. Bronchocele commonly ajipears as a soft, fluctuating, indolent tumor, occujiying the situation of the thyroid gland, of which either lobe, or the isthmus, may he alone or chiefly involved, though in other cases the whole gland is equally implicated. The causes of bronchocele are somewhat obscure; it jirevails in cer- tain localities, as in the Tyrol and some jiarts of England, as an endemic affection, but is occasionally met with sporadically in all parts of the world, and as Fio. 4^s—Bronchocele. an acute affection has been observed as an epidemic. (Gkeene.) Goitre is much commoner in women than in men, and, according to A. Ollivier, is in many instances a result of pregnancy. In some cases, the prevalence of the disease apjiears to be traceable to the use of melted snow or of water impregnated with certain saline constituents, for drinking purposes; but in other cases no such cause can be assigned. The use of a tightly fitting military stock, or other source of constriction about the neck, appears sometimes to have been an exciting cause of the affection. When of moderate size, bronchocele gives rise to no jiarticular incon- venience, except by the deformity produced, and by a certain amount, of 1 Cohnheim has recorded a case in which cystic bronchocele was followed by meta- static deposits in the lungs and bones. BRONCHOCELE OR GOITRE. 813 dyspnoea when stooping, with occasional pain in the head. In its more aggravated conditions, however, it may cause serious if not fatal interfer- ence with the functions of respiration and deglutition, cerebral conges- tion, organic disease of the air-passage, etc. When very large, as in a remarkable case under the care of Mr. Holmes, inflammation and suppura- tion of the mass may occur, and the patient may eventually sink under the drain thus occasioned. Treatment.—The treatment of goitre is not very satisfactory; the remedy which has acquired most reputation in this affection is iodine, which may- be given in the form of the Liq. iodin. compositus, of the U. S. Pharma- copoeia, and should be continuously administered for a considerable time. Iodine may also be used externally, in the form of the Ung. jilumbi iodid.j or the iodide of cadmium incorporated with lanolin Oj-£j), or, which is particularly recommended by Mouat, the biniodide of mercury ointment (gr. xvj-gj). The internal administration of chloride of ammonium has been successfully resorted to by a Canadian surgeon, Dr. A. D. Stevens. Pressure sometimes forms a valuable adjunct to iodine inunction, but care must be taken not to irritate the skin, lest the disease should be thereby aggravated. Change of residence, would naturally be recommended in any case in which the affection appeared to be due to climatic or other hygienic influences. Various Operative Measures have been employed in the treatment of bronchocele, each having been occasionally successful, but often resulting in failure, if not even more disastrously. The injection of iodine, arsenic, alcohol, or perchloride of iron, the formation of a seton, and the application of caustic, are probably the safest of these measures. The injection treatment is said by Lubka and Mackenzie to be equally efficient in cases of the serous and in those of the hard or fibrous variety. Injection of perchloride of iron would be specially indicated if the growth were of the character described as pulsating- bronchocele. The seton is particularly recommended by Lennox Browne, who has in several cases successfully employed it for fibrous goitre. Oilier dissects off the integument andapjilies a layer of Canquoin's jiaste to the tumor, allowing it to remain for four hours. Shrivelling gradually follows, and the cure is completed in three or four months. DaCosta and Coghill have derived advantage from the hypodermic use of ergotine. Ligation of the thyroid arteries, so as to cut off the vascular supjily of the diseased gland, is a dangerous mode of treatment, and one which, on account of the freedom of the collateral circulation, is very apt to result in failure. Division of the fascia in the median line is recommended by Meade and Mackenzie as a means of relieving the pressure on the air-passage, while, with the same object, Gibb advises that the thyroid isthmus itself should be divided or removed, hemorrhage being prevented by making the section between two ligatures. In cases thus operated on by Sydney Jones, Lennox Browne, and Stokes, consecutive atrophy of the lateral iobes followed, and a cure was obtained. A similar operation was performed (unsuccessfully) by Prof. Hamilton, of New York, in 1849. Extirpation of the gland is an exjiedient fraught with considerable risk to life, and can only be justifiable in exceptional cases ; when resorted to, care should be taken to plan the incisions so that the large vessels may, if possible, be encountered in an early stage of the jiroceeding, in order that, being secured once for all, the risk of subsequent bleeding may be less. Numerous successful operations ujion this plan have been reported by Greene, Fenwick, Maury, Watson, Michel, Billroth, Kocher, Xelson, and other surgeons, Kocher's statistics giving 414 cases with 15 deaths, a mortality of but little over 18 percent. In his own hands, the operation has been still more successful, his las* 814 DISEASES OF THE FACE AND NECK. series of 2n0 cases having given but 6 deaths, or 2.4 per cent. According to Kocher, Julliard, Beverdin, Burns, and Stokes, however, the ojieration is often—Semon says, in the proportion of one to three oases—followed hv the development of a cretinoid condition with my xcedema, and from experi- ments on the lower animals, Zesas, Schiff, Horsley, Wagner, Sanquirico, and Canalis, conclude that complete thyroidectomy is not justifiable. Exophthalmic Goitre (Graves's or Basedow's disease), supposed hv Filehne to depend upon a lesion of the restiform bodies, and observed hv Barie and Joffroy in connection with locomotor ataxia, comes more often under the care of the physician than under that of the surgeon ; its treat- ment demands the adoption of means to improve the general health, rather than of measures specifically directed to the cure of the thyroid enlarge- ment. Ancona, an Italian physician, rejiorts a cure from galvanization of the sympathetic nerve in the neck. Digitalis and bromide of potassium have been successfully employed by Dr. Curtin, of this city. Gangrene of the thyroid gland has been observed by Gascoyen and other surgeons. Inflammation of the Parotid Gland may occur as an ejiidcmic and jirobably contagious affection, when it constitutes the disease known as Parotitis or Mumps; or as the more serious condition denominated Parotid Bubo, which occurs in septic states of the system, or as a sequel of some of the exanthemata. The former affection very rarely, but the latter frequently, runs on to suppuration, demanding an early incision for the evacuation of matter, and the free administration of tonics and stimu- lants to support the strength of the patient. These cases are never unat- tended by danger, and in one case which I saw in consultation many years ago. death ensued from secondary hemorrhage into the cavity of the abscess. Tumors of the Parotid.—Most of the tumors met with in the parotid region do not, probably, involve the gland, though they overlie and compress its structure; in some cases, however, the parotid itself is implicated in the morbid growth, which may be of a fibrous, cystic, fatty, cartilaginous, or cancerous nature. The only treatment apjilicable to these cases is extirpation of the growth, and, if the tumor be of a non-malignant character, such an ojieration may he commonly undertaken with the probability of a favorable result. If, however, the growth be malignant, its at- tachments will probably be so deep as to forbid any hojie of successful operative interfer- ence. The mobility of such growths is, according to Fer- gusson, the best criterion by which to decide whether or not to operate; and in any case in which it can lie deter- mined that the tumor, though perhaps bound down by su- perincumbent tissues, is not firmly fixed to the parts be- neath, the inference is reason- able that an operation may be fio. 4S9.-Tumor of parotid region. (Fkrgusso.n.) attempted with hope of bene- TUMORS OF THE NECK. 815 fit. Another point of importance is the rate of increase of the tumor, one of a non-malignant being of much slower growth than one of a malignant character. In attempting the removal of tumors from the parotid region, the exter- nal incisions should be free, and may- be made in any direction that may be indicated by the shape of the growth ; after dividing the superincumbent tissues, and thus loosening the tumor, the surgeon should accomplish the rest of the ojieration as far as possible by pulling and tearing with his fingers, aided with the handle of the knife, being chary of employing the cutting edge in the deejier portions of the wound. The accidents to be particularly guarded against are wounds of the temporo-maxillary artery and facial nerve, division of the latter of which would of course entail paralysis of the corresponding side of the face. Excision of the Parotid Gland itself is probably less often done than is supposed; yet so many cases of this operation have been recorded by perfectly competent and trustworthy* observers, that it is impossible to deny the practicability* of the procedure. In this operation, which is one of the gravest in the whole range of surgery, the external carotid artery and portio-dura nerve are necessarily cut across, and in some instances it is said that the internal jugular vein, and even the spinal accessory* and pneumogastric nerves, have been likewise divided. Extirpation of the parotid, which is said to have been performed by Heister, is chiefly known in this country through the operations of the late Dr. George McClellan, of this city, who reported eleven cases with only one death.1 Tumors of the Submaxillary Gland__Cysts of the submaxillary gland are occasionally met with, and may be treated by incision, the cavity of the cyst being stuffed with lint, so as to promote healing by granulation, or by excision, which operation may* also be required in cases of cartilagi- nous, adenoid, or cancerous growths. The gland should, as far as possi- ble, be enucleated with the fingers and handle of the knife; the only large vessel necessarily severed is the facial artery, which will be found at the upjier and posterior part of the wound, and may usually be secured before it is divided. Tumors of the Neck.—Various morbid growths are met with in the side of the neck, where they may occupy the submaxillary space, or one of the triangles of this region. The most common varieties of cervical tumor aie the cystic, fatty, fibrous and glandular, though sarcomatous, carcino- matous, and epitheliomatous growths are also met with in this part. The remarks which were made as to the excision of parotid tumors are equally applicable here ; if the tumor be movable and of slow growth, its extirpa- tion may, if the other circumstances of the case are favorable, be properly undertaken. If, however, the deep attachments of the mass are firm, and if its rate of increase has been such as to render its malignancy probable, the surgeon will, as a rule, do wisely to avoid operative interference. Hydrocele of the Neck is a name applied by Maunoir, Phillips, Syme, and other surgeons, to a cy*stic tumor, usually met with in the posterior inferior cervical triangle, and containing a fluid which may be of a limpid yellow color, or of a deep, grumous, chocolate hue. The treatment consists in the evacuation of the contents of the cyst, with a trocar and canula, followed by the subsequent injection of iodine, the establishment of a seton, or the conversion of the cy*st into an abscess, by* cutting away a portion of its anterior wall. A similar course may be adopted in the treatment of 1 The operation is said to have been performed for the first time in this country by Dr. Richard Banks, of Georgia, in 1831. 816 DISEASES OF THE MOUTH, JAWS, AND THROAT. Cysts of the Parotid Region (unconnected with the gland itself), of Hygromata of the Hyoid Bursa, and of similar enlargements of the hio- cutaneous bursa sometimes found in front of the larynx, which constitute the " Superlaryngeal Encysted Tumors''' of Prof. Hamilton. Enlargement of the Cervical Lymphatic Glands is often observed as a manifestation of scrofula. Its treatment has already been described in the chaj)ter on that subject (see juige 4i;2). Congenital Tumor or Induration of the Sterno-mastoid Muscle is an obscure affection, which has been described by several surgeons, particularly by Bryant, Holmes, T. Smith, II. Arnott, and Planteau. In some cases the affection appears to originate from injury received in birth, but in other instances is a simple inflammatory or hypertrophic condition, with no apparent cause. It is probably sometimes a syphilitic lesion. Xo treat- ment is required, as the induration subsides spontaneously in the course of a few weeks or months. CHAPTER XXXVIII. DISEASES OF THE MOUTH, JAWS, AND THROAT. Diseases op the Tongue. Glossitis, or Acute Inflammation of the Tongue, may occur from trau- matic causes, from the abuse of mercury*, or as an idiopathic affection. The tongue rapidly swells, becomes cedematous, and protrudes from the mouth, preventing the jiatient from speaking or swallowing, and jierhaps threaten- ing actual suffocation. There is profuse salivation, and the teeth often become covered with sordes. The treatment consists in the local use of ice, with detergent and astringent gargles, the administration of tonics (if the jiatient can swallow), and, if necessary, the use of nutritive enemata. Free incisions on the dorsum of the tongue may be required if the symp- toms are urgent, and commonly afford great relief, by allowing the escape of the blood and serum by which the organ is distended. Trucheotovvj may possibly be required to avert suffocation. Chronic Superficial Glossitis is the name given by Cojiland and Fairlie Clarke to an affection of the lingual mucous membrane characterized by the formation of smooth, elevated patches, and believed by Clarke to be often of syphilitic origin; according to Butlin, it is closely* allied to psoriasis and ichthyosis linguae; it is sometimes followed by ejiithelioma. Clarke recommends the local use of nitrate of silver (gr. v. to f|j) and glycerite of tannin, with the internal administration of iodide of jiotassium and arsenic. Sub-Glossitis.— Under this name C. Holthouse has described a case in which inflammatory swelling, occurring without obvious cause, was limited to the sublingual and submental regions; the tongue was retracted instead of being protruded, and there was no dyspnoea, though speech and deglutition were both rendered difficult; there was profuse salivation. Incisions on the dorsum of the tongue were productive of no benefit, hut rapid recovery followed the use of borax gargles, with catajilasms, exter- nally, and the administration of quinia. Similar cases are described by Dolbeau under the name of acute ranula. ULCERATION of the tongue. 817 Hemi-Glossitis, an inflammatory swelling limited almost invariably to the left side of the tongue, has been observed by Langelot, De la Malle Graves, and recently by Gueneau de Mussy. Dr. Parella andDr. Cleborne report cases in which the right side of the tongue was affected. Abscess of the tongue is occasionally met with, and requires a free incision for the evacuation of pus. An abscess beneath the tongue may, by pressing on the glottis, threaten suffocation, in which case the incision must be made below the chin, through the mylo-hyoid muscle. Hypertrophy or Prolapsus of the Tongue may be met with either as a congenital or as an acquired affection. The protruded organ is very much swollen, with enlarged papillse, of a purple or brownish hue, and dry from exposure to the air. The saliva constantly dribbles from the mouth, and, in chronic cases, the alveolus and teeth of the lower jaw are displaced forwards by the pressure of the hypertrophied mass, which, ac- cording to Wegner and other modern pathologists, consists of a true lym- phangioma, The treatment consists in the use of astringents, with the application of compression by means of a pad and bandage, supplemented, if necessary, by excision of a Vshaped piece from the tip of the organ| with the knife, galvanic cautery, or ecraseur. Ligation is objectionable on account of the proximity of the organ of smelling to the point at which the slough would be produced, and the risk of septicpoisoning which would necessarily be entailed. The statistics of these various modes of treatment have been investigated by Fairlie Clarke, who finds that 20 cases in which cutting instruments were employed gave 19 recoveries and 1 death ; 10 cases in which compression alone was employed gave 9 recoveries and no deaths (one patient having been much benefited, though not entirely cured); 4 cases in which either the galvanic-cautery or the ecraseur was used gave 3 recoveries and 1 death: while 9 cases in which the ligature was used gave 7 recoveries and 2 deaths. The late Dr. Gurdon Buck, of New York, suggested that, as the thickness of the protruding portion was commonly more obnoxious than its breadth, the flajis for excision should be made antero-posteriorly rather than from the sides of the organ. Liga- tion of both lingual arteries is advised by Pirogoff as preferable to excision. Atrophy, affecting only one side of the tongue, has been noticed by several observers, including Dupuytren, Holthouse, Hughlings Jackson, Budd, Habershon, Jaccoud, Fagge, Webster, Fairlie Clarke, and Paget. In the case recorded by the last-named surgeon, the disease was connected with necrosis of the occipital bone, and yielded upon the extraction of sequestra from that part. Ulceration of the Tongue may be due to the irritation caused by broken or carious teeth, or to that caused by the use of tobacco, to dis- orders of the digestive system, to the existence of various diseases of the skin (such as psoriasis), to syphilis, to the presence of a malignant growth, to a deposit of tubercle, etc. The differential diagnosis between these various forms of ulceration is highly important in a therapeutic point of view, as the treatment required varies widely, according to the cause of the ulceration in each case. In most instances the diagnosis can be readily made by careful observation of concomitant symptoms ; the most difficult cases being, perhaps, those in which a chancre or tertiary syphilitic deposit is to be distinguished from an ejiithelioma (see pages 493, 500), or the latter from an ulcerated mass of tubercle. The Tuberculous Ulcer has been particularly studied by Trelat,1 who remarks that a chronic, intractable, superficial ulcer, with red, irregular 52 Archives Gen. de Medecine, Janv. 1870. 818 DISEASES OF THE MOUTH, JAWS, AND THROAT. borders, which occurs, without ajipreciable cause, and without enlargement of the neighboring lymjihatic glands, on the tongue or in the mouth, is probably a tuberculous ulcer ; and that the probability is increased if the patient be phthisical or tuberculous, or even predisjiosed to tuberculosis. The diagnosis, he adds, may be considered certain, if the surgeon can detect the presence of peculiar sjiots or |>atcbes, which are very slightly elevated, round, from half a line to two lines wide, of a yellowish, pus-like color, at first covered with epithelium, and exhibiting one or more follicular orifices —the epithelium disappearing in the course of a few days, and leaving an ulcerated surface. The only topical remedy which jiroved of benefit in M Trelat's case was the ajijilication of the actual cauterv, but Verneuil has successfully employed chromic acid, which, according to Hybord, is a jire- ferable remedy. Ichthyosis of the Tongue is the name given by Ilulke to a chronic condition of this organ (characterized by the apjiearancc of white or silvery patches), which may jiersist without cliange for years, but which ultimately leads to the development of ejiithelioma in the parts affected. According to Dr. B. W. Taylor, however, there are two varieties of ichthyosis ; one in which the papillae are primarily involved, giving the tongue a warty appearance, and the other beginning in the rete Maljiighii. The first variety- alone is, in Dr. Taylor's opinion, liable to malignant change. The treat- ment of this disease, of which examples have been reported by II. Morris, Fairlie Clarke, Goodhart, Weir, of New York, and others, consists in ex- cision, or, if this be not practicable, in removing sources of irritation, with attention to the digestive functions, and, as suggested by Fayrer, the ad- ministration of arsenic. Neuralgia of the Tongue has been treated by* Mr. Lucas by cutting down ujion and stretching the lingual nerve. Tongue-tie consists in a congenital shortening of the fraenum linguae, which jirevents the tongue from being protruded beyond the line of the teeth. If present in an aggravated degree, this deformity may interfere with suckling, and, under any* circumstances, the operation for its relief is so trifling that it may proj.erly be done, if, as usually haj»|>ens, the jiarents desire its performance. The operation consists simjily in dividing the fraenum for about an eighth of an inch with blunt-pointed scissors, the cut being made towards the floor of the mouth, so as to avoid the ranine vessels, and then separating the parts with the forefinger. There is a popular notion that tongue-tie may cause dumbness, and myotomy of the lingual muscles, through an incision beneath the chin, has even been jierformed, with a view of restoring the jiower of speech—a totally useless ojieration, since, as justly remarked by Holmes, the whole tongue itself may be ex- tirpated, and yet the power of speech remain. Tumors of the Tongue__Cystic Tumorsmay occur in various jiarts of the tongue, but are most common beneath this organ, or in the floor of the mouth below the buccal mucous membrane, constituting in these situa- tions the affection known as Ranula. The common form of ranula has thin walls, and contains a fluid somewhat resembling saliva, whence it was formerly supposed to be a dilatation of the duct of the submaxillary gland. Such is, indeed, probably the case in some instances, as when occlusion of the duct is caused by the presence of a foreign body or a salivary calculus; but the majority of ranulse appear to be distinct cystic formations, analo- gous to those which are met with in other organs. Masses of adipocert were found in a ranula in a case recorded by Waren Tay, and numerous rice-like bodies in one described by J. G. Richardson, of this city. True hydatids have been noticed in the tongue by Laugier, Molliere, and other TUMORS OF THE TONGUE. 819 surgeons. The common form of ranula may be treated by the formation of a seton, or by excision of a portion of its anterior wall, the cavity being subsequently allowed to heal by granulation. Prewitt, of St. Louis in- sures the permanence of the opening by means of a plastic operation. Panas advises the injection of chloride of zinc. That variety of the disease which is met with between the floor of the mouth and the mylo-hyoid muscles, often forms a more decided prominence in the neck than in the buccal cavity, and hence would ajipear to be most accessible through an external incision. The risk of hemorrhage, however, in any attempt at complete extirpation is so great that it is, as a rule, better to lay open the tumor from within, and turn out its contents, thus converting the cyst into an abscess, the healing of which may be promoted by stuffing the cavity with lint, Acute ranula. in which the tumor forms in the course of a few hours, is believed by Tillaux to consist in an accumulation of saliva (from obstruc- tion and rupture of Wharton's duct) in a serous sac known as Fleisch- mann's bursa ; the existence of this bursa is, however, denied by Sappey, Lefort, and others, and Duplay considers the acute ranula to consist in a dilatation of the duct itself. Dolbeau includes under the head of acute ranula, cases which are analogous to those already referred to under the name of sub-glossitis. Erectile, Vascular, and Papillary Tumors are occasionally seen in the tongue, and may be treated by the ligature, by excision, or by strangula- tion with the ecraseur, accord- ing to the size and situation of the growth. Dr. Busey, of Washington, D. C, reports a case of papilloma of the tongue successfully treated by the injection of acetic acid. Fatty, Glandular, and Fi- brous Tumors of the tongue may be treated by excision, the organ being drawn well forwards with a tenaculum or cord passed through its tip. Hemorrhage in these cases is sometimes rather trouble- some, but may usually be ar- rested by passing a metallic suture deejily around and across the bleeding point, by means of an ordinary naevus needle or one with a spiral extremity. Excision would appear to be a safer operation than ligation, in cases of tumor involving the root of the tongue. Apart from the risk of inflammatory swelling and oedema of the glottis, which attends the use of the ligature in this situation, severe or even fatal cerebral complications may be developed as reflex phenomena (as in a case recorded by Hunt), from injury to fibres of the glossopharyngeal nerve. If the tumor were situated very far back, and were pedunculated, the ecraseur might be projierly employed, as has been successfully done by Bigelow and Pooley. Hypertrophy'of the lymphatic follicles at the Fia. 490.—Ranula, between floor of mouth and mylo-hyoid muscles. (Fergusson.) 820 DISEASES OF THE MOUTH, JAWS, AND THROAT. back of the tongue (lingual tonsil), a condition analogous to the adenoid vegetations of the nose and pharynx, may be conveniently treated, as advised by Gleitsmann, with the galvanic cautery. Malignant Tumors of the Tongue, are almost invariably of an cpilhelio- matous character, though true lingual carcinomata, both of the scirrhonsand encephaloid kinds, are described by systematic writers. The only treat- ment which offers any prospect of benefit, consists in removing the diseased mass, which, when a portion only of the organ is affected, may be accom- plished by the ajijilication of the"galvanic cautery or the ecraseur, by the use of ligatures, as in cases of nsevus, or by excision, which is the preferable ojieration when the tip only is involved. H. Lee enqilov s, in addition to the ordinary ligature, one 'which is elastic, so as to prevent any risk of inijierfect strangulation and consequent absorption of septic material. The elastic ligature has also been employed by Despres, Helens, and other French surgeons. The tongue may usually be sufficiently exjiosed in these cases by drawing it well forwards, the jaws being held apart and the cheeks retracted, by such an instrument as is shown in Fig. 41)1. If, however, a large portion of the organ is to be removed, the ecraseur, the galvanic cautery wire, or ligatures, may be introduced through an incision in the cheek, as advised by F. Jordan and Coppinger, or between the genio- hyoid muscles, as practised by Cloquet, Arnott, and Whitehead, of Man- chester ; or Regnoli's plan may be adopted, in which the buccal cavity is ojiened from below (Fig. 492), and the tongue drawn out between the lower jaw and hyoid bone; or Kocher's jilan, in which the opening is made below the angle of the jaw. Southam has devised force|is to grasp and draw forwards the baseof the tongue, so as to allow the ecraseur to be used without making an external wound. Clamjis to prevent bleeding during operations ujion the tongue have also been devised by H. Lee and by J. \V. Howe, of New York. Tumors of the Epiglot- tis are occasionally observed, and Dr. W. Porter has recorded a case in which he successfully excised half of the epiglottis on account of a cartilaginous growth developed in its sub- F,o 491-Wood's gag for operations on the tongue. gtance< Tumors of the epiglot- tis have also been removed by MacKenzie, Prat, and Wagner, the latter surgeon having excised the whole epiglottis, after exposing the part by a sub-hyoidean pharvngotomv. Complete Extirpation of the Tongue was first performed by Svnie, of Edinburgh, and has since been repeated by Fiddes, Nunneley, Heath, Annandale, Lagenbeck, Buchanan, Barwell, and many other sur- geons, some operators having employed the knife, and others the ecraseur; Whitehead removes the whole tongue with scissors, and Fiorani with the elastic ligature. Whatever method be chosen, access to the organ may be facilitated by Svme's plan of dividing the lower lip and the symphysis oi the jaw, the parts being wired together again after the completion of the operation, or, which will usually "be sufficient, by simply laying open M COMPLETE EXTIRPATION OF THE TONGUE. 821 cheek by an incision from the angle of the mouth backwards. Annandale advises that the tongue should be split longitudinally, and each half re- moved sejiarately with the ecraseur. Xunneley's experience in extirjiation of the tongue apjiears to have been unusually- large ; he has, he declares, done the operation 19 times " without any untoward symptoms following in a single instance." Langenbeck prefers to Syme's median operation, an Fig. 492—Tongue exposed by Regnoli's Fio. 493.—Removal of tongue l»y division of method. (Erichsen.) lower j;iw and ecraseur. (Erichsen.) incision from the angle of the mouth to the thyroid cartilage, the jaw being then sawn through between the first and second molar teeth, and the shorter portion turned outwards and upwards. Barwell makes a small median incision, just in front of the hyoid bone, and by means of an armed needle carries the wire of an ecraseur around the base of the tongue, punc- turing the mouth on either side near the last molar tooth ; the tongue having been cut through, the operation is completed by- dividing its attach- ments to the floor of the mouth with a second ecraseur. The external wound being oblique and valvular, there is no danger of a fistula resulting. These operations are all dangerous in themselves,1 and are seldom pro- ductive of more than temporary- benefit; they are, as a rule, only applica- ble to cases in which the disease is limited to the tongue itself, extensive implication of the floor of the mouth, or of the neighboring lymphatic glands, being usually- a jiositive contra-indication.2 Hilton and Moore have recommended as a palliative measure, in cases not admitting of excision, the division of the gustatory nerve—an operation which may also be re- sorted to as a preliminary to the application of ligatures. The nerve may he reached just behind the last molar tooth, by an incision crossing its course, made from within the mouth, and carried freely down to the bone. Ligation of the lingual artery has been also practised as a means of ar- resting the progress of malignant disease of the tongue, and, according to Coote, Demarquay, and Haward, with encouraging results. The same 1 According to Barker, 34 cases operated on at University College Hospital, from 1£71 to 1*79, gave 11 deaths as the direct result of the operation. Whitehead, how- ever, finds that of 30 cases operated on by his method only one proved immediately fatal. Krause reports 91 cases of partial or complete excision for lingual cancer, with only 2 deaths attributable to the operation. ' In one case, however, I successfully removed about half of the tongue, with half the floor of the mouth, a considerable segment of the lower jaw, and the right sub- maxillary gland. 822 DISEASES OF THE MOUTH, JAWS, AND THROAT. operation is recommended by Weiebselbaum, Hirschfeld, Billroth, Shrndv, Croly, Treves, and Annandale, as a preliminary measure to extirjiation of the tongue; the risk of hemorrhage is thus reduced to a minimum, and the operation can be safely completed with the knife or scissors. Shradv urges that the vessel should be secured near its origin, before the giving off of the dorsalis linguie; Jessett, on the other hand, secures it in the mouth, separating the tongue from the floor of that cavity, ami then passing a ligature deeply around the vessel with an aneurismal needle. Tracheotomy, as a preliminary measure, is recommended by Barker. Contrary to what might perhaps be expected, the jiower of swallowing is not affected by extirjiation of the tongue, while sjieech, though at first rendered imperfect by the ojieration, is eventually completely restored. Diseases of the Jaws. Abscess of the Gum (Gum-boil, Alveolar Abscess) is a common affection, resulting from the irritation of necrosed or carious teeth. The abscess forms in the socket of the tooth, and may extend inwards—burst- ing through the gum—or may sjiread outwards through the cheek. In the early stage of a gum-boil, the ajijilication of a few leeches to the in- flamed gum will often afford great relief from pain, and may even jirevent the occurrence of sujijmration; if, however, pus have actually formed, it should be evacuated by an early and free incision, made from within the mouth as soon as fluctuation can be detected in that position. As it is very desirable to avoid the deformity caused by an external ojiening, an effort should be made to obtain resolution on the side of the cheek, point- ing being at the same time encouraged within the mouth. For this jiur- jiose it will usually be advisable to avoid the use of poultices, substituting an embrocation of the extract of belladonna, diluted with glycerine. The patient may be at the same time directed to wash out the mouth frequently with warm water, or the domestic remedy of a hot fig may be ajijilied to the inner side of the inflamed gum. As soon as the acute symptoms have subsided, whether by the occurrence of resolution or of sujipuration, the services of a dentist should be invoked to remedy the diseased state of the offending tooth, and thus avert a recurrence of the affection. Lancing the Gums is a little operation often required in cases of difficult dentition. It is most conveniently jierforiued with the instrument known as the "gum-lancet," though, in an emergency, the small blade of an ordinary jienknife will serve the purpose perfectly well. The child's hands should be restrained by the mother or nurse, while the surgeon, separating the jaws with the left forefinger, introduces the blade of the lancet guarded with the right forefinger; this serves to guide to the point at which the incision is to be made, and at the same time keejis the child 8 tongue out of the way of injury from the knife. Ulceration of the Glims may dejiend upon the presence of a scor- butic or syphilitic taint, or may result simply from a disordered state of the digestive "system, the accumulation of tartar around the teeth, etc. lhe treatment consists in the adoption of means to improve the jiatient's genera condition, with the enforcement of cleanliness of the part, and the local use of astringent and detergent washes. Epulis.—This is a general term signifying an outgrowth of the gum, the growth in these cases being rather of the nature of a continuous hyper- trophy than of a distant tumor. The ordinary epulis is of a fibrous struc- ture but myeloid, carcinomatous, and epitheliomatous growths are also seen in this locality. The disease chiefly affects the lower, but is also met with in the upper jaw, rarely occurs before adult life, and is equally common NECROSIS OF THE JAWS. 823 Fih. 491.—Fibrous epulis. (Bryant.) in either sex. It its usually traceable to the irritation produced by a de- caved tooth. Fibrous Epulis appears as a red, smooth, lobulated mass, cov- ered bv the natural structures of the gum, the mucous glands of which are sometimes abnormally developed. The growth is at first firm and resisting, but may become softened by central disin- tegration, or may ulcerate superficially. The Malignant Epulis, as it is com- monly, though improperly, called, is usually of a myeloid character; in some instances, however, as already observed, these growths are really malignant, being of an epitheliomatous or carcinomatous nature. The malignant differs in appearance from the simple or fibrous epulis, in being softer, of a darker color, more vascular, and of more rapid growth, and in its tendency to recur after removal. The most available mode of treatment, in any case of epulis, is excision, and as the growth commonly- involves the periosteum, this, with a thin layer of the subjacent bone, should be removed with the gouge-forceps, so as to prevent a recurrence of the disease. In ordinary cases, the whole operation may be done from within the mouth, but if the tumor be large, and particularly if of a myeloid character, it may* be necessary to make an incision through the median line of the lip, and then dissect off the cheek so as to freely* expose the whole growth. A tooth should be extracted on either side of the diseased mass, and the alveolus divided with a strong but small saw as far as the base of the tumor. Cutting pliers, with the blades at a right angle to the handles, are then to be applied, one blade on either side of the jaw, when the whole growth, with the bone from which it springs, can be readily* cut away. The base of the lower jaw should always be allowed to remain, in order to jireserve the symmetry of the part; the removal of the whole thickness of the bone appears to be quite unnecessary, epulis, according to Heath, never involving the lower border of the jaw. If the bone is very- thick, it may be desirable, before apply- ing the cutting forceps, to make a horizontal groove with a Hey's saw; but in most instances this will probably be found unnecessary. Hemorrhage is to be checked by compression, or, if this fail, by the use of the actual cauterv or Monsel's solution of iron, the external wound, if one have been made, being then accurately adjusted with harelip pins and the twisted suture. The bleeding is often profuse in operations for the removal of malignant epulis, requiring the free use of the hot iron ; in these cases, also, it may be necessary* to remove the entire thickness of the bone, by means of an external incision beneath the horizontal ramus of the jaw. Mr. Xunn has reported several cases of epulis successfully treated by electrolysis. Necrosis of the Jaws may result from traumatic causes, from syphilis, from the abuse of mercury, or from the contact of the fumes of phosphorus (as in the makers of lucifer matches); it is, moreover, some- times met with as a sequel of the eruptive fevers, and may* even occur without being traceable to any definite cause. In some few instances it has been found to be due to the presence of a fungus, as in the disease actinomycosis hominis, a rare affection, examples of which have been observed in this country* by Drs. Murphy*, Schirmer, Ochsner, and Bodamer. The fungus of actinomycosis has also been found in the lung, liver, and other organs. In the upper jaw, necrosis is almost invariably limited to the alveolar border, but in the low*er jaw may involve the whole thickness of the bone. The treatment consists in the administration of nutritious food and tonics, with the use of detergent lotions, and an early removal 824 DISEASES OF THE MOUTH, JAWS, AND THROAT. of sequestra; as long as a portion of dead bone remains in the month, the jiatient is constantly- exjiosed to the risks of sejitic jioisoning. Removal should, if |iossible, be effected without resorting to external incisions; in the upper jaw this can be readily accomjilished, but if the whole thickness* of the lower jaw be involved, an incision below the ramus may be absolutely necessary ; Perry and Boker have, however, each succeeiled in removing the whole lower jaw, in a state of necrosis, through the mouth; and Hutchison, of Brooklyn, has in a similar manner removed the whole upper jaw and the malar bone. Linhart, of Berlin, has removed the greater portion of both upper jaws, while preserving the muco-pcriosteal coverings of the hard palate, and the incisor teeth. Abscess of the Antrum.—Supjiuration may occur in the antrum as the result of traumatic causes, or of the irritation jiroduced by a diseased tooth or by a sequestrum resulting from syjihilitic or other disease of the jaw. The symptoms are those of deeji-seated suppuration in general, with enlargement of the part, causing swelling of the cheek, jirotrusion of the eyeball, occlusion of the lachrymal duct and nostril, and bulging of the hard palate. If the accumulation of purulent matter be very great, the walls of the antrum may* become so attenuated as to crackle under jnessure. Pointing may take place on the cheek, or within the mouth, or the abscess may jiossibly discbarge itself through the nostril. The treatment consists in making a free opening into the antrum, and, subsequently, in daily washing out the cavity by syringing with warm water. If one of the molar teeth be carious, this may* be extracted, and an opening made by thrusting a trocar, small perforator, or, which Fergusson recommends, an ordinary gimlet, through the socket, but, under other circumstances, it is better to make the opening through the front wall of the antrum beneath the cheek; the bone is here thin, and can be readily jierforated with a strong knife or scissors. External pressure may be afterwards employed to restore the part to its original sbajie. Cysts of the Antrum (Dropsy of the Antrum).—The antrum is not unfrequently the seat of a collection of thin glairy mucus, or of a brownish serous fluid containing crys- tals of cholestearine. The older surgeons looked upon these cases as the result of an obstruction of the orifice of the antrum, causing accu- mulation of the natural secre- tion of the part, and hence ajiplied to them the term hydrops antri. or drttpsy of the antrum. Modern patho- logists, however, believe that, at least in the large majority of instances, these are (as first pointed out by Giraldes) exanqiles of true cystic disease, analogous to those which are met with in other parts. The symptoms of a cyst of the antrum are very much the same as tho.-e wbich characterize abscess of that eavitv e.xeejit that Fig. 495.—Encephaloid of the antrum, encroaching upon . , ' -' . X „,„ the face. (L,sroN.) no evidence of an mflanima- SOLID TUMORS OF THE UPPER JAW. 825 tory condition is present. The diagnosis is important, as these cases are curable by a very slight operation, whereas solid tumors of the antrum demand a much graver procedure for their removal; hence, in any case of doubt, the surgeon should make an exjiloratory puncture before resorting to more serious measures. The treatment of cystic disease of the antrum consists in perforating the anterior wall of the cavity from within the mouth, the cheek being previously dissected up if necessary. A small portion of the anterior wall may be excised, so as to allow thorough exploration of the part, and prevent reaccumulation. If, as sometimes happens, a tooth be discovered within the antrum (in which case the cy*st is said to be dentigerous),1 the tooth should be removed with suitable instruments, introduced through the opening already made. Solid Tumors of the Upper Jaw.—These are of various kinds. Apart from those which have already been described under the name of epulis, there may be exostoses springing from the surface of the jaw, and projecting in different directions, requiring removal with gouge, saw, or cutting pliers. Tumors, again, may originate from either wall of the antrum, from the malar bone, from the pterygo-maxillary fossa, or from behind the jaw; fibrous, myeloid, and encephaloid growths (Fig. 495) are jirobably those most frequently- met with in these situations, though fatly, cartilaginous, bony (Fig 496), and epitheliomatous tumors have also been observed in the same localities. These various growths, as they increase in size, produce swelling of the cheek; encroach upon the orbit, causing jirotrusion or compression of the eye, and sometimes interfering with vision ; occlude the nostril, simulating nasal polypus; project into the pharynx, causing dyspnoea or dysphagia ; and depress the alveolus and hard palate, causing bulging of the roof of the mouth. Beside the deformity produced, they eventually endanger life, by in- terfering with respiration and deglutition, by giving rise to profuse and repeated hemor- rhages, or by involving the base of the skull, and inducing cere- bral complications. Diagnosis.—Solid tumors in- volving the antrum, may be distinguished from cysts or ab- scesses of the same part by noting the history of the case, by observing the uniform, elas- tic, and semi-fluctuating char- acter of the enlargement, in the case of a fluid collection, and finally by means of an explo- ratory puncture. It may, how- ever, happen, as in a Jiatient Fia. 496— Osteoma of the upper jaw. (From a patient under my care at the Episcopal in the university Hospital.) Hospital, that the entrance to the antrum is blocked by a solid growth, the natural secretion of the part accumulating as a consequence, and constituting a true dropsy of the cavity. 1 According to Magitot, maxillary cysts of spontaneous origin are invariably con- nected with some portion of the dental system. 826 DISEASES OF THE MOUTH, JAWS, AND THROAT. Under such circumstances the diagnosis would necessarily be obscure, until the gradual increase of the solid tumor should render its nature ajiparent. It is sometimes a matter of great difficulty- to determine the point of origin of a tumor involving the ujijier jaw ; those growths which spring' from the malar bone, dip downwards between the gum and cheek, causing the latter to project at an early period, and only secondarily involve the antrum ; tumors, again, which originate in the antrum, distend its walls in various directions, and render the line of the teeth irregular; while, finally, growths which originate behind the jaio (as naso-pharyngeal jiolypi), thrust the latter downwards and forwards as a whole without altering the line of the teeth, or changing the relative position of the several parts of the bone. These distinctive points are, however, in practice, often obscured by the fact that a tumor arising in one jiosition may send prolongations in several different directions, so that, in any particular case, it may be almost im- possible to decide from what jiart the growth originally sjirang. The diagnosis between malignant and non-malignant tumors of the an- trum is often extremely difficult, as long as the morbid growth is confined within the walls of that cavity. A malignant affection may, however, he susjiected, if the increase of the tumor be rapid, if the patient be past the period of middle age, and particularly if the submaxillary glands he enlarged and indurated. When the growth has sjiread beyond the cavity of the antrum, the diagnosis is comjiaratively easy, the ordinary cha- racters of a malignant tumor being, under these circumstances, speedily developed. Treatment.—The only treatment which can be of any service in cases of tumor of the upper jaw, is extirpation of the growth, which may require the removal, partial or complete, of the superior maxillary and jierhaps of the malar bone. In the case of a non-malignant growth, sjiringing from the antrum, there can be no question as to the propriety of the ojieration; and even if the tumor originate behind the jaw, excision, though attended with danger from hemorrhage and from the implication of the base of the skull, may be properly attempted, if the general condition of the jiatient he favorable to such a procedure. In the case of a malignant growth, provided that the glandular implication be not extensive, excision may be properly resorted to, if the case be seen before the tumor has spread beyond the cavity of the antrum ; if, however, the soft structures of the cheek be involved, or if the submaxillary glands be much enlarged and indurated, even though the growth be still limited by the walls of the antrum, operative interference is, as a rule, to be avoided; complete extirpation would scarcely be practi- cable under such circumstances, while a partial removal of the disease could but render the patient's condition worse than before. Lawson has, how- ever, reported a case in which he removed as much of the growth as could be reached, with the implicated integument, and then applied the hot iron, and dressed the wound with chloride of zinc paste; the cauterization was subsequently twice repeated, and the patient ultimately recovered. Excision of the Upper Jaw.—To Lizars is justiy ascribed the credit of having first proposed excision of the whole upper jaw for tumor of the antrum, and to Gensoul (in 1827), that of having first actually jierforrned the operation, though partial excision had been jirevioiisly resorted to by Dupuytren, Jameson, of Baltimore, and others. Various incisions are recommended by different surgeons, the best, in my judgment, being that advised by Fergusson, which consists in dividing the ujmer lip in the mesial line, laying ojien the nostril corresponding to the side of the tumor, carrying the knife (if more space be necessary) from the root of the ala, between the EXCISION OF THE UPPER JAW. 827 Fio. 497.—Excision of the upper jaw. (Fergusson.) side of the nose and the cheek, as far as the nasal bone, and then cutting transversely opposite the lower border of the orbit to the zygomatic pro- cess of the malar bone. The flap thus marked out being dissected up, sufficient room is afforded for the removal of the largest tumor. Lizars em- ployed an incision from the angle of the mouth across the cheek to the malar bone, supplement- ing this cut, if necessary, by one through the lip into the nostril, and by a short longitudinal inci- sion at the malar extremity of that first made. Liston's method, which, with various slight modifications, is still often adojited, consisted in making one incision from the external angular process of the frontal bone through the cheek to the corner of the mouth ; a second along the zy- goma, joining the first; and a third from the nasal process of the maxilla, detaching the ala of the nose, and cutting through the lip in the mesial line! By any of these methods, the whole upper jaw* may be readily removed, the flaps being dissected away from the surface of the tumor, and the bony connections of the part severed with a Hey's or other small saw, and strong cutting pliers. One, or, if necessary, two incisor teeth being extracted the saw may be applied to the alveolus, to the floor of the nostril, or to both, so as to cut a deep groove in which the blades of the cutting forceps may be applied; the hard palate is then cut through with the latte"r instru- ment, the soft palate being detached by a transverse incision, or, if practi- cable, the mucous covering of the roof of the mouth being turned backwards in the form of a flap. The malar bone is next cut across into the spheno- maxillary fissure, or, if this bone is itself to be removed, its orbital and frontal processes, and the zygoma, are similarly divided. Finally, one blade of the forcejis is introduced into the nostril, and the other into the orbit (the important structures of the latter cavity being pushed and held out of the way with the handle of the knife or spatula), and the inner angle of the orbit cut across. The tumor mav then be grasped with the lion- jawed forceps devised by Fergusson (Fig. 368), and forcibly depressed, the infra-orbital nerve being carefully divided far back, and any remaining attachments severed with a few strokes of the knife. Hemorrhage being arrested by ligation of any vessel that can be reached, or by the ajijilication of the hot iron, if necessary, the external incisions are brought together with sutures, and a strip of lint saturated with diluted glycerin, or^other light dressing applied. The cavity left by removal of the bone' must be kept clean by syringing with a solution of boracic acid or of permanganate of jiotassium. Partial Excision of the Jaw may often, in cases of non-malignant tumor, be advantageously substituted for complete extirpation: thus, if the orbital plate be not involved, this may be left, a groove being cut with the saw* across the bone below the orbit, and the cutting pliers subsequently applied in the same line; or if, on the other hand, the alveolus and hard palate, be healthy, the saw may be applied above and parallel to the alveolar border of the jaw, and again in a line perjiendicular to this, so as to connect the former section with the orbit; the inner angle of the orbit being then cut across, the upper part of the jaw may be separated with the lion-jawed for- ceps, as already described. Finally, it may be advisable, in some instances, to adopt Fergusson's suggestion of cutting into the centre of the diseased mass, and working with curved forceps and gouge towards the circumfer- 828 DISEASES OF THE MOUTH, JAWS, AND THROAT. ence, instead of undertaking a formal excision. The feeling of surgeons, generally, is unquestionably opposed to these jiartial operations, the |iro- fessionai mind being probably still influenced by Liston's unqualified con- demnation of such "nibbling and grubbing" procedures; but, as justly remarked by Mr. Heath, it remains to be seen which practice gives the best results. In the case of small tumors, or of necrosis, excision may be sometimes accomplished from within the mouth, without any external incision. The results of excision of the ujijier jaw are quite as favorable as could be expected, in view of the severity of the ojieration; 17 cases, quoted by Heath from the Medical Times and Gazelle, gave 14 recoveries; and 2U cases tabulated by Ohleman, of Bremen, gave 17 recoveries; while Incases of partial excision collected by the same writer were uniformly successful. The chief dangers of the operation appear to be from shock, from hemor- rhage, and (if an amesthetic be used) from entrance of blood into the air- passages. (1) Shock is not as much a source of risk in cases of excision of the jaw merely, as in those cases in which the jaw is removed as a preliminary steji in the extirpation of retro-maxillary tumors. It is diminished by the use of ether or chloroform, the latter of which, as the hot iron may be required in the later stages of the operation, is in these cases commonly preferred, on account of the inflammable nature of the former agent. (•2) Hemorrhage is always pretty free in these operations, during the early stage, particularly if the incision through the cheek is adopted, when the facial artery is cut at a point at which its calibre is considerable; the surgeon may, if he'think proper, ajiply a ligature to this vessel before pro- ceeding to the other stejis of the ojieration, but, as a rule, the jiressure of an assistant's fingers, or the ajiplication of a Plan's forceps, will suffice to control the bleeding until the whole excision has been completed. At a later stage of the ojieration, there is again pretty free bleeding from branches of the internal maxillary, which are necessarily cut or torn across when the jaw is removed ; these branches may be secured by ligation, or may be occluded by a few touches of the hot iron, which will often be found a more convenient application in this situation. In order to prevent hemorrhage during the operation, Lizars proposed and practised ligation of the carotid artery, as a preliminary proceeding; this plan is, however, abandoned at the present day, both as unnecessary, and as, in itself, seriously compli- cating the patient's condition. The tendency of modern surgical writers, indeed, is to speak very lightly of the risk of hemorrhage in excision of the upper jaw, and the late Prof/Gross, in alluding to this subject, went so far as to say that " no skilful surgeon now even employs compression of the carotid artery in these operations," and that " there are no structures in the body of the same extent, in their natural and diseased condition, the removal of which is attended with so little hemorrhage." With due diffidence, I must express my dissent from this opinion. I believe that profuse bleeding is a more frequent cause, if not of death, at least of danger, in excision of the upper jaw, than is commonly acknowledged, and consider comjiression of one or even both carotids, during the ojieration, a highly jiroper and judicious precaution. Another plan, which is suggested by Ferguson, may also be adopted with advantage; this is to notch, if not fairly dn,1(,(': the ascending process of the superior maxilla, with the alveolus and hard palate, before dissecting up the cheek or even cutting into the cheek at all —the most tedious part of the operation being thus accomplished before anv incision is made into the most vascular parts. Ligation of the carotid mav occasionally be rendered necessary by the occurrence of consecutive EXCISION OF THE UPPER JAW. 829 or secondary hemorrhage, as in a fatal case under the care of Le Gros Clark, in which "Wagstaffe tied the carotid for profuse bleeding occurring on the seventh day, and a successful case recorded by W. H. Fancoast, of this city. (3) The risk of suffocation from blood flowing into the air-passages, during the operation, is of course greater when the patient is in a state of anaesthesia, than it would be if no anaesthetic were employed; and in Mr. Hcwett's fatal case, the result was attributed to this cause. To prevent such an occurrence, anaesthesia should not be pushed further than abso- lutely necessary, and assistants should constantly mop out the mouth with sponges attached to sticks of a suitable length. Nussbaum, believing that this is the principal source of risk in jaw operations, advises the prelimi- nary performance of a temporary tracheotomy,1 the glottis to be closed with a piece of oiled lint, and chloroform to be administered through a tracheal tube; this plan has, with various modifications, been adopted by other surgeons, including Little, of New York, and Cheever, of Boston, but, I confess, seems to me rather adapted to complicate than to facilitate the operation, and I can but say the same of Bose's and Burow's suggestion, that the patient's head, during the operation, should be thrown back so far as to allow the blood to flow through the nostrils. Excision of the greater part of both. Upper Jaws was performed by Rogers, of Xew York, in 1824, and complete extirpation has since been practised by Heyfelder, Maisonneuve, Simon, Carrothers, Brigham, Stim- son, and others, the whole number of ojierations on record being about two dozen. The incisions for this operation, which is one of the gravest character, consist of a median division of the upper lip, with separation of both nostrils—a duplication, in fact, of the ojieration recommended for ex- cision of either jaw separately*. AVhen portions only of the jaws are to be removed, the surgeon may adopt a plan suggested and successfully* em- ployed by Porter, of Boston. This consists in making a Y-incis'on> tne long arm of the Y dividing the upper lip, and the small arms entering the nostrils, which can then be pushed upwards so as to afford a considerable amount of room. In all operations upon the ujiper jaw*, the skin covering the tumor should be scrupulously preserved, no matter how thin and distended it may appear ; if even punctured accidentally, a permanent fistula is apt to result. To complete the subject of excision of the upper jaw, the following statis- tics of the operation are quoted from Heyfelder :—• Nature of operation. Whole No. of cases. Cured. Relapsed or died. Result unknown. Complete excision of one jaw . . 141 Partial " " " . . j 153 Complete excision of both jaws . \ ]1 Partial " " " . 8 51 48 5 7 33 35 6 1 57 70 1 Gluck and Zeller advise that the trachea should be transversely divided between its third and fourth rings a few days before the principal operation, the lower end being fastened externally. The continuity of the windpipe can be ultimately restored by a final operation after convalescence from those which have preceded it. The ope- ration is said to have been successfully performed upon dogs. Trendelenburg and Gerster have devised ingenious tracheal tampons for preventing hemorrhage and per- mitting the administration of an anaesthetic through the tracheal opening. Stimson employs a tube to plug the larynx and pharynx during operations, but introduces it through the mouth, thus avoiding the necessity of opening the trachea. 830 DISEASES OF THE MOUTH, JAWS, AND THROAT. H. Braun has tabulated 23 cases of double excision, classified as follows:— Nature of operation. Complete extirpation for tumor . Partial or consecutive extirpation for tumor Excision for necrosis ..... Whole N. of cases. 11 5 Recovered. Died. •4 "i Tumors of the Lower Jaw__Cystic, Fibrous, Fibro-cellulttr, Cartilaginous, Bony, Myeloid, and Encephaloid growths are met within this situation, commonly* originating in the cancellous structure in the centre of the bone, and jirojecting both into the mouth and downwards into the side of the neck, in the form of rounded or irregularly lobed masses. Epithelioma of the lower jaw is usually secondary to ejiithelioma of the lip. The remarks which were made as to the importance of a correct diag- nosis, in cases of tumors of the upper jaw, are equally applicable with re- gard to those of the inferior maxilla—cystic growths being usually curable by* laving open the cyst and stuffing its cavity with lint—non-malignant, solid tumors requiring excision with saw and cutting pliers—and malig- nant growths, on the other hand, often not admitting of any o|>crative interference whatever. Maunder succeeded in two cases in removing solid tumors of the lower jaw, without making any external incision. Excision of the Lower Jaw.—It is occasionally jiossible, as advised by Heath, and as long ago done by the late J. Rhea Barton, of this city, to remove non-malignant solid tumors of the lower jaw, with- out sacrificing the whole thickness of the bone ; and it is certainly desirable, under such circumstances, to jiresorvc the base of the jaw, for the reasons already given in speaking of epulis of this part. If, however, the whole thickness of the bone on one side he involved, excision may be j>erforined by making a single incision along the base of the jaw, prolonging the cut, if necessary, in a line corresponding to the position of the ascending ra inns, and curving the anterior extremity of the wound upwards, toward but not through the prolabium. If the portion of the bone to be removed extend beyond the median line, a ligature should be passed through the tip of the tongue to prevent its re- traction when the muscles of the floor of the mouth are divided. In this first incision the facial artery will he cut, and should be immediately se- cured with ligatures. The flap, formed as above directed, should be care- fully dissected up, and the inner side of the jaw cautiously cleared, by separating the soft tissues of the mouth—a tooth having been previously extracted on either side of the tumor; the saw is to be applied so as to cut a deep notch through the alveolus, the bone section being subsequently completed either with the saw or cutting pliers. The part to be removed Fio. 498.—Disarticulation of the lower jaw. (Ferousson.) ANCHYLOSIS OR CLOSURE OF THE JAWS. 831 is then seized with the lion-jawed forceps, and wrenched out, any remaining attachments being severed with a few* strokes of the knife. If the morbid growth involve the angle of the jaw and part of the as- cending ramus, it will be necessary* to disarticulate the bone upon that side; in this case, the incision should be jirolonged to the back of the articulation, when the bone, having been divided in front of the tumor, is to be cleared by careful dissection, the surgeon then depressing the body of the jaw, so as to render tense and facilitate the division of the attach- ment of the temporal muscle to the coronoid process ; the jaw being twisted somewhat outwards, the joint may now be opened from the front, and dis- articulation completed. The edge of the knife should, throughout, be kept close to the bone, lest the internal maxillary or even the external carotid artery should be accidentally wounded. Hemorrhage being checked by ligatures, or, if from the dental artery in the cut surface of bone, by the application of Monsel's salt or the actual cautery, the external incision may he closed by means of the interrupted or twisted suture. Until union is completed, the patient's diet should be limited to liquid food, which mav be given through a tube. In order to avoid wounding the'jiortio dura nerve or parotid duct, J. L. Lizars, of Toronto, recommends, instead of the incision above described, one passing from the commissure of the lips out- wards towards the ear, disarticulation being readily efl'ected from within the mouth when its orifice is thus enlarged. As already mentioned, Maunder has reported two cases in which he succeeded in removing large tumors of the lower jaw*, without any external incision whatever. Metallic caps to fit the teeth of the remaining portions of the jaw, and connected with a spring to a similar contrivance applied to the teeth of the upper jaw, are sometimes employed to prevent distortion from the action of the muscles. Such an apparatus is, however, according to Heath, quite unnecessary, as the bone quickly resumes, unaided, its nor- mal position. If the tumor be very large, involving both sides of the jaw, a |J-shaped incision dividing both facial arteries may be employed, as recommended by Fergusson; or, as advised by Heath, the lower lip may be divided in the median line, and the flaps dissected back on either side. Excision of a part of the lower jaw for tumor, which was first performed by Deaderick, of Tennessee, in 1810 (though his case was not published till thirteen years afterwards), has been practised a great many times ; and, except in cases of malignant disease, with very good results. The propor- tion of failures under the latter circumstances (twenty-one out of thirty- nine cases, according to Heyfelder) authorizes the question whether, in a case of this kind, admitting of any operation, complete extirpation would not be better than any less sweeping measure. The following statistics of excision of the lower jaw, for all causes, are taken from Weber. Nature of operation. Whole No. Cured. Relapsed of cases. or died. Complete extirpation ...... Disarticulation of half the jaw .... Partial excision ....... 20 19 1 153 117 36 246 200 j 46 Anchylosis or Closure of the Jaws may follow sloughing result- ing from the abuse of mercury or from cancrum oris, or occurring in the course of low fevers; it may also be caused by rheumatoid arthritis, by the contraction of the cicatrix of a burn, or by a wound of the temporo- maxillary articulation. If the case be one of actual anchylosis (i. e., due to 832 DISEASES OF THE MOUTH, JAWS, AND THROAT. articular changes), osteotomy of the ascending ramus should be tried ; this operation has, according to Schultcn, been emjiloyed in nineteen cases with invariably good results. If the closure of the jaws be due to cicatri- cial contraction, and be confined to one side, it may be remedied by a resort to Rizzoli's or Esmarch's ojieration (see p. 320), the latter j>roced- ure being probably the better of the two. The section of the bone should always be made in front of the cicatrix. If both sides of the jaw are affected, provided that the whole thickness of the cheek be not involved, an attempt may be made to restore the mobility of the part by dividing the cicatricial bands from within, and gradually sejiarating the jaws by means of a screw dilator, or, which Heath prefers, by the use of metal shields adapted to the teeth, and forced apart with wedges. This mode of treatment, though both tedious and painful, can, according to Heath, he made with care and attention to yield very good results. An ingenious arrangement of pulleys and leather straps has been successfully employed by Dr. B. J. D. Irwin, of the U. S. army. Excision of the condyle of the lower jaw for temporo-maxillary anchylosis has been successfully resorted to by Humjihry, Bottini, Little, Abbe, Gerster, Rage, and Heath, the latter of whom considers this operation preferable to either simjile oste- otomy or Esmarch's method. The angles of the jaws have been excised with'good result by W. H. Bennett. Dr. Mears, of this city, has effected a cure bv removing both condyle and coronoid process, with the up|>er half of the ascending ramus. Similar successes have been recorded by Dr. Bull and Dr. Lange, of New York. Diseases of the Palate. Cleft Palate__This is a congenital deformity consisting of a division In the median line of the part, which may be confined to the uvula (Bifid Uvula), or to that and the soft palate, or may involve the whole roof of the mouth, being, perhaps, additionally complicated by the coexistence of harelip. More rarely, the hard palate is cleft (in connection with harelip), the soft palate and uvula escaping. In some cases there is a double fissure anteriorly, the intermaxillary bone projecting between the two clefts. If the deficiency be extensive, a cleft palate may interfere seriously with deglutition by allowing regurgitation through the nose, and in all cases it causes indistinct articulation, with a disagreeable modification in the tone of the voice. Treatment.—If very slight, and limited to the soft parts merely, a cure1 may sometimes be obtained by Cloquet's plan, recently revived by Mason, of repeatedly cauterizing the angle of the cleft, and then waiting for cicatrization to produce contraction. As a rule, however, cleft palate can only be remedied by the use of the knife, the operations applied to the soft palate being called Staphylorraphy and Staphyloplasty, and that to the hard palate, Uranoplasty. Staphylorraphy.—If the case be complicated with harelip, this should be operated on in infancy, the patient wearing subsequently a sintalilc cheek-compressor, so as to encourage contraction of the fissure. As the operation of staphylorraphy is both painful and tedious, it was formerly considered necessary to wait until the patient should be old enough to he himself anxious for a cure, and willing to co-ojierate with patience and for- titude in the surgeon's effort for his relief. At the present day, however, 1 Tuckey recommends preventive treatment as in the case of harelip (see foot-note to page 809). STAPHYLORRAPHY. 833 Fio. 499.—Mason's gag. with the aid of anaesthetics, and particularly with the facility afforded by the use of one or other of the ingenious gags devised by Coleman, T. Smith, Wood, Mason, Whitehead, Weir, and other surgeons, it is no longer thought imperative to wait in all cases until adult life, and numerous highly success- ful operations upon young chil- dren have now been performed under these circumstances, Wolff, indeed, having operated successfully- at the early* age of five months. The great object of operating at an early period, in these cases, is that the fissure may be closed before the child has acquired the peculiar nasal tone of voice which habitually accompanies the deformity; and the age at which the operation should ordinarily be attempted, in suitable cases, may be given, upon the authority of Holmes, as about three years. The first successful staphylorraphy vyasdone by Boux, in 1819, and the operation has since been illustrated by the Warrens, father and son, Mutter, Dieffenbach, Liston, Fergusson, Sedillot, Mettauer, J. Pancoast, Avery, Collis, Pollock, and others. In its simplest form, the operation consists in freshening the edges of the cleft, and then bringing them together with a sufficient number of interrupted sutures. In order to diminish the tension upon the stitches, Boux employed transverse incisions, for which Dieffen- bach judiciously substituted incisions parallel to the fissure. Warren, in 1843, introduced a further improvement, which consisted in dividing the muscles contained in the posterior pillar of the fauces; but to Fergusson, in 1844, is due the credit of first distinctly pointing out the importance of a preliminary myotomy, so as to temporarily para- lyze the velum, and thus prevent disturbance of the line of union by the muscular action of the parts Fergusson's operation consists in dividing the levator palati on either side, by introducing a curved knife through the fissure and cutting from above— then dividing the palato-pharyngeus by snipping the posterior pillar of the fauces (as was done by War- ren), and, if necessary, similarly dividing the ante- rior pillar, containing the palato-glossus. Pollock and Se'dillot divide the levator palati by what might be called a submucous section, thrusting a knife through the palate near the hamular process on either side, and severing the muscular fibres by raising the handle and depressing the blade of the instrument. This division of the muscles is often attended with more bleeding than any other part of the operation, and hence, if an anaesthetic is to be used, may be advantageously postponed, as recommended by T. Smith, until after "the introduction of the sutures', or, on the other hand, may be done, as advised by Callender, without an- esthesia, a few days before the rest of the operation is performed.1 1 According to Lawson Tait, myotomy by any method is occasionally followed by atrophy of the palate. Willett and Marsh have met with secondary hemorrhage oo Fio. 500.—S6dillot'\ opera- tion for staphylorraphy. 834 DISEASES OF THE MOUTH, JAWS, AND THROAT. Paring the edges of the fissure may be either the first or the second step of the operation, according as myotomy has or has not been previously j>er- formed. The surgeon may seize the tiji of the uvula on either side and pare the edges from before backwards, by transfixing the part withasharj)- pointed bistoury- near the angle of the cleft, the angle itself being suhse- quently freshened ; or, as advised by Smith, may cut from behind forwards —the advantage of this plan being that the blood flows backwards, and thus does not obscure the line of incision. Drs. Packard and Cohen, of this city, have adojited with advantage the plan of splitting instead of paring the edges, as practised by Langenbeck and Collis in eases of vesico- vaginal fistula, and Prof. Forbes has, in cases of slight extent, ingeniously adapted Nelaton's harelip operation, surrounding the fissure with an in- verted /\ incision, the resulting wound becoming, by the drojqiing of the flap, of a diamond y sbajie. (See page 810.) The introduction of the sutures is probably the most difficult part of the operation for cleft jialate. If the ordinary silk suture is to be used, the plan suggested by Avery will be found very convenient. This consists in introducing, with a small naevus needle, on one side a single thread, and on the other side a loop of silk; one end of the single thread being then passed through the loop, the latter is withdrawn, carrying the single thread with it, and thus readily bringing the suture into jilace. By this mode of proceeding the needle is introduced on either side from below, thus enab- ling the surgeon to regulate the distance between his stitches with greater accuracy than would otherwise be possible. Instead of the silk suture, T. Smith employs fine catgut or horsehair, while most American surgeons consider silver wire preferable to any other material. If wire be used, a tubular needle may* be employed, or, if this be not at hand, a short curved needle, its introduction being facilitated by the use of a suitable handle or forceps. In my own operations I have usually employed two long- handled needles, one for either side, an assistant threading them with wire through the fissure, after they have been introduced. The mode of fastening the suture is a matter of some imjiortance. Fer- gusson passed one end through a slip noose formed upon the other, and drawing this noose tight, ran it up so as to ajijiroxirnate the edges of the fissure, securing the whole with an ordinary surgeon's knot. If horsehair be used, a triple instead of the common double knot is, according to T. Smith, necessary* to jirevent slipping. The wire suture may be secured by clamping upon it a perforated shot. From three to five sutures are usually required, and they should enter and leave the palate about a quarter of an inch from the freshened edge on either side of the cleft; they must not he drawn too tight, it being always remembered that they are meant not to pull, but merely to hold the edges together. The anterior suture is usually introduced first, and when all are secured, if, in spite of the relaxation afforded by myotomy, the parts appear tense, free lateral incisions should be made on either side. The sutures, as a rule, should not be removed until the eighth or tenth day, and then one or two at a time—the patient during the interval being fed on liquid but nutritious food, and kept as quiet as possible, though not necessarily confined to bed. After the operation, the voice is occasionally observed to have under- gone immediate and decided improvement, but in most cases, at least in adults, a considerable length of time and a long course of vocal gymnastics requiring the operation of plugging the posterior palatine canal, and I have rnyBeli been obliged to plug the incisions made in dividing the muscles. uranoplasty; uraniscoplasty. 835 will be found necessary to restore distinct articulation. The impairment of voice which persists in these cases is, as pointed out by F. Mason, due to the tension of the palate, which forms a curtain tightly stretched across the fauces, while the air enters the posterior nares above ; to remedy this, Mason supplements the ordinary operation by severing the attachments of the palate to the fauces on either side. Staphyloplasty is a name employed by Dr. Schonborn, a German surgeon, for an operation which consists in taking a flap of the mucous membrane from the posterior wall of the pharynx, and dove-tailing it be- tween the freshened edges of the palatal cleft; the advantage claimed for this method is that the improvement in voice is greater than after the ordi- nary operation. Uranoplasty; Uraniscoplasty.—The merit of first devising an operation for the cure of fissure of the hard palate is due to the late Dr. J. Mason Warren, of Boston, who published an account of his procedure in 1843. His plan was to dissect up, with a long double-edged knife curved on the flat, the mucous covering of the hard palate, beginning on either side of the fissure, and carrying the dissection back to the alveolar processes; the pendulous flaps thus formed were then united in the median line. Another jilan, w'hich Fergusson preferred, is to make an incision par- allel to the alveolus on either side, and carry the dissection toward the free margin of the fissure.1 Langenbeck used a blunt instrument with which to separate the periosteum from the bone, in order to take advantage of the osteo-genetic power of that membrane; and his operation, wbich has been frequently performed in Germany, has been successfully rejieated in this country by several surgeons, myself included. Dr. Win. B. White- head published an excellent paper on this subject, with an analysis of 55 cases, in the American Journal of the Medical Sciences for October, 1868. Fergusson, reviving a suggestion of Dieffenbach's, proposed, as an im- provement upon Langenbeck's method, to divide the hard palate on either side with a chisel, and then forcibly press and wire the segments together so as to diminish the median fissure. Eighty-two cases had thus been treated by Sir Wm. Fergusson up to the end of 1875, and, with some few exceptions, with very remarkable success; but the method has not ob- tained the approval of surgeons generally*. Woakes has modified this ope- ration by partially* sawing through the palate from the nostril, and then bending the bones into the required position. It is a disputed point among surgeons, whether, in dealing with a fissure of both hard and soft palate, an attempt should be made to close the whole gap at once, or whether the operation should be divided between several sittings : no positive rule can be given upon this point, but Holmes's advice appears judicious, viz., to be content with closing a portion of the hard palate at the first operation, provided that the parts come easily together, but, if it should be found necessary to detach the soft parts through the whole extent of the cleft, then to attempt complete closure at one opera- tion. According to T. Smith, if staphylorraphy be performed at an early age, the fissure of the hard palate will subsequently undergo contraction to such an extent as to render it possible, in most cases, to dispense with any further operation. In cases of cleft palate not admitting of surgical treatment, and in most cases of Acquired Perforation of the Hard Palate, particularly as the result of syjihilis, obturators of metal, ivory, or vulcanized India-rubber, 1 Lannelongue reports a case successfully treated by detaching and bringing down the nasal mucous membrane. 836 DISEASES OF THE MOUTH, JAWS, AND THROAT. may be worn ; one of the best instruments of the kind is that devised by Kingsley, of New York ; it is provided with a soft curtain of India-rubber, to take the jilace of the natural velum. Dr. Arthur combines a jiartial operation with the use of an obturator, so arranged as to be under the con- trol of the palatal muscles. A judicious caution as to the use of obtura- tors, in cases of necrosis, is given by Heath. This is, that no j>lug should be introduced into the aperture itself, which would inevitably become still further enlarged by the pressure on its edges, but that the occluding apjia- ratus should consist of a properly fitting plate, arching below the palate, and attached to the teeth. Elongation of the Uvula.—This affection is usually remediable by the use of astringent gargles or caustic solutions, but, if persistent, may require a surgical operation for its relief. This operation consists simply in cutting off the pendulous part with scissors, at about a third of an inch from the root of the organ. The tip of the uvula may be seized with forceps held in the left hand, while the scissors are applied with the right, or an instrument may be used which has been constructed for the purpose, and by which the part to be removed is caught and cut off at the same moment. (Fig. 501.) Tumors of the Palate__Adenoid, fibrous, and cartilaginous tumors of the palate have been observed by Ne'laton, Marjolin, Laugier, Watson, King, Bickersteth, Dobson, Eliot, and other surgeons. As the growths increase in size, they affect the tone of the voice, and ultimately interfere with deglutition; the treat- ment consists in enucleation, which is usually readily effected with the finger introduced through an incision corre- sponding to the long axis of Fib. 501. Forceps-scissors for cutting uvula. f ° T ,ir ° , , the tumor. In Watson s and King's cases it was thought necessary to facilitate access to the tumor by a preliminary section of the lower jaw. Meplain reports a case of mucous polypus of the palate successfully treated by the injection of acetic acid. I have seen one case of carcinoma of the palate, involving more than half ■ of the velum pendulum palati with the adjoining portions of the fauces and pharynx. The growth was removed without much trouble, but the case ter- minated fatally from pneumonia on the fourth day. Diseases of the Tonsils. Tonsillitis, Inflammation of the Tonsils, or Quinsy, may terminate in resolution, or run on to suppuration—in which case the patient may suffer a good deal from dyspnoea, before relief is afforded by the sponta- neous opening of the abscess. Local depletion, by scarification of the part with a probe-pointed knife, may sometimes be of service in these cases, and, if the presence of pus can be determined, an incision may be made for its evacuation ; the ordinary gum lancet is a safe and convenient instru- ment for this purpose. Gine* and Armangue' advise applications of bicar- bonate of sodium, which thev consider almost a specific in this affection. In diphtheritic tonsillitis, Menzel has derived advantage from the injection into the gland of a few drops of the liq. iodinii compositus. MALIGNANT AFFECTIONS OF THE TONSILS. 837 Chronic Enlargement or Hypertrophy of the Tonsils may- occur in healthy children as the result of frequent attacks of tonsillitis, croup, diphtheria, etc., or may be a manifestation of the scrofulous dia- thesis, occurring without any obvious exciting cause. If excessive, this hypertrophy may lead to unpleasant results, such as snoring during sleep, obstruction to nasal respiration (giving rise to a habit of keeping the mouth open), and even permanent dyspnoea—producing perhaps contraction of the chest, and eventually interfering with the general nutrition of the patient. Deafness, also, is often attributed to tonsillar enlargement. The treatment consists in the use of astringent gargles, the application of nitrate of silver, in substance or solution, the muriated tincture of iron, or the tincture of iodine (which Dr. Dabney advises should be combined with ergotine and glycerin), and in the adoption of means to improve the general health. Inhalations of diluted creasote vapor, or the use of the atomizer, may also prove of service. Krishaber recommends ignipuncture with Paquelin's cautery, and Chisolm cauterization of the tonsillar crypts or follicles with a saturated solution of chloride of zinc. As a last resort, excision of a portion of the enlarged tonsil may be performed, either by seizing the projecting part with forceps and cutting off a slice with a probe- pointed bistoury, wrapped so as to protect the lips, or by means of an instrument devised for the purpose by Fahne- stock, and since modified by others, which is known as a tonsillotome or tonsil guillotine. If the simple knife be used, care should be taken to keep its edge directed some- what towards the median line, so as to avoid the possi- bility of wounding the internal carotid artery. J. Wood advises that the section should be made from below up- wards. The surgeon may stand behind the patient in operating on the right tonsil, and to the patient's right side in operating on the left. Evulsion of the tonsil with the fingers is recommended by* Bernardino, Borelli, Larghi, and Farmer. Hemorrhage is rarely troublesome after these operations, usually yielding readily to the applica- tion of ice, or simple astringents ; if bleeding should, how- ever, persist, a turpentine gargle, as advised by Erichsen, might be tried, or the part might be lightly touched with a brush or sponge dipped in Monsel's solution. Panas recommends digital compression through the mouth with counter-pressure externally*. Malignant Affections of the Tonsils.—The ton- sil is occasionally, though rarely, the seat of carcinoma, which may be either scirrhus or encephaloid, the latter being (according to Poland, who has particularly investi- gated the subject) the commoner form of the' disease ; epithelioma has also been observed as a primary growth in this locality, and Dr. Donaldson has collected 9 cases of the kind, including one observed by himself. The whole number of recorded cases of tonsillar carcinoma is, according to the same author, 71. Sarcoma of the tonsil has been observed by Bichardson. The diagnosis of malignant disease from simple hypertrophy may be made bv observing the greater hardness of the tumor, its tendency to ulceration, and the implication of neighboring lymphatic glands. From syphilitic disease of Fio. 502. Fahnestock's ton- sillotome. 838 DISEASES OF THE MOUTH, JAWS, AND THROAT. the tonsil, the diagnosis is sometimes very difficult, but may be aided by observing the efficacy, or want of efficacy, of anti-syphilitic treatment. In most cases of malignant disease, in this situation, palliative measures are alone applicable, but if the nature of the affection is recognized at an early period, while the disease is as yet confined to the tonsil itself, excision may be properly attempted. Weinlechner records a case believed to be one of sarcomatous tumor of the tonsil, in which recovery followed inter- stitial injections of iodoform. Extirpation from within the mouth has been practised by Veljieau, Warren, Lucas, and Demarquay—the latter surgeon having employed the ecraseur—but, upon the whole, the ojieration by ex- ternal incision, as successfully- resorted to by Cheever and (JoIding-lJird, would appear preferable. In a case recorded by the former surgeon, two incisions were made, one from within the angle of the jaw downwards, in a line parallel to the sterno-mastoid muscle, and the other along the lower border of the jaw ; by dissecting away the jiarts on either side, an enlarged lymphatic gland was first exjiosed and removed, and then, the digastric, stylo-hyoid, and stylo-glossus muscles being cut, the fibres of the superior pharyngeal constrictor were separated, so as to allow the finger to enter the pharynx, when the tonsil was readily enucleated. The largest vessel divided was the facial artery, twelve ligatures in all being required. The transverse wound was closed with a single suture, and recovery was com- plete in about a month. Successful operations are also attributed to Czerny, Quintin, Mikulicz, and Bicbardson. Diseases of the Pharynx and (Esophagus. Erysipelas of the Pharynx is occasionally met with, either as a primary affection, or as a conqilieation in cases of ordinary facial erysipe- las ; the treatment consists in the administration of tonics and stimulants, with the local use of a solution of nitrate of silver, and of gargles of chlorate of jiotassium. Should sloughing occur, the mineral acids may be emjiloyed, both internally and topically. Laryngotomy may become necessary in the event of the sudden sujiervention of oedema of the glottis, while free incisions into the affected parts would be indicated by the occur- rence of suppuration. Retro-Pharyngeal Abscess.—Abscesses are occasionally met with behind the pharynx, originating either in the areolar tissue in front of the vertebral column, or in the lymjihatic glands which exist in that situation. The formation of pus in some cases evidently depends upon disease of the cervical vertebra?. Betro-pharyngeal abscess is commonly- a grave affec- tion, 41 out of 97 cases collected by Gautier having proved fatal, though Bokai reports 144 cases observed by himself, of which only 11 terminated in death. No age is exempt from the disease, though it is most common among young children. The early symjitoms are in no wise distinctive, but when pus has formed, a distinct tumor may be observed, by the touch if not by sight, usually involving one side of the pharynx only, and soon leading to unilateral swelling of the neck, and often to stiffness of the lower jaw. The treatment, which should be promptly applied to jirevent suffocation, consists simply in making a free opening (jueferably through the mouth) for the evacuation of the pus, either with a wra|iped bistoury, a trocar and canula, or an instrument devised for the purpose- and known as a pharyngotome. Pharyngeal Tumors may arise in the postpharyngeal areolar tissue, may descend from the nasal cavities, or may spring from the epiglottis. They may be of the nature of polypi (fibrous or fibro-cellular tumors, myxomata, etc.), or may be malignant growths, either of a sarcomatous, SPASM OF THE (ESOPHAGUS. 839 carcinomatous, or epitheliomatous nature. As they increase in size, they* imjiede both deglutition and respiration, and may thus lead directly to a fatal termination. Operative interference, further than tracheotomy to avoid suffocation, can rarely* be justified in a case of malignant growth in this situation (though extirpation of the pharynx for cancer has been recom- mended and practised by Langenbeck and Billroth, and in two cases by Carle), but the treatment of innocent pharyngeal tumors may be more hojiefully undertaken. In some cases, it may* be possible to remove the mass through the mouth by avulsion or enucleation, or by the use of the ligature, ecraseur, galvanic cautery, etc., but in dealing with growths springing from the epiglottis or adjoining parts, such a course would rarely be practicable, and under these circumstances the operation known as Sub-hyoidean Pharyngotomy might be performed. This process appears to have been first described by Malgaigne, under the name of Sub-hyoidean Laryngotomy, and has been revived by Lan- genbeck. In a case narrated by* this surgeon, a preliminary tracheotomy- having been performed and a tube introduced, the operator made a small transverse incision close beneath the lower edge of the hyoid bone, and divided the sterno-hyoid and omo-hyoid muscles. The thyro-hyoid mem- brane being ojiened, the finger of an assistant was placed in the pharynx, pushing forward the tumor for the removal of which the operation was undertaken, w-hen the mucous membrane of the gullet was divided, and the epiglottis, which was found to be healthy, drawn forward with a strabismus hook The tumor—a fibro-my-xoma, the size of a pigeon's egg—was now seen arising from the left aryteno-epiglottic fold, and ex- tending by a broad base to the left side of the pharynx. Excision was accomplished by drawing out the growth with forceps, and carefully sepa- rating it from its attachments, blood being kept from entering the larynx by pressing a sponge over the glottis. For several weeks it was necessary to feed the patient through a tube, but the ultimate result of the case was quite satisfactory. This operation has also been successfully* employed by Baum, in a case of round celled sarcoma, and by* Lefferts, in a case in which a foreign body had been fixed in the larynx for four years. It has, accord- ing to Iversen, been performed, in all, in 18 cases, of which 6 ended in permanent recovery, while relief was afforded in several others. Wheeler, of Dublin, has successfully* removed a pharyngeal growth by pharyngotomy. Pharyngocele, a dilated and sacculated condition of the pharynx (pressure diverticulum), has been successfully* treated by Mr. Wheeler by* laying open the part, removing a sufficient portion of the dilated pharyn- geal wall, and closing the wound with sutures. (Esophageal Tumors of a non-malignant character are occasionally met with, and, according to Cohen, are usually* fibromatous and polypoid. Ligation has been practised in these cases by Dallas, Dubois, Hofer, Mid- deldorpf, and Minkewicz. Spasm of the (Esophagus, or, as it is often called, Spasmodic Stric- ture of this tube (CEsophagismus), may be met w*ith in connection with other hysterical phenomena, or may be a reflex condition depending upon slight inflammation or ulceration of the part, upon hepatic disease, upon the irritation caused by hemorrhoids, etc. The diagnosis from actual ob- struction may be made by observing the intermittent character of the affection, and by the use of the oesophageal bougie, which, in a case of this description, will meet with little if any resistance. According to Ham- burger and Mackenzie, information may also be gained by auscultation of the oesophagus, regurgitation of food, etc., being heard to take place in- stantly in cases of spasm, but after an appreciable interval in cases of organic stricture. The treatment consists in removing any source of reflex irrita- 840 DISEASES OF THE MOUTH, JAWS, AND THROAT. tion which can be detected, and in the administration of tonics, antispas- modics, and laxatives, with the use of cold bathing, and attention to the quality of the food, which should be unirritating and thoroughly masticated. Girard recommends hypodermic injections of atropia. Paralysis of the (Esophagus may occur as a symptom of disease of the central nervous system, and may be distinguished from (esophageal spasm by the absence of pain or any sense of choking. Food may be cautiously administered in these cases through a stomach-tube, or the strength of the patient may be sustained by the use of nutritive enemata. The application of electricity- is said to have occasionally proved beneficial. A Dilated and Sacculated Condition of the (Esophagus is sometimes met with—usually, however, as a consequence of organic stric- ture. A comparatively slight degree of obstruction, and one which does not prevent the passage of a bougie, may yet allow the temporary reten- tion in the gullet of a portion, at least, of the food sw*allowed, and thus gradually lead to a dilatation of the part, and to the formation of pouches extending among the muscles of the neck in various directions. Such a condition existed in the case of the late Dr. Marshall Hall. The treatment of oesophageal dilatation, without stricture, can be palliative merely, consisting in the administration of liquid food, through a tube, or in the use of nutrient enemata. Wheeler, of Dublin, recommends a resort to gastrostomy. Stricture of the (Esophagus.—Dysphagia, which is the prominent symptom of oesojihageal obstruction, may depend upon a number of condi- tions totally indejiendent of any organic disease of this part. Thus, as has been already mentioned, difficult deglutition may be due to the existence of enlarged tonsils, of pharyngeal tumors, or of retro-pharyngeal abscess; it may also be caused by various affections of the larynx, by the jiressure of cervical or intra-thoracic tumors, by aneurism of the carotid, innominate, or aorta, bv displacement of the sternal extremity of the clavicle, or by the presence of a foreign body. Hence, the diagnosis of stricture of the oeso- phagus should only be made after a careful investigation of the history of the case, and of all its circumstances; and the surgeon should beware of hastily thrusting in a bougie, which, if it might, by perforating the wall of an abscess, effect a cure, would, if it should perforate the sac of an aneurism, as cer- tainly cause death. Varieties of Stricture.—Apart from the condition known as spasmodic stricture, which has already been referred to, we may recognize two varieties of the disease, the fibrous and the malignant. The fibrous stricture is usually due to traumatic causes, especially the contact of hot water, or of caustic alkalies or acids, but has also been occasionally observed as a lesion of constitutional syphilis. It may occur in any part of the tube, and varies in extent from a few lines to several inches, involving sometimes a part onlv, and sometimes the whole calibre, of the gullet. The (esoj.hagus above the seat of stricture is usually dilated, and often ulcerated, that portion which is beh.w being normal, or slightly contracted. The malignant stricture is due to the presence Fio. 503—stricture of the oesopha- •? . /.,„.,„ 11,, eniirhniiiil or gus. (druitt.) of a carcinomatous (usually scirrhous; or INTERNAL O3S0PHAG0T0MY. 841 epitheliomatous deposit which forms a more or less distinct tumor, and is often recognizable by external examination. The rational symptoms of these two forms of stricture are much the same ; in both" there is gradually increasing difficulty- in deglutition, which culminates at last in total inability to swallow*—food of all kinds being arrested at the point of obstruction, and ultimately rejected by vomiting after a longer or shorter interval. The diagnosis between fibrous and malignant stricture may, however, usually- be made by investigating the etiology and previous history of the case, and by exploration with a gum-elastic bougie, or ivory- headed probang. The sensation given to the surgeon by the passage of the instrument through the stricture differs according to its nature ; thus, a fibrous stricture is felt to be smooth and evenly resisting, and the with- drawal of the bougie is unattended with bleeding, whereas a malignant growth gives the sensation of a rough and ulcerated surface, and a dis- charge of pus and blood is apt to follow the exploration. Treatment.—The treatment of stricture of the oesophagus is very unsatis- factory. The strength of the patient must be maintained by the'adminis- tration of liquid or finely chopped food, and, if necessary, by the employment of the stomach-tube, or the use of nutritive enemata. If the stricture be of a fibrous character, temporary advantage, at least, may often be gained by*the cautious use of bougies of gradually increasing size; by the employ- ment of fluid pressure, applied by means of a flexible catheter surrounded with a tube of vulcanized India-rubber, which can be distended with air or water after introduction ; or by the use of an ingenious instrument de- scribed by Dr. Morrell Mackenzie under the name of oesophageal dilator, which acts much on the principle of Holt's instrument for stricture of the urethra. Instruments for the dilatation of oesophageal strictures have also been devised by Fletcher and Wakley, but seem to be inferior to that of Dr. Mackenzie. Krishaber recommends the introduction of a canula through the nostril, and its retention in the oesophagus, so as to effect "continuous dilatation," as is done in stricture of the urethra. Durham, Franks, and Symonds, also advise the retention of the canula, but prefer to introduce it by the mouth. The application of caustic, as recommended by Home and others, is seldom resorted to at the present day, but Bceckel and Fort have successfully employed electrolysis. Internal (Esophagotomy, or section of the constricted part of the oesophagus from within, was introduced by Maisonneuve, who attempted the operation in four cases; three of these terminated fatally, the instru- ment in one having jierforated the wall of the gullet and entered the pos- terior mediastinum. The section should be made from below upwards, and ingenious instruments for the purpose have been devised by Dolbeau| Trelat, and Mackenzie. Of 21 cases of internal cesophagotomy, 15 are said to haye terminated successfully. Dilatation after the operation must be maintained by the use of a bougie. Great caution must be exercised in using any* instrument w-ithin the gullet; Demarquay and Bidan record cases in which attempts at catheterization of the oesophagus proved fatal from the passage of the bougie through the oesophageal wall into the bronchi or pleural cavity* Gussenbauer begins by opening the oesophagus above the stricture, and then dividing the contracted part with a herniotome guided by a filiform bougie. This operation of combined cesophagotomy has been twice successfully employed by Gussenbauer, and once by Berg- mann. The latter surgeon has, in other cases, successfully attacked the stricture from below (retrograde dilatation), after opening the stomach. (See page 844.) Two cases of combined cesophagotomy reported by bands terminated fatally, one, however, after gastrostomy also. 842 DISEASES OF THE MOUTH, JAWS, AND THROAT, Cases of Internal GZsophagotomy. Operator. Operator. 1 Czerny, Died. 12 2 Demons, ( < 13 3 Dot beau, Recovered. 14 4 Id. " 15 5 Elsberg, " IrJ 6 Id. " 17 7 Lannelongue, it ]s 8 Mackenzie, n 19 9 Maisonneuve, t < 20 10 Id. Died. 21 11 Id. " Kcsult. Maisonneuve, Hied. Roe, Recovered. Id. " Sands, i< Id. ■< Scliilz, d Id. Died. Studsgaard, Recovered. Tillaux, u Trelat, ii If the stricture be of a malignant character, the use of bougies, or other means of dilatation, will in most instances be rather prejudicial than advan- tageous; the bougie may, indeed, be cautiously employed, as a palliative measure, in the early stages of the disease, but after the establishment of ulceration can scarcely be expected to be of much benefit. Under these circumstances the best that can be done is probably to sustain the strength of the patient with nutritive enemata, and to relieve his sufferings by the free use of anodynes; excision of the affected jiart is said to have been suc- cessfully jierformed by Czerny, Kolaczek, Caselli, Novaro, and Mikulicz, and twice by Carle; but three cases in which the operation was resorted to by Langenbeck all terminated fatally, as did one in which Billroth re- moved the pharynx, larynx, and thyroid gland. Fatal excisions of the pharynx are also attributed to Koenig, Gussenbauer, Yon Bergmann, and Israel. Iversen reports seven cases of partial excision, of which three are said to have been successful. Thiersch advises the performance of a pre- liminary gastrostomy. Tracheotomy may sometimes be required to pre- vent suffocation in the later stages of the disease. It occasionally* hapjiens that, even in a case of non-malignant stricture, the jiassage is so tightly occluded that the smallest instrument cannot be introduced, and that the patient is in consequence reduced to a state in which death from starvation is imminent. Under such circumstances it has naturally been suggested that an opening should be made into the alimentary canal below the seat of stricture, and a fistulous orifice thus established, through which the patient might be fed ; and it has been reasonably argued that though such an operation might not be justifiable in a case of malig- nant disease, from which the patient must inevitably perish at no remote period, yet that in a case of impermeable fibrous stricture, the circum- stances would be altogether different. The ojierations which have been performed in these cases are gastrotomy, or, as Sedillot, its introducer, has more accurately termed it, gastrostomy, and cesophagotomy, or, as it is now called by analogy, cesophayostoviy. (Esophagostomy, or (Esophagotomy for Stricture, is manifestly best adajited to cases in which the obstruction is in the uppermost jiart of the tube, and unfortunately* the stricture usually extends to such a point as to prevent the surgeon from reaching the oesophagus below it. In a suitable case, however, the operation may be tried, the necessary incisions being those described in speaking of cesophagotomy for the removal of foreign bodies (p. 385), though the procedure, in the case of stricture, would, of course, be more difficult on account of the impossibility of intro- ducing an instrument into the gullet as a guide upon which to cut. If the GASTROSTOMY. 813 stricture w'ere of a non-malignant character, it might be proper, as Ogston did, to attempt a radical cure by extending the incision through the con- tracted part, as in the analogous operation of external urethrotomy. (Eso- phagotomy for stricture appears to have been suggested by Stoffel, but was first practised in a case recorded by Taranget, whose patient survived six- teen months. The operation has since been repeated in a good many instances, the whole number of cases to which I have references being 86, and the results being known in 35. Of these, 8 were so far successful that the patients' lives were prolonged for three months or more, while the remainder terminated fatally* at an earlier period. The mortality* of the operations is thus 77.14 per cent. This record is certainly far from encour- aging, and, as will be presently seen, is even less so than that of gastrostomy; still, as the operation, though difficult, is not necessarily* dangerous, it may, I think, in suitable cases, be looked upon as a legitimate surgical resource. Cases of CEsophagostomy. No. Reporter. Result. No. Reporter. Result. 1 Annandale, Died. 19 Menzel, Died. 2 Id. ti 20 Monod, Recovered. 3 Id. ii 21 Nicoladoni, Died. 4 Billroth, Recovered. 22 Ogston, " 5 Id. Died. 23 Packard, ii 6 Bruns, n 24 Poinsot, " 7 Id. u 25 Podradzki, " 8 Bryk, Recovered. 26 Reeves, Undetermin'd 9 Chiene, " 27 Richet, Died. 10 Cohen, Died. 28 Simon, <> 11 De La Vacherie, k 29 Studsgaard, Recovered. 12 Evans, ii 30 Id. Died. 13 Hadlich, Recovered. 31 Taranget, Recovered. 14 Holmer, Died. 32 Watson, ii 15 Holmes, " i 33 Weinlechner, Died. 16 Horsey, " 34 Id. <> 17 Kappeler, ti 35 Willett, ii 18 Id. << ' 36 Zenker, ' Gastrostomy is, as its name implies, an operation designed to estab- lish an artificial mouth, communicating directly with the stomach. Its performance is naturally suggested by observation of the success with which gastric fistulae can be established in the lower animals, of the recov- eries with persistent fistulae which are occasionally met with after pene- trating wounds of the stomach, and of the remarkable success which has attended gastrotomy, or gastric section for the removal of foreign bodies (see p. 414). Sedillot, who first performed the operation, recommends a crucial incision on the left side of the abdomen, over the gastric region ; the peritoneal cavity being opened, the surgeon feels for the left border of the liver, which is the guide to the stomach, and having reached the latter organ, draws it forwards with forceps, and fixes it in the wound by per- forating the gastric wall with a steel-pointed ivory cylinder, secured exter- nally on a disk of cork ; after some days, when adhesions have formed, an ojicning is made into the middle of the stomach, at a point equidistant from either curvature, and from either extremity. Forster, Durham, Verneuil, and others, prefer a single incision in the line of the left linea semilunaris, open the stomach immediately, and stitch the margins of the aperture closely to the abdominal parietes. Verneuil and Bryant insist that the gastric opening should be a small one. No attempt should be made 844 DISEASES OF THE MOUTH, JAWS, AND THROAT. to introduce food into the stomach until several days after the operation, lest primary union should be interfered with. Gastrostomy appears to have been jierformed in about 3152 cases, of which 120 are"said to have recovered, at least temporarily, while 239 seem to have proved fatal in periods varying from a few hours to three months, the result in 3 cases not having been ascertained. The mortality of terminated cases would, according to these figures, be 6(5.5 per cent. In the American Journal of the Medical Sciences for July, 1*84, the late Prof. S. W. Gross analyzed 207 cases of gastrostomy, of which 158 appear to have proved fatal within the first three months; to these I have been able to add 155 more, giving a total of 3G2 cases. The results may be seen in the following table :— Cases of Gastrostomy. Cases. Deaths. Undeter-mined. 3 3 Operation for malignant disease (Gross) " " cicatricial contraction " " " miscellaneous causes " Additional cases ...... 167 37 3 155 135 21 2 81 Aggregates .... 362 239 Mortality per cent, 80.8 56.7 66.6 53.2 66.5 An ojieration which has been performed nearly four hundred times, and which has in a third of the cases in which it has been adopted given at least temporary relief, can no longer be looked upon as always unjustifiable. At the same time, it should, I think, be reserved for excejitional cases, and I cannot resist the conviction that it has often been resorted to when it would have been better to avoid it. In at least two cases, after the successful completion of the operation, the patient's disgust for the artificial means of feeding provided, has been so great that he has voluntarily allowed himself to starve to death For malignant disease gastrostomy is certainly unadvisable: what right-thinking surgeon would recommend an ojieration for external cancer, if he knew that even should his patient escape the risks of the knife, the chances were four to one that death from recurrent disease would follow within three months? The risks are so great, and the possible gain so slight, that the operation is not to be recom- mended under these circumstances. In cases of cicatricial stenosis, the question is somewhat different; here the risks of the ojieration are less, and the prosjiects of permanent benefit much greater, than in eases of malignant disease ; and if the milder methods of dilatation and internal oesophagotomy were unavailable, if the stricture were placed so low as to forbid eesophagostomy or combined cesophagotomy, and if the jiatient were really in danger of starvation, the advisability of ojiening the stomach might properly be considered. The weight of testimony is decidedly in favor of the operation d deux temps, the stomach being first exposed and stitched to the external wound, but not opened until after the exjiiration of several days. Dilatation of the oesophageal stricture by the use of in- struments manipulated through the gastric opening (retrograde dilatation) has been practised by Bergmann, Schattauer, Weinlechner, Maydl, Loreta, Kocher, Hjort, Caponotto, and Hagenbach. , . Introduction of the Stomach-Tube—This may be required in cases of narcotic poisoning, in which vomiting cannot be excited, or as a means of administering fluid nutriment, in cases in which the patient can- not or will not swallow. The tube is introduced in the same manner as DISEASES OF THE AIR-PASSAGES. 845 an oesophageal bougie, and the following description will apply to the use of either instrument. The patient is placed in a sitting posture with the head thrown backwards, so as to bring the mouth and gullet as nearly as possible into the same line ; the mouth being held widely open (by means of a gag, if necessary), the surgeon passes the tube, previously warmed and oiled, directly backwards to the pharynx without touching the tongue, and guiding the instrument over the epiglottis with the forefinger of the left hand, cautiously presses it onwards into the stomach. If any obstruc- tion be met with, the instrument should be slightly withdrawn and then again pushed forwards, very gently, however, lest the cesophageal wall should be perforated. When food is to be introduced into the stomach, the surgeon may employ a small gum-elastic bag, provided with a nozzle w-hich closely fits the projecting portion of the tube ; when it is designed to wash out the stomach, a pump is required, by which one or tw*o pints of tepid water may be injected and a less quantity immediately pumped out again, the process being repeated until the returning fluid is colorless; the object of not completely emptying the stomach at once, is to prevent the mucous coating of the organ from being sucked into the orifice of the tube and thus lacerated. The risk of passing a stomach-tube into the trachea instead of the oeso- phagus is not entirely imaginary, as is shown by cases in which, after death, food and medicines have actually been discovered in the lungs. Diseases op the Air-Passages. Laryngitis, Tracheitis, Croup, Diphtheria, and other affections involving the larynx and trachea, are commonly treated by the physician, and are described in works on the Practice of Medicine. These diseases are chiefly interesting to the surgeon on account of the necessity w*hich oc- casionally arises for a resort to the operation of laryngotomy, or to that of tracheotomy, the comparative merits and modes of performing which have already* been sufficiently discussed in a previous portion of the volume (pp. 378-383). The results of tracheotomy* for diphtheria, in this country, have not been very favorable, the proportion of recoveries, according to the statistics collected by Drs. Lovett and Munro, having been only 23 per cent. The annexed table, borrowed from these writers, gives the re- sults in over 20,000 cases, the largest number, I think, that has yet been collected. Total. Recovered. Died. Per cent. recovered. German authors 5795 1851 3944 31 German hospitals 3063 939 2124 30 British authors 433 138 295 31 French authors 9242» 2242 6834 24 Various countries 1993 657 1336 32 American authors .... 1327 308 1019 15,552 23 21,853 6135 28 Mv own rule, like that of most surgeons, has been to delay opera- tion in these cases until life is threatened by the increasing difficulty of respiration ; Cheyne, however, advises tracheotomy as soon as the larynx is found to be implicated in diphtheria, in order to facilitate direct applications intended to prevent the spread of the membrane downwards. 1 166 not healed. 846 DISEASES OF THE MOUTH, JAWS, AND THROAT. Abscess of the Larynx is a rare affection which has been well described by Parry, of this city, and by Stephenson, of Kdinburgh; the treatment consists in making an early incision, and preferably* in the me- dian line of the neck. Prolapsus of the Laryngeal Sac, causing partial occlusion of the glottis, has been observed by Cohen, of this city, and was relieved by in- sufflation of astringent powders. Tracheocele, or hernia of the lining membrane of the trachea, is a rare affection which has recently been well described by Devulz, of Bor- deaux. It appears to originate from violent and repeated attacks of cough- ing, and is chiefly interesting from the likelihood of its being mistaken for goitre ; it admits of no treatment. Tumors, Warts, or Polypi of the larynx are sometimes met with, belonging usually to the fibro-cellular, papillary, or epitheliomatous varie- ties of tumor. They produce hoarseness, aphonia, croupy cough, and dyspnoea, the difficulty of breathing recurring paroxysmally*, and eventually causing death by suffocation. A flajijiing sound may often be heard as the tumor moves up and down in the act of breathing, and, by the use of the laryngoscope, the size and position of the morbid growth may sometimes be accurately de- termined. Angeiomata of the larynx are very rarely met with, Glasgow-, of St. Louis, having- been able to collect only six cases, including one observed by himself. A seventh, recently re- corded by Perreri, proved fatal by secondary hem- orrhage after removal with forcejis. Treatment—In any case of laryngeal tumor in which respiration is or has been at any previous time seriously embar- rassed, there should be no delay in opening the trachea and inserting a tube ; for experience shows that fatal dyspnoea may in such a case sup- ervene at any moment, and, besides, a preliminary tracheotomy will greatly facilitate any operation for the removal of the tumor. Various plans may be adopted in dealing with the new growth itself: thus, an attempt may be made to extract it by means of a wire snare or ecraseur (Fig. 505), as has been successfully done by Walker, Gibb, Johnson, and others; or delicate laryngeal forceps, as advised by Mackenzie, may be used to twist off or crush the tumor; or, if too firmly attached, this may be cautiously excised with the knife, scissors, or " laryngeal guillotine," or may be severed by the application of the galvanic cautery; simple 504.—Epithelioma of lar- ynx. (Erichsen.) Fio. 505.—Gibb's laryngeal ecraseur. puncture may suffice in the case of a cystic growth, while in other in- stances a cure may perhaps be effected' by the repeated application of nitrate of silver in substance or solution. The latter mode of treat- ment may also be employed to prevent repullulation of the tumor after EXTIRPATION OF THE LARYNX. 847 extirpation. In all of these methods, the application of the instrument should lie guided by the use of the laryngoscope. Voltolini has removed soft polypi by simply swabbing out the larynx with a sponge attached to a flexible "wire. To facilitate treatment by any of the above plans, Eysell suggests that the tumor should be pushed upwards by means of a needle introduced from below in the median line of the trachea. Rossbach intro- duces a delicate knife in the median line of the thyroid cartilage, and, guid- ing its movements by the aid of the laryngoscope, removes the growth by cutting from below. To render the larynx less sensitive, Tiirck and Schrot- ter advise the successive application of chloroform and of a saturated solu- tion of acetate of morphia. Cocaine may be used for the same purpose. Another method (laryngo-fissure) is to open the crico-thyroid mem- brane and divide the thyroid cartilage, so as to expose the interior of the larynx and allow* free excision of the morbid growth with knife or scissors : this operation ajipears to have been first successfully performed by Ehr- man, and has since been repeated bv Holthouse, Holmes, Durham, Buck, Sands, Cohen, Czerny, Harte, and many others. Krishaber, of Paris, has recommended, under the name of Restricted Thyroideal Laryngo- tomy, an operation in which the thyroid cartilage alone is'divided in the median line, this incision being in his opinion ample for the removal of polypi situated in the ventricle of Morgagni; the vocal cords are not inter- fered with, and the voice is consequently uninjured by the operation, which is in this respect decidedly* preferable to that of Ehrman. Finally, in some cases, Malgaigne's operation, described at page 839, under the name of Sub-hyoidean Pharyngotomy, or Langenbeck's modification, in which the larynx is opened below the epiglottis (true sub-hyoidean laryngotomy), may perhaps be preferred to any other. Dr. Sands has tabulated 50 cases of laryngeal tumor treated by opera- tion ; in 11 the growth was removed by external incision, and in 9 of these the patients recovered; in 39 cases the tumor was removed by the mouth, and recovery follow*ed in 38. The operation was performed with the aid of the laryngoscope in 34 cases. Still more extended statistics have been published by Mackenzie and Durham, those of the former author showing conclusively that, when applicable, laryngoscopic treatment is jireferable to the operation by external incision. The latter operation is not, how- ever, attended with much risk, 104 cases collected by Hoffa since 1878 having given but 4 deaths, and 120 cases studied by Becker having given but 7 deaths. The following table is condensed from Durham's article in Holmes's System of Surgery, and from a paper by the same writer in the Medico-Chirurgical Transactions, vol. lv. Whole Completely Partially Unsuc- Not Operation. number of cases. successful. successful. cessful. Died. termi-nated. Application of caustics, etc. 16 12 4 Forceps .... 37 33 3 1 Wire snare . 32 28 3 1 Galvanic cautery 5 3 2 Excision 20 14 5 1 Puncture 4 4 Operation by external section 40 22 7 7 2 2 Extirpation of the Larynx, or Laryngectomy, has been per- formed on numerous occasions, usually for papilloma or some form of malignant disease, though Heine has also excised the anterior portion of the larynx for chronic thickening of the cartilage. Langenbeck has excised 848 DISEASES OF THE MOUTH, JAWS, AND THROAT. not only the entire larynx, but the hyoid bone, and portions of the tongue, pharynx, and oesophagus ; Caselli the larynx, pharynx, and base of the tongue; and Billroth the larynx, pharynx, and thyroid gland. Unilateral laryngectomy, first practised by Billroth and by (Jerster, of New York, is a safer operation, and should be jireferred whenever the disease is limited to one side of the larynx. The most complete statistics of laryngectomy yet published in this country are those collected by Dr. Cohen, and the results of the operation may be seen from the following summary, which I have compiled from his elaborate tables in the fifth volume of the Inter- national Encyclopaedia of Surgery:— Complete Laryngectomies. Recovered .......... 17 Died within one month ....... 34 Died subsequently ........ 34 Undetermined ......... 6 Total.........91 Unilateral Laryngectomies. Recovered .......... 9 Died...........3 Undetermined ......... 1 Total.........13 Additional successful cases of complete laryngectomy have been recorded by Burckhardt and Shech (each two cases), and by Labbe, Newman, Boc- comini, Pean, Gardner, Demons, Lange, Schede,. Symonds, and Park. Regnier's jiatient was doing well three days after the operation. Fatal laryngectomies are recorded by H. Morris, Pean, Agnew, Branham, Om- boni, Lloyd, and Parker. Successful jiartial excisions have been reported by* Halm, Butlin, Socin, Kiister, Demons, and Lennox Browne. Adding these figures to Dr. Cohen's, we have for complete larijngectomy, 113 cases, with 31 recoveries, 7 undetermined cases, and 75 deaths, or nearly 71 per cent. ; and for partial laryngectomy 19 cases, with 15 recoveries, one unde- termined, and only 3 deaths, a mortality of less than 17 per cent. Hahn's personal exjierience has given 12 complete operations, with 2 recoveries and 10 deaths ; and 6 partial excisions, with 4 recoveries and only 2 deaths. Salomoni's tables of 128 cases (104 total and 24 partial) show that the immediate mortality in cases of carcinoma has been 43.6 per cent., but in sarcoma only 16.6 per cent. Scheier's statistics of laryngectomies for cancer reported since 1881, give for the complete operation 68 cases with 23 deaths, 17 relapses, 6 deaths unconnected with the operation, and 22 more or less permanent recoveries; and for partial extirpation 23 cases, with 5 deaths, 5 relapses, and 13 recoveries. With regard to the indications for comjilete laryngectomy, Dr. Cohen's conclusion seems to me to be well founded : that while the oj»eration may be justifiable in exceptional cases, in which the disease is limited in extent, the greatest good to the greatest number will be promoted by, as a rule, declining attempts at extirpation, and being content with tracheotomy and other palliative measures. Tracheal Tumors may be most safely treated by opening the wind- pipe and then attacking the growth with scoop, forceps, or finger-nail, and subsequent cauterization. Tracheal carcinoma only admits of palliative measures. Stricture of the Trachea has already been referred to at page 368. GALACTOCELE OR MILK-TUMOR. 849 CHAPTER XXXIX DISEASES OF THE BREAST. Fia. 506.—Simple hypertrophy of breasts. (Bryant.) Hypertrophy of the Breast may occur during the early months of pregnancy (when it may disapjiear spontane- ously after confinement), or may be met with in young girls, originating usually at the period of puberty, and increasing until the bulk and weight of the enlarged gland prove a source of great inconvenience, and even of suffering. Labarraque has collected 32 cases of this affec- tion, in one of which (Durston's) the enlarged breast attained the enormous weight of 64 pounds. Both mammae are commonly affected, though not to the same extent. The treatment of this affection is usually unsatisfactory. Local applications of belladonna and iodine, with compression, may be tried, while atten- tion is given to the state of the patient's gene- ral health, and to the removal of any uterine disorder that may be present. As a last re- source, excision of the hypertrophied mass may be employed, but the operation should be re- served for extreme cases. Occasionally the removal of one hypertrophied breast has been followed by rajiid diminution in the size of the other, and by complete recovery of the patient. Hence, though both mammae be enlarged, only one should be removed at first, in hope that the other may return to its normal condition. The enlargement sometimes disappears spontaneously after matrimony. Supernumerary Nipples or Mammae are occasionally met with, usually in the neighborhood of the normal organs, but sometimes in remote portions of the body. The malformation is, according to Bruce, most common in the male sex, the proportion of men affected, among those examined, being more than 9 per cent., and of women less than 5 per cent.; if from its situation the superfluous organ cause annoyance, excision may be resorted to. Galactocele or Milk-Tumor consists in an accumulation of milk, in either a fluid or a concrete condition, due to obstruction of one or more of the lactiferous ducts, from inflammation, or from the presence of a calcareous nodule—the latter constituting what is called a lacteal or mam- mary calculus. The quantity of milk which is found in these lacteal tumors is sometimes enormous. Birkett quotes from Scarpa the case of a woman aged twenty, in whom, two months after delivery, the breast was thirty- four inches in circumference, and rested on the thigh. The introduction of a trocar and canula allowed the evacuation of ten pints of fluid, which, by chemical examination, was shown to be normal human milk. Le Gros Clark has recorded a remarkable case in which two pints of milk were found in a large cystic adenocele. The treatment in these cases consists in making an opening into the tumor, this being probably best done, as advised by Cooper, by introducing 54 850 DISEASES OF THE BREAST. a trocar and canula, obliquely- from the nipple towards the seat of »('cumu- lation, so as to leave a fistulous passage for the discharge of the milk. The child should, at the same time, be weaned (if the woman is suckling), and an attempt should be made to arrest the secretion by the local use of bella- donna, the internal administration of iodide of potassium, etc. In those cases in which the accumulated milk is coagulated, an effort should be made to promote absorption by gentle friction and kneading with warm olive oil, or some other unirritating substance. Should these means fail, the tnnior must be incised, when suppuration and subsequent healing will follow. The operation should not, however, be performed during pregnancy, lest abortion follow*, an event which did occur, and w ith a fatal result, in one of the cases collected by Birkett. The treatment of lacteal calculus, which appears to be the result of calcareous degeneration in the seat of old in- flammation, consists in excision. Fissures and Excoriations of the Nipple and Areola consti- tute the affection commonly known as Sore or ('racked Nipple, and are particularly apt to be met with in the early jieriods of lactation, and after first labors. Beside interfering with the process of suckling, on account of the intense pain produced by putting the child to the breast, these cracks or fissures are apt, if neglected, to lead to acute inflammation of the nijijile, if not of the mammary gland itself. This affection is sometimes traceable to contact of the delicate skin of the part with ajihthous ulcerations in the child's mouth. The fissures, if deep, sometimes bleed, and the blood, being swallowed by the child while nursing, may be subsequently vomited. I have known a child only a few weeks old to be dosed with styptics, by direction of the practitioner in attendance, in order to check supposed haematemesis, until an inspection of the wet-nurse's breast, by another physician called in consultation, revealed the source of the vomited blood in a fissured state of the nipple. The treatment of cracked nipple consists in the employment of frequent ablutions, and in the use of astringent washes, such as those containing borax, alum, tannin, or catechu, with emollient ointments, such as that of oxide of zinc. The application of nitrate of silver, in substance or solution, to the bottom of the crack, is an efficient but very painful remedy. Collo- dion, or the styptic colloid of Prof. Richardson, is useful in protecting the part from irritation. A large number of salves and ointments of different kinds are in popular use in the treatment of excoriated nipples, but are, with few exceptions, more often injurious than otherwise. The compound resin cerate of the U. S. Pharmacopoeia has, under the name of Dohler's salve, acquired in this community a high reputation as a remedy for sore nipples. Fleischman speaks very favorably of a preparation containing lactate of zinc with glycerin and starch, while Charrier highly commends a solution of picric acid. E. T. Blackwell advises equal parts of glycerin and calomel. Whatever substance be employed, it should, for obvious reasons, be carefully washed off before applying the child to the breast. Nipple-shields, of lead or other metal, or of India-rubber, are recom- mended by some authors as a means of protecting the part during the act of suckling. I should add that Le Diberder advises the administration of quinia in large doses, and considers local treatment of secondary importance. Abscess of the Areola is to be treated by the application of emollient poultices, and by the early evacuation of the contained jms. The incision made for this purpose should be in a line radiating from the nipple towards the circumference of the breast, so as to avoid wounding any of the milk- vessels—an accident, the occurrence of which might lead to the formation of a troublesome fistula, or to permanent occlusion of the duct. MAMMITIS. 851 Fig. 507.—Paget's disease of nipple. (From a patient in the University Hospital.} Condition of the Areola Preceding Mammary Cancer- Paget's Disease—Sir James Paget has described a granular state of the nipple and areola, in which the part resembles the glans penis when at- tacked by balanitis, and which he has observed in fifteen cases, in each of which cancer attacked the neighboring mammary gland within two years. Similar cases have been since recorded by other surgeons, including Law- son, H. Morris, Manby, C. B. Porter, and myself. (Fig. 507. )Darier believes Paget's disease to be of parasitic origin. Should this condition be recog- nized,early excision would be indicated as a prophy- lactic measure. Dr. Crocker has recorded a case of "Paget's disease" oc- curring in the scrotum. Mammitis (Mastitis, Mazoitis, Inflammation of the Breast, Mam- mary Abscess, Gathered Breast).—Inflammation of the breast may occur during any stage of lactation, more rarely during pregnancy, or even at other periods. It is, perhaps, most common a few days after delivery__ when it occurs as an exaggeration of the natural raptus, or determination towards the mammary glands, which accompanies the establishment of the flow of milk—and again towards the end of lactation, when, the functional activity of the glands being exhausted, these organs appear to resent the effort to force a continuance of the secretory act. The occurrence of this affection is often traceable to exposure to cold, to injury (as from sleeping with the distended breast compressed between the arm and the body), to over-distention from a neglect to suckle the child at proper intervals, or to the irritation produced by a cracked nipple. The symptoms of mammitis vary somewhat according to the seat of the inflammation, whether in the supra-mammary or submammary areolar tissue, or in the structure of the gland itself. In supra-mammary inflam- mation, the symptoms are those of ordinary phlegmonous inflammation in any situation ; the affection is usually circumscribed, the resulting abscess rarely (according to Birkett) exceeding one or two inches in diameter. The skin over the seat of inflammation is, in these cases, red from the very beginning of the affection, the redness often preceding the other signs of the disease. The symptoms of submammary inflammation are more obscure; the form of the swelling is, however, characteristic in these cases, the whole breast being thrust forwards, and assuming a conical appearance. This is a more serious affection than that last described, suppuration fol- lowing more constantly, and the abscess sometimes discharging itself by numerous openings around the circumference of the gland. In inflamma- tion of the mammary gland itself, one or several lobes may be involved, the swelling in the latter case sometimes presenting a distinctly lobulated appearance. The skin over the inflamed part becomes cedematous, and, when suppuration is impending, assumes a dusky-red and polished appearance. 852 DISEASES OF THE BREAST. Treatment.—The constitutional treatment of inflammation of the breast consists in the administration of mild laxatives and anodyne diajihoretics, during the early stages of the affection, when there is often much fever and general sympathetic disturbance, followed by tonics, when suppuration has occurred. The patient's diet should be nutritious and abundant throughout the whole course of the affection, and malt liquors, or even more powerful stimulants, are often required in the later stages of the disease. An almost infinite variety of topical remedies has been recommended, and every nurse and neighbor "of the patient is usually provided with at least one infallible cure ; these volunteered prescriptions are, however, more often ada|>teil to aggravate than to alleviate the patient's condition. Leeches are advised by many authors, but, besides debilitating the patient by the abstraction of blood, often seem to hasten, rather than to prevent, suj)|)uration; if employed at all, they should be applied, as advised by Dewees, below rather than immediately* over the affected surface. Rest of the inflamed organ is of the highest importance ; to secure this, the breast should he supported in a sling, or in an elastic suspensory bandage (such as is in this city made for the purpose), and the arm should be kept to the side so as to "prevent motion of the pectoral muscle. The application of cataplasms, or of warm emollient fomentations, is commonly both more soothing to the patient and more efficient than the use of evaporating lotions, (ientle and methodical friction with warm olive oil and laudanum, when it can be borne, is a valuable adjuvant to the other remedies employed. Belladonna plasters are used by many surgeons, and are supposed to arrest the flow of milk ; they have, in my own experience, rarely been of much service. Dr. Dugas, of Georgia, recommends methodical pressure with a bandage. Fig. 508—Mode of supporting the breast by strapping. (Urijitt.) As long as there is a prosjiect of obtaining resolution, the breast should be kept constantly exhausted, either by suckling, or, if this give too much pain, by the use of a breast-pump. When suppuration has occurred, the child should, I think, as a rule, be weaned ; few women can, without in- jury, sustain the drain of a mammary abscess superadded to that of lacta- NEURALGIA OF THE BREAST. 853 tion, while the milk furnished under these circumstances is necessarily unsuited for a child's nutriment. When an abscess has formed, the use of poultices should be continued, and as soon as decided fluctuation is manifested, a free incision should be made, in a line radiating from the nipple to the periphery- of the breast. In most instances, the exact spot at which the opening should be made will be indicated by the occurrence of pointing, but should this indication not be present—as will often be the case if the abscess originate in the submam- mary region—the incision should be made where fluctuation is most dis- tinct, and, if possible, preferably- I think at the upper part of the breast; this advice is contrary to that usually given, an opening in the most de- pending situation being commonly recommended ; but the advantage of the superior incision is that, in the after-dressings, it allow-s the walls of the abscess to be more closely* brought together by strapping. As jirolonged suppuration is undesirable, poulticing should be discon- tinued a few days after the opening of the abscess, and a piece of oiled lint, or a little cosmoline, laid over the wound. The breast should then be care- fully strapped (Fig. 508 ). strijis of adhesive plaster being apjilied in an imbricated manner, so as to firmly- support and gently compress the whole organ. In some instances, particularly if the case have been neglected in its early stages, several openings form, which may persist and degenerate into troublesome sinuses; these may usually be induced to heal by careful strapping, and by the use of stimulating or astringent injections—tonics and concentrated food being at the same time freely administered—and if these means fail, the establishment of a seton (as recommended by Dr. Physick) should be tried, before resorting to the extreme measure of laying open the sinuses with the knife. Chronic or Cold Abscess of the Breast is to be treated by making an opening in a convenient situation, and, if necessary, introduc- ing a drainage-tube, the breast being supported by strapping, while the general condition of the patient is improved by the administration of tonics and nutritious food. The arm should be kept to the side and supported in a sling. Encysted Abscess is chiefly interesting on account of its having been frequently mistaken for solid tumor, and excision of the breast having, as a consequence, been unnecessarily performed. The diagnosis may* be made by observing that abscess almost invariably* originates during the pregnant or puerperal state, is not distinctly* circumscribed, nor freely movable, is accompanied with subcutaneous oedema, and is commonly elastic, if not positively fluctuating. The exploring needle may be used in any case of doubt, and should always be employ*ed before resorting to excision. The treatment of encysted abscess consists in the evacuation of the contained pus, and the subsequent formation of a seton or the use of stimulating injections, to promote the healing of the cavity. External support should at the same time be afforded by strapping. The induration in these cases may persist for a very long period. Neuralgia of the Breast.—This is a distressing affection which may occur in connection with small glandular or other mammary tumors, or may exist independently of any* discoverable local lesion. It is, according to Erichsen, commonly* associated with uterine derangement. The treat- ment is that of neuralgia in general; tonics, such as iron and the vale- rianate of zinc, are usually indicated, and, as topical remedies, plasters of belladonna or opium will often be found serviceable. If the neuralgic con- dition be dependent upon uterine irritation, this must of course receive due attention. 854 DISEASES OF THE BREAST. Tumors of the Breast. The female breast is very frequently the seat of tumors, the chief forms of morbid growth of a non-malignant character met with in this situation being the cystic (simple or proliferous) and the glandular, though fibroid, sarcomatous, cartilaginous, and osseous tumors are likewise occasionally found in the breast, as are also true hydatids, scrofulous and tuberculous deposits, etc. Of the malignant growths, scirrhus is by far the most fre- quent, encephaloid coming next, and colloid and melanoid cancer being comparatively rare. Cystic Tumors of the Breast. 1. Simple Cysts.—These are com- monly single or unilocular, although multiple or multilocular cysts are also found in the breast. The most common variety* is the serous cyst, but oily cysts are also sometimes met with in the mammary region. The pathology and treneral characters of these growths have already been con- sidered (pp. 509, 510), and it merely remains to be stated that they com- monly occur in young and otherwise healthy persons, increase very slowly in size, are rarely painful (except perhaps at the period of the menses), have a globular appearance, and an elastic or even fluctuating feel, are movable, occupy usually a limited portion of the breast, do not implicate the neigh- boring lymjihatic glands, and are rarely attended with retraction of the nipple, or discoloration of the superjacent skin. If, however, a unilocular cyst be very large, and the skin over it thin and tense, the hue of the contained fluid may be ajqiarent through the integument, or the tumor itself may be translucent, the affection being then sometimes designated as Hydrocele of the Breast. If, as sometimes happens, the cyst communi- cate with a milk duct, pressure may cause a small quantity of fluid to exude from the nipple. Diagnosis.—The diagnosis of simple mammary cysts, if sujierficial, is attended with little or no difficulty, but if deeji-seated these growths may be readily mistaken for cancer. Hence, in any case of doubt, the surgeon should not neglect the use of the exploring needle. Treatment.—If the cyst be single, or unilocular, a cure may sometimes be effected by the application of stimulating embrocations, such as the tincture of camjihor with lead-water, or the tinc- ture of iodine. Should these means fail, the cyst may lie punctured and a seton established, or stimulating injections, with pressure, may be employed, so as to induce adhesion of the cyst walls ; or a free incision may be made, and the cavity stuffed with lint, so as to convert the cyst into an abscess. Finally, if the cyst wall be thick, the whole tumor may be dissected out, the mammary gland itself being allowed to remain. In cases of multiple or of multilocular cysts, excision is the only mode of treatment to be recommended ; and it may even be proper, in some cases, to remove the whole gland, so as to insure thorough extirpation. Fig. 509.—Brodie's sero-cystic sarcoma. (Drditt.) PAINFUL MAMMARY TUMORS. 855 2. Proliferous Cysts with Vascular Intra-cystic Growths.__The breast is the favorite seat of this variety of cyst, which constitutes the Sero-cystic Sarcoma of Sir Benjamin C. Brodie (Fig. 509). Its pathology, mode of growth, and symptoms, and the means by wbich it may be diagnosticated from a cancerous growth, have already* been sufficiently referred to (jiao-e 512). The only treatment likely to result in a permanent cure is complete excision of the affected breast. Glandular Tumor of the Breast (Adenoid Tumor, Adenocele, Chronic Mammary Tumor)—This affection appears sometimes to origi- nate as a proliferous cyst, the intra-cystic growth gradually encroaching upon and filling the cavity of the cyst, which is thus converted into a solid tumor. The glandular tumor usually occurs in young women, and often accompanies irritation or other derangement of the reproductive organs. It is usually of slow growth (occasionally, however, increasing very rapidly), commonly painless, except, perhaps, at the menstrual periods, movable, circumscribed, and with a curved outline ; it is somewhat nodu- lated, and does not implicate the neighboring lymphatic glands. Though often apparently isolated and unattached, this form of tumor is, according to Birkett, invariably connected with the tissue of the mammary gland__ sometimes by a narrow peduncle—and is inclosed within the fascia of that organ. A section of the growth presents a somewhat granular appearance, and is at first of a bluish-white color, becoming, by exposure to the air' pinkish, and finally quite red. A viscid, glairy, synovia-like fluid may be sometimes expressed from the cut surface of the tumor, but is very differ- ent in character from the "cancer-juice" of scirrhus. By microscopic ex- amination, the chronic mammary tumor is found to consist of gland-struc- ture in various stages of development, surrounded bv an investment of areolar tissue which divides the growth into minute lobules (see Fig. 2G6); the caecal terminations of the gland-tubes contain epithelial scales. According to Ranvier, Virchow, and other modern pathologists, these growths are really fibrous, sarcomatous, or myxomatous tumors, in which the presence of hypertrophied gland-structure is a mere secondary phe- nomenon. These tumors frequently contain cysts, and sometimes attain to a very large size; as in a case reported by Le Gros Clark, in wbich an adenocele weighing in all eleven pounds contained in a cyst no less than two pints of milk. Treatment.—These growths sometimes cause little or no inconvenience, and remain without change for many years; this circumstance, together with the fact that their removal has sometimes been followed by a develop- ment of cancer in situ, should make the surgeon hesitate to recommend excision in any case in which the tumor is indolent and not increasing. bnder such circumstances, the treatment should consist simply in the adoption of measures to improve the general health, with the application of sorbefacients and compression. Should, however, the tumor assume a rapid growth, or should its presence be a source of anxiety to the patient, excision may be practised, and usually with excellent results. In such a case, it will commonly be sufficient to remove the tumor itself, with that lobe of the gland to which it is attached. Painful Mammary Tumors (Irritable Tumor of the Breast).— Iwo varieties of tumor are embraced under this name, one of an adenoid or glandular character, and the other a true " painful subcutaneous tuber- cle (see page 524) The treatment consists in the administration of tonics, with compression, and the local use of anodvnes—or in excision, which may be confidently expected to give permanent relief; 856 DISEASES OF THE BREAST. Fig. 510.—Mammary sarcoma witb large cyNts ; the tumor weighed over six pounds. (From a patient in the Episcopal Hospital.) Sarcomata of the Breast are chiefly of the round-celled or spindle- celled (fibro-plastic) variety, though myeloid (giant-celled) growths are also occasionally met with in this local- ity. Mammary sarcomata often contain cysts, and are sometimes indistinguisha- ble from encephaloid growths, without microscopic examination. The treat- ment consists in excision, but the growth is apt to recur. Cancer of the Breast. —The breast1 is the favorite seat of Scirrhus, which is also the most frequent form in which carcinoma occurs in this local- ity. Atrophic Scirrhus is a term used by Collis, and some other writers, for those forms of scirrhous cancer which reduce the organ in which they are seated below the normal size, while the term Lardaceous Scirrhus is used to designate those tumors in which, along with the cancer cells, there is also a deposit of a large quantity of fat—the name aptly indicating the brawny feel and appearance (like "that of a hog's skin) which is observed in these cases. The lardaceous cancer must not be confounded with the cancer " en cuirasse" (p. 534), which commonly runs a course as chronic as that of the other is acute. Encephaloid of the breast is a much rarer affection than scirrhus, the proportionate number of cases being variously estimated, by different writers, as from one-twentieth to one-fifth. In some cases, the tumor appears, microscopically, to occupy an intermediate position between scirrhus and encephaloid, and to such growths the terms Acute Scirrhus and Firm Medullary Cancer have been applied. Melanoid and Colloid Cancer are also occasionally, but very rarely, found in the breast. Many cases which would formerly have been considered examples of encephaloid cancer of the breast, are classed by modern pathologists as cases of round- celled or spindle-celled sarcoma. They are clinically quite as malignant as true cancers. Diagnosis.__The structure and microscopic appearance of these various forms of cancer, as well as their course and symptoms, have already been sufficiently described in Chapter XXVI., and I shall, therefore, in this place merely recapitulate those points which may serve to aid in the diag- nosis between scirrhus and non-malignant solid mammary tumors; en- cephaloid is not likely to be confounded with any other tumor, except certain varieties of sarcoma which, clinically, are equally malignant. i According to Torok and Wittleshofer, the right breast is somewhat ofttmer atfected than the left. CANCER OF THE BREAST. 857 Non - malignant Tumors are somewhat nodulated, not very hard, occasionally partially elastic, movable, and non-ad- herent. They are covered with healthy skin, except in the ulcerative stages of the sar- comata, and the skin even then does not appear infiltrated, as in the case of scir- rhus. The nipple is rarely retracted, and the superficial veins are not markedly dilated. There is seldom much pain, except in the case of the "irritahle tumor," and then continuous, and of a neuralgic character. The neighboring lymphatic glands are not involved; there is no tendency to multiplication in internal organs, and, therefore, no cachexia ; and the tumor, which grows slowly, rarely recurs if it have been thoroughly excised. (Sarco- mata, however, grow rapidly and are very apt to recur.) Non-malignant mammary tumors may occur at any age, but are most common in women less than forty years old. Scirrhus, on the other hand, originating as a small nodule, is from the first of a stony hardness, and soon becomes fixed and adherent to subjacent tissues, being evidently infiltrated1 among the structures in which it is developed. The skin becomes widely involved, hav- ing a peculiar pitted or dimpled appear- ance, from the shortening of various sub- cutaneous fibres. In an extreme degree, this pitting gives the wliole breast a brawny or lardaceous appearance. The nipple is commonly retracted, and the superficial veins dilated. The pain is severe, but not continuous, of a lancinating or "electric" character. The neighboring lymphatic glands, par- ticularly those in the axilla and above the clavicle, become involved in the disease, which is often attended by a marked state of cachexia. The tumor usually grows pretty rapidly, is attended with ulcera- tion often of a peculiar character (p. 531), and frequently recurs after apparently thorough removal. Scirrhus is seldom met with in persons under forty years of age. Prognosis.—The prognosis of cancer of the breast is, of course, unfavor- able. The most rapidly fatal cases are those of encephaloid, and of larda- ceous scirrhus, and the least so, those which assume the atrophic form. The latter are chiefly met with among old persons, and, the course of the disease being chronic, death may ensue from some other cause. In the cuirass-like form of the affection, again, life is often prolonged for a con- siderable period; in these cases the virulence of the disease appears to be expended mainly upon the skin, the lymphatic glands and internal organs not being implicated until at a comjiaratively late stage. Thickening and tenderness of the periosteum in the upper portion of the humerus of the side affected have been observed by Snow, and is by him supposed to indi- cate implication of the medulla—of course an unfavorable symptom. Treatment.—The only treatment which offers any prospect of permanent benefit, in cases of mammary cancer, is excision of the tumor, together w*ith the whole mammary gland—though, as jialliative measures, compression and the application of cold may occasionally be of service (see page 541). If the tumor, though in the region of the breast, do not appear to involve the mammary gland, it will usually be sufficient to remove that portion of this organ which is nearest the cancerous mass—unless the tumor be below or on the sternal side of the gland, when, as the latter becomes infiltrated at an early period, total excision should be practised. Operative measures are not, however, to be indiscriminately resorted to in every instance. Certain cases are totally unsuited for excision : such are those in which there are multiple tumors ; in which there is extensive implication of the lymphatic glands, particularly of those above the clavi- cle ; in which the disease appears to have involved internal organs; in which there is wide-spread ulceration ; or in which the whole integument of the breast is brawny and lardaceous. The presence of any of these 1 A remarkable case of capsulated scirrhus has, however, been recorded by Culling- worth, of Manchester. 858 DISEASES OF THE BREAST. conditions would forbid the hope of being able to effect thorough extirjia- tion, and would therefore render ojierative interference improper. Nor, again, would, excision be, as a rule, advisable in a case of atrophic or cuirass-like cancer, occurring in an old person, nor in any case in which, from the general condition of the patient, or from other circumstances, the operation would probably be in itself attended with unusual risk. Ex- cluding all these cases, however, there remain a large number—probably a majority-—in which early excision is highly desirable, and in which the surgeon should urge its performance. The reasons upon which this advice is grounded have already been given (jiage 542). Slight brawniness of the integument, limited ulceration, moderate adhesion to subjacent struc- tures, or even slight lymphatic imjilication, though unfavorable circum- stances, do not necessarily contra-indicate the operation. While no rule of universal apjilication can be laid down upon this subject, the surgeon will not, I think, have cause to regret his decision, who ojierates in those cases (and those only) in which it appears practicable to safely extirpate the entire mass of disease. When excision is to be done at all, it should be done as soon as the nature of the case has been ascertained, there being no advantage to be gained by delay. Caustics may be employed in some rare cases to which the knife may be deemed inapplicable (see jiage 541). Recurrent growths should be removed as soon as detected, with the same limitations as in the case of the primary tumor. Excision of the Mammary Gland.—The operation is thus jier- foriued : The jiatient, being in the recumbent posture, is thoroughly ether- ized, and her clothing so arranged as fairly to expose the breast and upper extremity. The arm is then held out of the way by an assistant, in such a manner as to render tense the fibres of the pectoral muscle. If the tumor be non-malignant and of moderate size, a single incision will suffice; this may be a Hiujile oblique cut in the direction of the muscular fibres; or, if more room be required, may be made in the form of a double curve, or S. In the removal of malignant growths, however, the affected portion of in- tegument must itself be excised ; and here two semilunar incisions may be emjiloyed, one below and the other above the nipple, which is included between them, or a double § incision (Fig. 291), or, if the tumor be very large, an oblique incision over its upper part, and two shorter longitudinal incisions meeting below the nipple, which is thus removed with a triangular portion of the skin. In other cases again, the surgeon may prefer a cir- cular or an oval incision around the nijiple, as advised by the late Mr. Collis, of Dublin. The particular line of incision is a matter of but small importance, provided that care be taken to remove every part of the integu- ment which ajijiears adherent or infiltrated. Having completed his external incisions, the surgeon dissects rapidly down to the pectoral muscle, and turns up the edge of the mammary gland (Fig. 511), which may then often be sejiarated by the fingers, aided by a few strokes of the knife. In other cases, a portion of the pectoralis itself may require removal, and I have often been obliged to carry the dissection so deep as to expose even the surface of the ribs and the intercostal muscles. When, by careful examination of both tumor and wound, the surgeon has satisfied himself that all the diseased structure has been removed, atten- tion should be directed to the state of the axillary glands. It may happen that a single gland is enlarged, but not markedly indurated, and that it is so, apparently, as the result of transmitted irritation, rather than from being itself carcinomatous. Under such circumstances, the axilla -hould not be interfered wTith, the gland being watched, however, and, if nece>sary, sub- sequently removed by a separate operation. If the axillary glands are EXCISION OF THE MAMMARY GLAND. 859 evidently involved in the disease, though not so extensively implicated as to forbid operative treatment altogether, it is usually advised that they should be removed, the upper extremity of the incision being extended as far as necessary for this purpose. This is the course which I have myself always pursued, and it is, as mentioned, in accordance with the teachings of most authors. It is but right to add, however, that the late Mr. Collis Fig. 511.—Excision of the breast. (Fergusson.) (for whose opinion I have the highest resjiect) deprecated incisions into the axilla in almost all cases, believing that such incisions were apt to be followed by the development of lardaceous cancer of the arm and side, and that they were likely to hasten the death of the patient. When axillary glands are to be removed, they should as far as possible be enucleated with the fingers and handle of the scalpel, rather than excised—the use of the edge or point of the knife being, in the deep portions of the axilla, attended with considerable risk. If the implicated glands should unfortunately be so deeply attached as not to admit of complete removal, the best that can be done is to draw down the mass and throw a strong ligature around its base, cutting off the part below the seat of strangulation, in hope that the remainder may be destroyed by sloughing. The wound left by the operation of excision of the breast should be simply dressed. A few ligatures only are commonly required ; the lips of the wound are brought together with sutures, a drainage tube being fixed at either end, and the ordinary antiseptic dressings are then applied, and are held in place with a closely fitting but not tight bandage. The arm should be laid across the chest, so as to relax the parts, and thus facilitate union, but should not be closely confined. The mortality from the operation is small, in view of the extent of the wound, being, eveu in hospital practice, less than ten per cent. Of 147 cases of mammary cancer operated on. by Syme, only 10 terminated fatally, while the result in 55 excisions of the breast for non-malignant tumors was uniformly successful. The chief risks are from the development of erysipelas or pyamiia. Dr. B. W. Richardson has excised the breast with scissors, the parts being previously rendered insensible by using the ether spray, and the same plan has since been suc- cessfully adojited by Mr. Thomas Moore. Dr. T. G. Thomas has suggested an ingenious mode of removing non- malignant mammary tumors without the production of deformity. He makes a curved incision immediately below the breast, turns up the gland, 860 HERNIA. and enucleates the morbid growth from beneath. The gland is then replaced, and the resulting cicatrix is entirely hidden from view. The Mammary Gland in the Male may occasionally be the seat of disease; thus it has been found hypertrophied, and has been known to furnish a secretion of milk, while it is sometimes the seat of cystic or adenoid growths, or of cancer. Wagstaffe has collected 71 cases of the latter form of disease occurring in this situation. The treatment is the same as for similar affections in the female. I have myself been called upon to excise the male breast in three cases. CHAPTER XL. HERNIA. The term Hernia signifies a protrusion of any portion of the viscera through an abnormal opening in the walls of the cavity within which the protruded part is naturally contained. A jirotrusion through a normal aperture is not a hernia; thus the term is never applied to a protrusion of the bowel through the anus, or of the womb through the vulva. Hernia of the brain and of the thoracic viscera have already been considered in previous portions of the volume; and the subject for discussion in this place is therefore limited to Abdominal Hernia, or, as it is familiarly called, Rupture. . Any jiart of the abnormal jiarietes may give passage to a hernia, but rupture is most likely to occur where the muscular and tendinous struc- tures are comparatively weak, as where the sjiermatic cord or round liga- ment issues from the "abdomen, where the femoral vessels pass into the thigh, or at the umbilicus. Causes of Hernia. The Predisposing Causes of rupture may be divided into such as pertain to the general condition of the patient, as age, sex, etc., and such as pertain to the 'local condition of the jiart in which hernia subsequently occurs; the latter are called by Birkett the Inciting Causes. The Immediate or Ex- citing Cause of rupture, when any such can be alleged, is usually some violent exertion, as in lifting, coughing, or straining. General Predisposing Causes. 1. Age.—The majority of cases ot hernia are developed in infancy, or early adult life ; more, that is, before the age of thirty-five years than afterwards. This statement is contrary to the ordinarily received doctrine, but has been clearly established by the researches of Mr. Kingdon (of the City of London Truss Society), Mr. Birkett, and Mr. Croft. As, however, the number of infants and[young persons in everv community is much larger than that of adults, the rela- tive frequency of hernia is greater as old age approaches. Thus advancing a«-e may be considered a predisposing cause of hernia. c2 Sex.—The male sex is umqiiestionably more predisposed to^the oc- currence of hernia than the female, the proportion of all ages and form> or the disease being, according to Croft, about three to one. The diRercnee is most marked in infancy and early childhood, on account of the ire- quency of a congenital malformation in the male, which will be presently referred to. CAUSES OF HERNIA. 861 3. Occupation.—The majority of cases of hernia occur among the labor- ing classes, but there does not appear, according to Kingdon, to be any direct connection traceable between the development of rupture and the pursuit of any particular occupation. 4. Inheritance.—A predisposition to hernia is frequently inherited, the first year of life being that in which the hereditary influence is most marked. The anatomical peculiarities on which the frequent occurrence of hernia at this early age depends, are, (1) imperfect closure of the ventral orifice of the vaginal process of the peritoneum, and persisting patulousness of that canal, and (2) abnormal lengthening of the mesentery. The first-named malformation is always, and the second often, probably, of congenital origin; they will be again referred to under the heading of inciting causes. Local Predisposing or Inciting Causes. 1. Wounds, etc.—The occurrence of hernia is occasionally predisposed to by wounds or subcu- taneous lacerations of the abdominal parietes. Ventral hernia usually results under these circumstances (see page 399), but if the wound be suitably situated, inguinal, or any other form of hernia may ensue. 2. Weakening of the Abdominal Parietes, as the result of previous inflammation, abscess, etc., or from over-distention by the pressure of the gravid uterus, by the accumulation of fat in the omentum or mesentery, or by the development of ovarian tumors, or of ascites, may act as a predis- posing cause of hernia. 3. A Patulous Condition of the Vaginal Process of the Peritoneum, or of its Ventral Orifice, is a frequent predisposing cause of hernia. It is known that the testicles are, in the earlier periods of foetal life, situated in the lumbar region, whence they gradually descend into the scrotum. During their descent, they are behind and partially invested by the peri- toneum, a prolongation of which membrane accompanies them into the scrotum, where it forms the tunica vaginalis on either side. This vaginal process of the peritoneum at first forms one common sac with that of the peritoneum itself, and the communication between them often persists at birth, or even a month or two later. Usually, however, about the period of birth, the vaginal process divides into two portions, by the contraction of the sheath and the formation of adhesions between its sides, at about the position of the head of the epididymis. The lower portion invests the testicle (forming the tunica vaginalis propria testis), while the upper por- tion lies in front of the spermatic cord, and constitutes the tunica vaginalis propria funiculi. In the normal state, the tunica vaginalis of the testicle continues through life as a closed sac, while the tunica vaginalis of the cord becomes obliterated and converted into a delicate fibrous band. It not unfrequently happens, however, that the funicular portion of the vaginal process persists as a tube of small calibre, closed at both ends, or, more rarely, that either its ventral or testicular orifice, or both, remain patulous. The testicular orifice is, of course, that by which the funicular portion communicates in foetal life with the testicular portion of the vaginal pro- cess of the jieritoneum, while the ventral orifice is that by which it com- municates with the general cavity of the peritoneum, and corresponds in position with the internal abdominal ring*. From the above brief anatomi- cal description, it can be readily understood that a patulous state of the vaginal process, or of its ventral orifice, would predispose the person in whom it existed to the occurrence of rupture. 4. A Relaxed and Elongated Condition of the Mesentery acts as a pre- disposing cause of hernia. That the mesentery is actually elongated, in many cases of hernia, can scarcely admit of a doubt—for the bowel could not descend as low as it is observed to do in the scrotum, were its mesen- 862 HERNIA. teric attachments not abnormally relaxed—but whether this relaxation and elongation be a cause or consequence of hernia, is a different quest ion ; that it is often a cause of rupture, is rendered probable, as pointed out by Hir- kett, by the facts that (1) persons with a hernial sac are more troubled by the descent of a hernia when out of health than at other times ; (2) persons of a relaxed frame are more apt than others to become subjects of hernia, as they advance in life; and (3) in middle-aged persons of either sex, affected with hernia, the abdominal viscera generally are less firmly held in place by their peritoneal attachments, than in those who have no dis- position to hernia. This elongation of the mesentery may, as just niem- tioned, be due to a relaxed state of the fibrous tissues, acquired at any jieriod of life, or may probably, in some cases at least, be of congenital origin. 5. The Gradual Stretching and Protrusion of the Parietal Peritoneum at weak parts of the abdominal wall, as the result of frequently repeated muscular exertion, of coughing, of straining at stool, or in urinating, etc., may act as a predisjiosing cause of hernia, by leading to the ultimate development of a sac or pouch into which the viscera may be received, this pouch then constituting the sac of the hernia. 0. The existence of phimosis appears in some cases to act as a predis- posing cause of hernia by causing straining in micturition. Immediate or Exciting Causes.—In the majority of instances, probably, a hernia is slowly developed, and may not attract the patient's attention until fully formed; in other cases, however, the rupture occurs suddenly, as the result of a fall, or of some violent muscular effort. Nomenclature. Herniae are classified according to their (1) locality, as inguinal, femoral, scrotal, umbilical, etc.; (2) condition, as reducible, irreducible, strangulated, etc.; (3) contents, as intestinal (enterocele), omental (epiplocele), vesical (cystocele), etc.; and (4) period of development, as congenital, infantile, etc. The latter mode of classification is, however, incorrect, as many cases of so-called congenital and infantile hernia do not occur until adult life. Structure of a Hernia. The hernia consists essentially of a sac and its contents, the coverings being the tissues external to the sac—the skin, subcutaneous fascia, etc., of the part in which the hernia occurs. In some cases the sac is wholly or par- tially deficient, as in caecal and vesical hernia?, certain congenital umbilical hernias, and in ventral hernise resulting from penetrating wounds. With these exceptions, every hernia has a sac (or peritoneal investment), that part which communicates with the peritoneal cavity being the neck, and that which surrounds the protruded viscera being the body of the sac. Varieties of the Hernial Sac__There are two distinct varieties of the hernial sac, the congenital and the acquired. 1. The Congenital Sac consists of the patulous vaginal process of peri- toneum, or of its funicular portion, and is therefore only met with in those forms of oblique inguinal hernia which are often, though improperly, termed congenital and infantile. It may exist through life as a pouch, communi- cating with the peritoneal cavity, without ever becoming the seat of an actual hernia. 2. The Acquired Sac is slowly developed by the gradual stretching of a portion of the parietal peritoneum, as the result of frequently repeated pressure from within, exercised by the organs which ultimately form the CONTENTS OF THE HERNIAL SAC. 863 contents of the hernia. This is the form of sac which exists in the ordi- nary oblique and direct inguinal herniae, as well as in femoral hernia, and in those which occur in other regions. The mode of development of the acquired hernial sac has been particu- larly studied by Cloquet and Demeaux, and is well described by Birkett. When the parietal peritoneum first protrudes through the abdominal wall, the widest portion of the sac is that which communicates with the perito- neal cavity, but in the fully formed sac, the neck is smaller than the body, the sac being puckered like the mouth of a purse, by the constriction of the fibrous or muscular ring through which the hernia has escaped. In this stage of the hernial sac's development, which is called the period of forma- tion, the neck of the sac itself exercises no constriction upon the protruded viscus, and the puckering which has been described disappears upon reduc- tion of the hernia, or upon division of the ring of the abdominal wall through which the rupture has occurred. At a later stage, the period of organization, the puckered folds at the neck of the sac adhere together, while at the same time the fat disappears from the adjacent subserous areolar tissue, this becoming converted into an indurated and vascular ring which is said to contain a layer of contractile fibres. In this stage, the neck of the sac exercises an essential constricting power, and requires to be divided if the hernia becomes strangulated. The ultimate stage is the period of contraction.; as soon as a hernia ceases to descend, the orifice of the sac manifests a disposition to contract, and may even become obliter- ated, thus accomplishing the cure of the disease—as is occasionally wit- nessed in the hernia? of infants, and more rarely in those of adults. During this stage, the ring which surrounds the neck of the sac becomes thicker, and of a fibrous or cartilaginous hardness. If the hernia protrude in this stage, strangulation is very apt to occur. The sac of a hernia is thus at first thin and translucent, but often at a later period becomes thick and indurated, and may even become the seat of calcareous degeneration ; in other instances, as in cases of large umbilical hernia, the sac may by distention become extremely attenuated. The aperture in the abdominal wall through which a hernia has escaped eventually assumes a more or less circular outline, and often becomes en- larged ; it may* become displaced by the weight of the protruding viscera, being usually dragged dow*nw*ards and towards the median line of the body ; thus in an oblique inguinal hernia of long standing, the internal may come to be placed directly behind the external abdominal ring. The superficial tissues frequently become thinned and stretched, but, if a truss have been employed for a long time, may be indurated and thickened from the pres- sure of the pad of the instrument. Contents of the Hernial Sac.—Almost any of the viscera may be occasionally found in herniae, but the parts most commonly* protruded are the bowel and omentum. The small intestine, and particularly the ileum, is much more frequently involved in a hernia than the large intes- tine ; only a portion of the calibre of the gut may* enter the sac (as in " Littre's hernia"), or a large coil of bowel with its mesenteric attachment. In some very large herniae, almost the w*hole of the small intestine may descend into the sac. When long protruded, the bowel becomes thick- ened and contracted, and of a grayish hue externally ; its mesentery at the same time becomes hypertrophied and vascular. When the sac of the hernia is habitually occupied by omentum, the latter tissue becomes indurated and thickened, and often matted together into a conical mass, theajiex of which corresponds to the neck of the sac. The omental veins become distended and varicose, and apertures or depressions often exist 864 HERNIA. in the dense mass, into which a knuckle of intestine may slip, and become strangulated. AVhen a hernial sac contains both bowel and omentum, the latter usually protrudes in front of, and may completely surround, the gut. Cysts sometimes exist in the protruded omentum, and may, in the ojiera- tion of herniotomy, confuse the surgeon by their resemblance to knuckles of intestine. In addition to the viscera which are contained in the hernial sac, a certain amount of serous fluid always exists in its interior, under ordinary circumstances the quantity is but small, but if the hernia become inflamed or strangulated, may be very much increased. Adhesions often exist in the sac of an old hernia, gluing together the contained viscera, or binding them to the wall of the sac itself; while recent, these adhesions are soft and easily separated, but in cases of long standing they become firm and form an impediment to reduction. Loose bodies, consisting ap- parently of detached appendices epiploicee, are occasionally found in the interior of a hernial sac. Hydrocele or Dropsy of a Hernial Sac is the name given to an unusual condition which consists in the accumulation of fluid in the bottom of a hernial sac, the communication of which with the abdominal cavity is occluded, either bv obliteration of the orifice, or by the formation of adhe- sions between the wall of the sac and the viscera which occupy its ujijier portion. Cases of this form of disease, which, rare in any situation, is particularly so in connection with femoral rupture, have been recorded by various surgeons, including Pott, Pelletan, Boyer, Lawrence, Curling, Erichsen, Langton, Ford Thompson, and W. F. Atlee, of this city. Drs. McArdle and Kolipinski have given an interesting account of the affec- tion, of which they have collected 29 cases. The treatment consists in evacuating the fluid by means of a trocar and canula, and, as advised by Langton, if the effusion recurs, in the establishment of a seton. Symptoms of Hernia in General. Fig. 512.—Scrotal hernia in a child; a, position of left testis. (From a patient of Dr. C B. Nancrede.) The patient often experiences a sensa- tion of weakness in the groin or other region in which a hernia is about to occur, before any protrusion takes place. There is also frequently a decided ful- ness in the part, which is most marked in the erect posture, or upon contract- ing the abdominal muscles. The hernia, if gradually developed, appears as a small tumor, not larger, at first, per- haps than the tip of the finger, which can be reduced by pressure, and which disappears spontaneously when the re- cumbent posture is assumed. In young children, the hernia is often of consid- erable size when first noticed, and the same is true of those cases of rupture which are suddenly developed as the result of violent exertion ; in the latter cases, the formation of the hernia is often attended with pain. A fully de- veloped hernia forms a round or oval tumor, usually broader below than TREATMENT OF REDUCIBLE HERNIA. 865 above (the neck, of the hernia), increasing in size when the patient stands up, holds his breath, or coughs, either subsiding spontaneously when the patient lies down, or being readily reduced within the abdomen by gentle pressure, and reappearing upon the resumption of the erect posture. When the patient coughs, a distinct impulse may be commonly perceived in the hernial tumor. The symptoms of hernia are somewhat modified by* the nature of the contents. Intestinal Hernia or Enterocele—When the hernia contains bowel only, the tumor is smooth, gurgles under pressure, and is often tympanitic and resonant when percussed. The hernia is often the seat of borborygmus or flatulent rumbling. The impulse on coughing is well marked, and the patient frequently complains of dyspeptic symptoms, and of an uncomfortable, dragging feeling. Reduction is attended with gurg- ling, and with a peculiar, characteristic sensation, which, when once felt, can scarcely- be mistaken, and which is spoken of by* some writers as the "slip" or "flop" of a hernia. Omental Hernia or Epiplocele___In these cases the tumor is ir- regular and comparatively ill-defined, having a doughy feel, and with a less distinct impulse on coughing than in the form of the disease last de- scribed; reduction is effected gradually, and without the characteristic gurgling sensation which has been referred to. Omental hernia is said to be most frequent on the left side, and is chiefly seen in adults. Mixed Hernia or Entero-Epiploeele___In these cases the symp- toms of the intestinal and omental hernia are variously combined. Caecal Hernia is of course confined to the right side, and is commonly* irreducible, from that portion of caecum which is uncovered by peritoneum forming adhesions to the subjacent structures. Hernia's of the Stomach or Bladder are of rare occurrence; the former (Gastrocele) has been observed in the inguinal and umbilical regions, and in cases of diaphragmatic rupture ; there are no distinctive symptoms by which it can be certainly recognized during life. Hernia of the bladder (Cystocele) is irreducible, and attended with difficult micturi- tion ; urine mav be made to flow by compressing the tumor. Hernia of the Ovary is occasionally met with, Hamilton having collected 13 cases, to which Balleray has added 5 others. Treatment of Reducible Hernia. The treatment of reducible hernia -may be palliative, or may aim at effecting a radical cure. Palliative Treatment.—This consists in preventing the descent of the hernia by* the application of a suitable truss or bandage. In eases of umbilical and ventral rupture, an elastic band and pad may be the best means of retention, but a truss is preferable for the ordinary forms of hernia. I do not propose to enter into any discussion of the comparative merits of the many forms of truss which are offered by their respective inventors to the profession and the public, but shall merely mention what may be considered the requisites of a good truss. A Truss consists essentially of a pad and a spring; the pad should be firm, slightly convex upon the surface (except in particular cases), of an oval or elongated, triangular shape, and sufficiently large to compress not only the aperture through which the hernia escapes, but the w*hole canal through which it has passed to reach the surface. The pad mav be of buckskin, firmly stuffed, of polished wood, or of such other material as may be found by experience to produce least irritation of the skin, some 55 866 HERNIA. patients in this respect differing from others. In certain cases, in which the ring through which the hernia protrudes is very large, the ordinary convex, oval, or triangular pad may be advantageously rejilaced by one of a horseshoe or ring shape, as recommended by Mr. J. Wood, or by a jm.—Stricture in the neck of the sac, laid open. (Erichsen.) 1. In cases of recent hernia, in which the sac has not jiassed beyond the period of formation (p. S63), strangulation is commonly due solely to the compression exercised by the tissues external to the neck of the sac ; this is usually the case in small strangulated hernial which occur as the result of sudden efforts in young |>ersons. 2. In a large number of instances, the neck of the sac itself is the seat of constriction: this is the case usually when the hernia has existed for a considerable time before the occurrence of strangulation. Occasionally, the seat of constriction may be in the body of the hernial sac, which may present an hour-glass shape, due either to a congenital peculiarity (p. 888), or to the formation of a recent sac above an old one, the neck of which has undergone contraction. 3. In some rare cases, the seat of constric- tion is entirely within the hernial sac, being due to the presence of bands of organized lymph ; or strangulation may result from a knuckle of intestine being caught in a rent or pocket of omentum, in cases in which both are involved in the hernia. Structural Changes Resulting from Strangulation__These are first manifested in the contents of the hernia itself, and subsequently in its sac and other coverings, and in the contents of the abdominal cavity. 1. Changes in Contents of Hernia.—The first effect of strangulation is to produce congestion of the strangulated part, followed more or less quickly by inflammation and gangrene. In cases of acute strangulation, the bowel may jiresent a distinct groove at the part corresponding to the seat of con- striction, and ulceration and jierfora- tion may take place at this point. The congested portion of intestine is swollen, of a " leathery" consistency, dark-red or brownish-pur|»lc in color, and often dotted with ecehvmoses. In the stage of inflammation, jiatches of lymph may be observed on the peri- toneal surface of the bowel, and the part will feel sticky to the touch. As gangrene approaches, the serous cover- ing of the intestine loses its natural lustre, the gut becomes soft and doughy, the color is a grayish-black, and the various layers of the bow*el become readily separable from each other; ultimately- the part gives way, and fecal extravasation occurs, result- ing either in death or in the formation of a fecal fistula. Fortunately, before perforation occurs, adhesions have usually sealed the sides of the gut to the neck of the sac, so that the contents of the bowel do not enter the peri- toneal cavity. The omentum, in the stage of congestion, presents a good deal of venous engorgement, assuming a reddish hue when inflamed, and becoming purjile or grayish-yellow when gangrene supervenes. The flu id of the hernial sac is usually increased in quantity, and assumes a reddish- Fio. 516.—aa. The portion of bowel which bas been protruded ; constricted, dark, aud engorged. At b, the upper portion, dilated, and of dark color. At c, the lower portion, com- paratively empty, flaccid, and pale. (Liston.) SYMPTOMS OF STRANGULATED HERNIA. 873 brown color from the transudation of blood, becoming cloudy, dark, and fetid, upon the occurrence of gangrene. Hemorrhage into the sac is occa- sionally met with, and, still more rarely, suppuration takes place, proba- bly as the result of injury inflicted by the prolonged employment of the taxis. 2. Changes in Sac and Coverings of Hernia.—The sac and its external coverings become inflamed, if the strangulation be not relieved, the skin over the hernial tumor becoming, on the approach of gangrene, of a red- dish-purple hue, tender, doughy, and ultimately emphysematous, from the occurrence of mortification or the escape of gas from the ulcerated bowel; finally, if the case be left to itself, sloughing will ensue, when the patient may possibly recover with a fecal fistula. 3. Changes in Abdominal Cavity.—The peritoneum always, probably, becomes inflamed when strangulation has persisted for any length of time! the inflammation usually assuming a diffused character, and being attended with the effusion of cloudy serum, and the jiroduction of ill-formed lymph or pus. Symptoms of Strangulated Hernia—These are either local or constitutional. 1. Local Symptoms.—If the hernia have existed for some time, it will be found, when strangulated, to be larger than usual, and somewhat painful, and if it contain bowel, to be tense, resisting and semi-elastic to the touch ; an omental hernia, however, may be soft and doughy, though strangulated; or if, as rarely happens, a recent hernia becomes strangulated behind an old and empty sac, the flaccidity of the latter may mask the tenderness of the former. The hernia is, of course, irreducible. There is no longer any impulse on coughing, the constriction preventing any fresh descent of bowel, and not allowing the shock of coughing to be transmitted to the hernial contents—a fact which suggested to Luke an ingenious plan of determining the seat of strangulation, by noting the exact point at which the impulse ceased to be felt. The hernia may continue to increase in size, after the occurrence of strangulation, from the effusion of serum into the sac ; this is particularly observed in cases in which the taxis has been repeatedly, though fruitlessly employed. On the approach of gangrene, the hernial tumor, as already mentioned, presents the ordinary signs of inflammation, and, in some instances, suppuration or sloughing'may ensue. 2. Constitutional Symptoms.—These are referable to obstruction of the intestine, and to subsequent inflammation of the sac and peritoneum. (1) The symptoms of intestinal obstruction are essentially the same, whatever may be the cause of obstruction ; they consist of griping pains about the umbilicus, a sense of constriction, with flatulence, tympanites, tenesmus, constipation, nausea, and vomiting. There may be one or two passages from the lower bowel after the establishment of strangulation, and, if the hernia be altogether omental, there may not be at any time com- plete constipation. There is also a variation in the degree to w'hich vomit- ing is present; in some cases early and profuse, in other cases there may- be merely slight nausea, as long as the patient is quiet, though even in these instances vomiting may be induced by the administration of liquids. The matter ejected consists at first of the contents of the stomach, next of the gastric fluids mixed with regurgitated bile, and ultimately of the intestinal contents, the vomiting then being called fecal or stercoraceous. As the patient becomes exhausted, and particularly if opium has been freelv given, the vomiting may subside; the surgeon should not, however, be deceived by this delusive calm, which is really indicative of a most dangerous con- dition ; the pulse now becomes feeble, the surface cold, and the extremities 874 HERNIA. shrivelled, while the countenance assumes a pinched and anxious expres- sion. Death may ensue in this stage, or, on the other hand, the extreme relaxation may allow* reduction to be readily accomplished. (2) The symptoms of peritonitis, when this condition is fully developed, are commonly* well marked. Often, however, there are but little pain and tenderness, and but for the peculiar small and wiry pulse, and anxious countenance, the existence of jieritoneal inflammation might not be recog- nized. Lpon the occurrence of gangrene, the patient falls into a state of collapse: the pain suddenly- ceases, the skin is cold and bathed in a clammy sweat, the pulse is weak and running, sometimes intermittent, and death may be preceded by slight delirium. The jieriod at which the inflammatory symptoms occur is a matter of some importance. In a ease of acute stran- gulation (page 871), such as is met with in young jicrsons as the result of violent exertion, inflammation sets in early, and may terminate in fatal gangrene in the course of a few hours ; while, if the strangulation be of a more chronic character, the synijitoins of obstruction may last for several days before the occurrence of any serious inflammatory changes ; hence, while in the former case an early operation is imperative, in the latter more time may be properly spent in a trial of other measures. Diagnosis of Strangulation.—A strangulated may usually be dis- tinguished from an incarcerated hernia by noting the absence of impulse on coughing, the persistent vomiting and stercoraceous character of the matters ejected, and, in an acute case, the sudden onset of the symjitonis. From an inflamed hernia, or from general peritonitis coexisting loith an irreducible hernia, it may be distinguished by observing the character of the vomit and the completeness of the constipation. In a case of merely coincident peritonitis, moreover, the jioint of greatest tenderness may be at a distance from the hernial sac. The vomiting of pregnancy, if the patient have an irreducible hernia, may simulate strangulation, but may be distinguished by observing the nature of the matter ejected (which is never stercoraceous), and the absence of complete constipation. The co- existence of an irreducible hernia with intestinal obstruction from another cause, may deceive the most skilful surgeon, the existence of an impulse on coughing, being, in such a case, probably the only symptom to distinguish it from one of strangulation. If there be two or more herniae, one only of which is strangulated, it will probably be found that there is most ten- sion and tenderness about the neck of that which is the seat of constriction. Certain tumors, as for instance an inflamed lymphatic gland, occurring in one of the common localities of hernia, in connection with the rational symptoms of strangulation, may closely simulate the latter condition, and the true state of the case may be only revealed by making an exploratory- incision. Inflammation of an undescended testicle may be distinguished from strangulated hernia, by observing the absence of the gland from the corresponding side of the scrotum. According to Englisch, when bowel is strangulated the urine contains albumen, but does not, unless from some coincident cause, when the strangulated part is omentum. Prognosis___In cases of acute strangulation (page 871), the prognosis is extremely grave, ulceration and gangrene sometimes occurring in the course of a few hours. In chronic strangulation, there is less immediate danger, though the affection is always one of a very serious character. It is difficult to estimate projierly the death-rate of strangulated hernia, from the fact that the operation, which, in many, if not most, cases affords the only chance of life, is unfortunately too often postponed until death is inevitable under any circumstances. I cannot subscribe to the dogma, which has been promulgated by high authority both at home and abroad, TREATMENT OF STRANGULATED HERNIA. 875 that surgeons generally* are too prone to operate in cases of strangulated hernia. I am well convinced, on the contrary (and in this view I am sus- tained by the almost unanimous testimony of hospital surgeons of large experience), that lives are constantly- sacrificed by the hesitancy which manv medical men feel in resorting to herniotomy; and yet this is an ope- ration which, like tracheotomy, every- physician, as well as every surgeon, should feel himself competent to perform. While no one can deprecate more than I do a premature resort to the knife, I firmly believe that many lives would annually be saved, wrere the profession, as well as the public, more aware of the dangers attending a strangulated hernia, and of the responsibility w-hich attaches to him who undertakes its treatment. This much is certain: that everv strangulated hernia, if not relieved in a vari- able, but always brief, period, will almost inevitably- cause the death of the jiatient; and that, if a moderate and cautious employment of the taxis does not afford relief, the sole hope of safety lies in the use of the knife— the operation, moreover, not, as a rule, adding anything to the danger of the case, though from being postponed until too late, it unfortunately- often fails jto save life. Birkett estimates the proportion of patients lost by delay as being two-thirds of those who die after the operation, and judiciously advises that the surgeon should not feel himself justified in leaving, for any length of time, a case of strangulated hernia, until the constriction has been, in one way or another, relieved. Even in a case in which the diagnosis is not quite clear, an exploratory incision may be highly proper, and the oft-repeated rule, "when in doubt, operate," is unquestionably- founded on sound surgical principles. Treatment of Strangulated Hernia.—The two principal methods employed in the treatment of strangulated hernia are the taxis and herni- otomy. There are, besides, certain auxiliary measures, which are employed either before resorting to, or in connection with, the taxis. It is of the utmost importance, in regard to treatment, that the surgeon should dis- tinguish betw*een the two conditions which have been referred to as acute and chronic strangulation. In the acute form (w hich, it may be repeated, usually occurs in young persons, often as the result of sudden and violent exertion, the hernia itself being commonly of small size), but little time is allowed for the employment of expectant treatment; and if the intensity- of the constitutional disturb- ance, the restlessness and anxiety* of the patient, and the constant vomiting, with pain and other evidences of threatening inflammation, show* the case to lie one of this class, the surgeon should resort at once to the taxis, aided by the induction of complete anaesthesia, with the understanding that, if a moderate trial of this method prove unavailing, herniotomy is to be immediately- proceeded with. If, on the other hand, the case be one of chronic strangulation (which is usually met with in old persons who have long been ruptured, in which the hernia is comjiaratively large, and in which the symptoms are at first simply those of obstruction), the necessity- for immediate action is less urgent. If no vomiting have occurred, or if merely the contents of the stomach have been rejected without there having been any regurgitation from the bowels, it may even be proper to postpone the taxis, and try the effect of rest, position, and cold, with the internal administration of opium. The jiatient may be placed in bed, with the hips elevated and the knees flexed, the scrotum (in case of scrotal hernia) being well supported, and an ice-bag, guarded by flannel, applied over the neck of the sac and adjacent parts. The lower bowel may be emptied by the use of an enema, and a full dose of opium or morphia given by the mouth (or by the rectum if 876 HERNIA. there be much nausea), the room being then darkened and the jiatient left to sleep. Upon the surgeon's return, after an interval of four, six, or eight hours, according to the greater or less urgency of the case, he will often find that reduction either has been sjiontaneously accomplished, or is readily effected by slight manipulation. It is impossible to lay down any positive rule as to" the length of time during which this exjiectant mode of treatment may be properly employed, but probably twenty-four hours may be given as an extreme limit; at the end of this period, or before (if urgent symp- toms should arise), the patient should be thoroughly anaesthetized, and then, if the taxis fail, the surgeon should at once proceed to the ojieration. The above remarks are based upon the supposition that the surgeon has had the opportunity of directing the treatment of the case from the very beginning. It unfortunately happens, however, that, in many instances, precious time is wasted on account of the ignorance or obstinacy of the patient, or, still worse, that his condition has been greatly aggravated by ill-judged and perhaps violent efforts at reduction by himself or others. The surgeon is often not called to the case until ulceration or gangrene of the gut is impending, if, indeed, it have not already occurred. Uncler.such circumstances, an operation is, of course, the only treatment admissible. In any case, if the matters vomited be colored with bile, showing that intestinal regurgitation has begun, and still more if the vomiting be ster- coraceous, no time should be lost in relieving the constriction, and if the taxis have been already fairly tried by another practitioner, it may, under these circumstances, be even jiroper to operate without its repetition. As justly remarked by Birkett, "The vital importance of liberating the bowel from constriction, at the earliest moment, cannot be overestimated. As upon the sjieedy accomplishment of this the salvation of life depends, a little precipitate action may even be forgiven, so hazardous is the jiosition of a patient with the bowel strangulated. But what is the risk attending the operation of exposing the hernial sac, dividing the impediment to the reduction of the hernia, and reducing it, even should the peritoneal sac require to be opened? Practically none. In comparison with that of leaving the bowel strangulated, it is harmless." The Taxis.1 This is the name given to the various manipulations by which the sur- geon endeavors to effect the reduction of hernia without resorting to any cutting ojieration. The ordinary and commonly the best mode of apply- ing the taxis is as follows: The'patient being thoroughly anaesthetized, in the recumbent posture, with both the shoulders and hips slightly raised, the thighs abducted and flexed (so as to relax the abdominal muscles), and the bladder and rectum emptied, the surgeon fixes the orifice and neck of the hernial sac, by surrounding the corresponding jiart of the tumor with the thumb and fingers of the left hand, while with the palm and fingers of the right he gently compresses the body of the tumor, so as, if jiossible, to empty it of some of its gaseous or fluid contents. Then drawing down the tumor a little, so as to dislodge the hernia from the constricting neck of its sac, and drawdown the mesentery, which, as pointed out by Berger, acts as a conical plug in impeding reduction, he attempts, by a combina- tion of gentle kneading, rolling, and compressing movements, to return the protruding viscera into the abdominal cavity, the line of pressure strictly corresponding to that by which the hernia came down, and that » From the Greek rifa, from ris-irv, I arrange or put in ordi ADJUVANTS TO THE,TAXIS. 877 portion of the hernial contents being first replaced which last descended. The success of the manipulation is made apparent by the disappearance of the tumor with the peculiar gurgling and slipping sensation which has been already referred to as characterizing the reduction of a hernia (p. 835). The mode of applying the taxis above described maybe advantageously varied in certain cases; thus, if the seat of constriction be not hidden by the thickness of the superincumbent fat, the surgeon may attempt to dilate the hernial aperture, by introducing the tip of the finger or the finger-nail, and drawing the edge of the ring to one side, while pressure on the tumor is maintained with the other hand. This plan, the suggestion of which is attributed to Seutin, is chiefly- applicable in cases of femoral hernia, and should only be tried in cases of quite recent strangulation, for if the con- stricted bowel were already softened by inflammatory* changes, the pressure of the finger might possibly lead to serious consequences; a somewhat similar manoeuvre has recently been recommended by P. C. Smvly, of Dublin; and H. R. Allen, of San Francisco, has devised a special instru- ment for effecting the same purpose. In some cases, in which the ordinary taxis fails, taxis with inversion may* succeed. This consists in drawing the lower extremities and body of the patient upwards in a vertical direc- tion, while the shoulders rest on the bed, thus bringing the force of gravity* to aid the manipulations of the surgeon. The same end may be sometimes attained with less discomfort to the patient by simply elevating the pelvis, and practising slow and gentle frictions of the abdomen, in a direction from below upwards, so as to encourage the recession of the viscera from the seat of constriction. Again, success may* be occasionally attained by- causing the patient to lie on one or other side in a semi-prone position (as advised by Gay, of Buffalo), by placing him on his elbows and knees, or >houlders and knees (as suggested by Nikolaus), or by directing him to stand erect, or to lean forwards over the back of a chair. In a case admit- ting of procrastination, any or all of these plans may be tried before resorting to severer measures. A curious case is recorded by* Froumuller, in which reduction of an umbilical hernia was effected by the application of an exhausted cupping-glass ; the sac and overlying tissues rose into the glass to fill the vacuum, and the strangulated gut instantly slipped back into the cavity- of the abdomen. A similar plan is recommended by Dr. Washington, of Nashville. Dr. Haddeu, of New York, records a case of inguinal hernia in which the taxis w*as aided by introducing the left hand through the rectum into the descending colon, and making traction upon the incarcerated bowel. The taxis should invariably be practised with the utmost caution and gentleness ; forcible squeezing and pushing is not at all likely to be pro- ductive of the slightest benefit, while it will almost certainly, by increasing the tendency to congestion, hinder reduction, and may not "improbably lead to a serious and perhaps fatal termination. The time during which the taxis may be employed should not, as a rule, exceed from a quarter to half an hour on each occasion ; if on its first trial it do not prove success- ful, and if the urgency* of the case admit of delay, a trial should be given to opium, cold ajiplications, etc., in the w*ay already described, the taxis being renewed after some hours' interval; if the second attempt also fail, herniotomy- should ordinarily be at once resorted to. Adjuvants to the Taxis.—Of these the most valuable is unques- tionably anaesthesia. Chloroform is preferred to ether by manv surgeons, as being less likely to provoke vomiting; but as the fullest effect of the amesthetic agent is required, ether is probably safer, and will, I believe, 878 HERNIA. be found quite satisfactory. Etherization should be pushed not only until the patient is insensible to pain, but until complete muscular relaxation is induced. Venesection was formerly much employed in these cases, the bleeding being sometimes carried ad deliquium, but since the introduction of anaesthetics is comparatively seldom resorted to; the same may be said of the use of the tobacco enema, an uncertain and dangerous remedy. The warm bath is often an efficient adjuvant to the taxis, and may be jiroperly used in hospitals, or wherever there are facilities for its emjiloynient, as a preliminary to the taxis in acute cases. The patient may be kejit in a bath of a temperature of about 95° Fahr., until some relaxation or faint- ness is induced, when he should be wrapped in blankets and immediately etherized. The taxis is then employed, and if this fail, herniotomy. The warm bath is less applicable in cases of chronic strangulation, in which it seems, sometimes, to increase the tension and bulk of the hernial tumor. The local application of cold, by means of the ether-spray, or in the form of an ice-bag guarded by flannel, is often of great use in cases admitting of some hours' delay, in conjunction with a position which insures relaxation of the abdominal walls, and the internal administration of opium (see page 875). The hypodermic injection of atropia has been successfully resorted to by a French surgeon, Dr. Rahn, and that of morphia by Dr. Philippe. Planat, of Nice, recommends the use of ergot, both internally and as a local application. Pressure by means of an elastic bandage appears to have been originally suggested by Maisonneuve, and has been occasionally em- ployed with advantage. Purgatives are very commonly taken by jiatients on their own responsibility, or by the prescription of non-professional advisers, but can exercise only an injurious influence. They may, as already mentioned, be of service in the treatment of incarcerated hernia (p. 870), but should be strictly interdicted when actual strangulation ex- ists. A purgative enema of castor oil and oil of turpentine, suspended in gruel or soapsuds, may, however, be properly administered in a case of chronic strangulation, with a view of emptying the bowel below the seat of constriction, and thus, by lessening the distention of the abdomen, facilitating the reduction of the hernia. Puncturing the hernia by means of a delicate trocar,1 with or without the subsequent use of an " aspirator," so as to diminish the tension of the strangulated gut by withdrawing its gaseous and even its liquid contents, has been recommended by Dieulafoy, Fonssagrive, Duplony, Autun, Chauveau, and other surgeons. Unsuc- cessful cases have, how*ever, been recorded by Doutrelepont, Madelung, Fleury, Verneuil, and Panas, and there is reason to believe that the opera- tion is not as free from risk as was at first supposed. Inflation of the bowel by the use of bellows has been successfully employed by Dr. Joy, ot Tamworth, and other surgeons, the distention of the gut apparently pro- ducing a vis a tergo which draws back the strangulated portion ; and with a similar object Torres has oddly suggested the use of successive enemata of bicarbonate of sodium and tartaric acid, so as to insure a free formation of gas within the intestine. Management of the Case after Reduction__The symptoms of strangulation commonly disappear immediately or very soon after the ac- complishment of reduction ; all that is then necessary is to ajiply a com- press and bandage to prevent the re-descent of the hernia, and to keej) the patient in bed until any constitutional disturbance that may be present has subsided. If the bowels are not moved spontaneously in the course of two or three days, an opening enema may be administered. 1 This mode of treatment was described by Peter Lowe, in the early part of the seventeenth century. PERSISTENCE OF SYMPTOMS AFTER REDUCTION. 879 Persistence of Symptoms after Reduction__It occasionally happens that, though the hernial tumor has disappeared under the use of the taxis, the symptoms of strangulation still continue : this may arise from the occurrence of what is called reduction in mass (only met with in inguinal hernia) ; from the gut having been so tightly constricted as to be more or less completely paralyzed, in which case gangrene will probably follow ; from the existence of strangulation within the sac (as from the existence of internal adhesions, or from a knuckle of intestine being caught in a pocket of omentum, in a case of entero-epijilocele); or from the coex- istence of a second strangulated hernia in another locality. 1. Reduction in Mass (en bloc).—This name is commonly applied to several distinct pathological conditions. (1) The whole hernia may be pushed back behind the abdominal walls; into a space formed by the separation of these from the parietal peritoneum; this is a very rare accident, according to Birkett, who believes that more frequently only the neck and mouth of the sac are detached from their ex- ternal connections, the scrotal tissues being pushed up with the body of the sac, which then lies partially within the inguinal canal. In either case, the strangulation is maintained by the neck of the hernial sac. (2) The neck of the sac may give way under forcible pressure, the hernia as a consequence escaping into the subserous areolar tissue, where it forms a pouch for itself between the peritoneum and the internal abdo- minal fascia. (3) There may be an inter-parietal sac, or rather the sac may consist of two jiarts which are separated by a contracted portion ; if the seat of strangulation be at the ventral orifice, the hernia may be pushed from the outer into the inner or inter-parietal sac (w-hich is situated in the abdominal wall), the .tumor as a consequence disajipearing, though the strangulation still continues. The occurrence of reduction in mass is not attended with the gurgling sound and sensation which is characteristic of the return of a hernia from its sac into the cavity of the abdomen ; and hence, if this sign should in any case be absent, the surgeon would at once suspect that the accident in question had hapjiened. If the reduction in mass should have taken place before the surgeon is called to the case, he would be forced to rely mainly ujion the history- of the accident, in making a diagnosis, though if the whole hernia were within the abdominal wall, he would be aided by ob- serving that there was no fulness of the part such as would be caused by the sac remaining in situ, and that the inguinal canal and abdominal rings were unusually patulous. In the case of rupture of the neck of the sac, or of the existence of an inter-jiarietal sac, these signs would of course be absent. The treatment of reduction in mass consists in directing- the patient to cough, so as if possible to cause the re-descent of the hernia (when herni- otomy should be at once performed) ; or, if this fail, in making an ex- jiloratory incision, exposing the abdominal ring, prolonging the wound if necessary into the inguinal canal, laying open the sac of the hernia, and dividing the neck of the sac or other source of constriction. 2. Paralysis of the Bowel.—This condition may be suspected if the ^ymjitoms of strangulation continue in spite of reduction attended with the characteristic gurgle, so often referred to. Under these circumstances, the surgeon should wait for a few hours, for it may be that the constriction, though sufficient to cause temporary paralysis of the gut, has not impaired its vitality, in which case the vomiting will by degrees lose its stercoraceous 'haracter, the tympanites subside, and all the symptoms of strangulation 880 HERNIA. gradually disappear ; to operate under such circumstances would ex|io>e the patient to a totally* unnecessary risk. If, however, the symptoms per- sist with unabated violence for several hours, the best that can be done is to lay open the hernial sac and deal with the gangrenous intestine (if this can be found) in the way* which will be presently described, or, as a last resort, to cover the wound with a light poultice, in the hope that when the gut sloughs the patient may recover with a fecal fistula. 3. Internal Strangulation.—The symptoms in this case, if the hernia were inguinal, might be indistinguishable from those of reduction in mass; the hernial sac could, however, always be felt in the inguinal canal, and there would be no undue patulousness of the abdominal rings. The treat- ment would consist in laying open the sac, and in searching for and re- moving the cause of constriction, dividing bands of adhesion, and unravel- ling, as it were, the omentum, by the folds of w7hich the strangulation might probably be caused; if it should be found that the seat of constric- tion was not within reach, the case being one of internal strangulation and the existence of the hernia a mere coincidence, the surgeon would, in my* ojiinion, be justified in extending the incision upwards into the ab- dominal wall, so as to allow* a careful exploration of the adjacent intestine; by such a proceeding, Bryant was enabled to discover and divide a fibrous band which produced internal strangulation, and thus saved his jiatient's life. A similar operation in my own hands was effective in relieving the strangulation, though the jiatient ultimately died from jieritonitis. 4. Coexistence of another Hernia.—If a second hernia should exist in a state of strangulation (which could be ascertained by a careful examina- tion of the various parts in which herniae may occur), it should of course be at once reduced by the taxis, or, if necessary*, by herniotomy. Rupture of the Intestine__This is the most serious complication w'hich can follow* the employment of the taxis, and is only likely to ensue when the force used has been very great; it must not Ik; forgotten, how- ever, that a portion of bowel which has been strangulated for twenty-four hours or longer, is very much softened, and will give way under much slighter pressure than in its normal condition. The signs by which the occurrence of this accident may be recognized are sufficiently obvious; the hernia disappears, but without the characteristic gurgle which is perceived when reduction is properly accomjilished, and the development of intense abdominal pain, with hiccough and collapse, indicates the occurrence of fecal extravasation into the jieritoneal sac. Death is almost inevitable, unless, as rarely* happens, adhesion should have previously shut off the part from the general cavity of the peritoneum, when recovery with a fecal fistula might ensue. The treatment would consist in laying open the hernial sac, and, if necessary*, the abdominal wall, and in securing the gut to the parietes so as to facilitate the latter termination. Herniotomy or Kelotomy. There are two principal modes of ojierating for the relief of strangulated hernia, in one of which the hernial sac is, and in the other of which it is not, opened. The latter, which is sometimes known as Petit's operation, is preferable in certain selected cases, and will be referred to in its proper jilace. Instead of operating at the seat of hernia, it has been recommended to open the abdominal cavity at a neighboring point and endeavor to draw the strangulated gut backwards out of the hernial sac. The introduction of this mode of operating has been incorrectly attributed to Cheselden; it HERNIOTOMY OPENING THE SAC. 881 'Vv Fiu. 517.—Herniotomy searching for the seat of stricture. (Liston.) appears to have been adopted in about fifteen cases, of which at least seven have terminated fatally. Herniotomy Opening the Sac—The ordinary operation, in which the sac is opened, is thus performed. The patient is thoroughly' anaesthe- tized, his bladder and rectum emptied, and the hair removed "from the seat of operation, which should be thoroughly cleansed. The surgeon makes his first incision, from two to four inches long, through the skinand superficial fascia over the neck of the sac, either by transfixing a fold of integument and cutting from without inwards, or, which is safer, by simply cutting down as if for the removal of a tu- mor. After the first in- cision, the operator should proceed cautiously, picking up each successive layer of tissue with forceps, and notching it, so as to intro- duce a grooved director, upon which it is then to be slit up; any artery that bleeds should be at once se- cured. When the sac is reached, it is in the same way picked up (at its ante- rior and lower part) with delicate forceps or a tenacu- lum, notched by a light touch of the knife laid flatwise, and then slit up upon a broad director. The sac may be usually recognized by its tension, its rounded, semi-trans- lucent appearance, its fibrinous structure, and the arborescent distribution of its vessels. A flow of serum commonly marks the opening of the sac. The next step is to di- vide the source of constriction ; this is ef- fected by passing the left forefinger up to the neck of the sac (Fig. 517), and insinuating fig. sis.-Hemia-knife. the nail beneath the tense edge (drawing the coil of intestine slightly downwards, if necessary, for the purpose, and then introducing flatwise, along the palmar surface of the finger, a probe-pointed " hernia-knife" with a limited cutting edge (Fig. 518); by turning the edge forwards, as soon as the blade has entered the stricture, the latter may be readily divided, an incision of from tw*o to three lines being usually quite sufficient. If the stricture will not admit the fingernail, a grooved director must be substituted. As soon as the constriction is relieved, the surgeon examines the contents of the hernia, dealing with bowel and omentum according to the condition in which each is found; if their state be satisfactory, reduction is cautiously effected, the gut being first returned, and the edges of the sac held in place so as to avoid the accident which has been referred to as reduction in mass. The finger should then be cautiously introduced into the abdominal cavity, to make sure that the constriction has been removed, when the wound mav be closed with stitches, and an antiseptic dressing with a compress and firm 56 882 HERNIA. bandage apjilied. A drainage-tube should be left in the lower part of the wound, the dressings being renewed when necessary. The after-treatment consists in keeping the patient in bed, and under the influence of moderate doses of opium, liquid diet only being allowed for four or five days. If the bowels are not moved spontaneously, a simple enema may be given after forty-eight hours, but the administration of purgatives by the mouth should be avoided. Treatment of Complications__Various comjilications may arise during the jierformance of herniotomy, or subsequently, the treatment of which must now be briefly considered. Treatment of Intestine.—If the bowel contained in a strangulated hernia be merely congested, it should be gently returned into the abdominal cavity, in the way already directed. If it be inflamed, and present a distinct groove or sulcus corresponding to the seat of constriction (see page 872), it should be left, after division of the stricture, at or near the orifice of the hernial sac, so that if, as is likely to happen, perforation ensue, the jiart will be in the most favorable position for the formation of a fecal fistula. Bourguet, of Aix, advises that the gut should be fixed at the level of the internal wound by means of catgut sutures. The external wound should be lightly dressed. If the bowel be absolutely gangrenous, it should he slit up and left in situ; to return the gut in this condition would be to in- sure the occurrence of fecal extravasation, and the development of fatal peritonitis. In every case, the source of constriction should be freely divided. A wound of the intestine may be accidentally inflicted, either in ojiening the sac prematurely or in dividing the stricture, if a grooved di- rector be used instead of the finger-nail in this jiart of the operation—the gut spreading over the groove of the instrument, and thus coming in the way* of the knife. Hence, if a director be employed, the surgeon should see that it is free from the bowel, and then keep it firmly jiressed against the stricture, until the latter has been divided. To avoid the risk of wound- ing the gut, Richardson, of Dublin, has recommended a knife with a broad flange attached to its back, and projecting in front and on either side, thus serving the double purpose of knife and director; somewhat similar instru- ments have been employed by others, in the last century by Ledran, and more recently by* Patterson, of Glasgow, and Allis, of this city. The treat- ment of wounded intestine has been already considered in another portion of the volume (see page 406). Treatment of Omentum.—If the omentum found in the hernial sac be but small in quantity, and unaltered in structure, though congested, it should be returned into the abdominal cavity. If thickened and indurated, it should, on the other hand, be left in the sac, as it is apt in this state to become inflamed, and its reduction would probably lead to the development of general peritonitis If, in addition, the protruded omentum be deejily congested, it should, as a rule, be excised, and this should invariably be done, if the omentum be inflamed or gangrenous. Excision is effected by transfixing the base of the constricted omentum with a double ligature, tying it in two jiarts so as to avoid hemorrhage, and then cutting off the mass below the seat of ligation. Retraction of the stump is prevented by securing the ligatures to the external w*ound, which may be closed over the stump, except in the case of gangrene, when it should be left open and lightly dressed. If an ovary be found in the sac, it may be dealt with in the same manner as the omentum. It is perhaps scarcely necessary to say that before excising any portion of the omentum, it should be thoroughly unravelled, and carefully examined, to make sure that no portion of gut is entangled in its folds. Any cysts that may be found may be treated by simple puncture. HERNIOTOMY WITHOUT OPENING THE SAC. 883 Irreducibility after Operation.—It sometimes happens that, though the constriction is relieved, the hernia cannot be reduced ; this is usually owing to the existence of adhesions between the protruded bow*el and the inner surface of the sac, but may occasionally be due to extreme distention of the intestine itself. (1) The Management of Adhesions dejiends chiefly on the state of the bowel; if this be in a condition to admit of its being returned into the abdominal cavity, the adhesions should, as a rule, be gently separated with the finger or handle of the knife, or, if necessary, cautiously dissected through. In some instances, however, the adhesions may be so broad and firm as to render it jiroper to leave the intestine unreduced. In case the bowel be ulcerated or gangrenous, the adhesions around the neck of the sac should be scrupulously respected, as upon them dejiends the prevention of fecal extravasation into the peritoneum. Bands of adhesion passing be- tween the gut or mesentery and the omentum, should be carefully divided, as they may be the real source of constriction (pp. 872, 880); the operation must be done with great care, to avoid the risk of wounding the intestine. (2) Distention of the Bowel by an accumulation of gas, may impede reduction, particularly if the gut contain a large quantity of indurated fecal matter as well. The treatment consists in making one or more punc- tures with a very fine trocar, as has been successfully done by Tatum, of London, and by several German surgeons. Hemorrhage.—It sometimes happens that, from an abnormal distribu- tion of a vessel, or from other causes, serious arterial hemorrhage arises when the neck of the hernial sac is divided. The treatment consists in enlarging the wound and securing both ends of the bleeding vessel. If the proximity of an artery be suspected, Erichsen advises that the edge of the hernia-knife should be dulled by drawing it over the back of the scalpel; it will then push the artery before it, though still sharp enough to relieve the strangulation. Corley and Hayes, both surgeons of Dublin, have devised special knives designed to avoid the risk of dividing an artery in this ope- ration, but the instruments seem to me unnecessarily complicated. Complications arising during the After-treatment.—The most important of these are the development of peritonitis, which usually assumes a dif- fused character, and the formation of a fecal fistula. For the treatment of these conditions, see pages 401 and 411. Sloughing of the hernial sac is a rare occurrence, and one which is very apt to prove fatal; its treat- ment presents no features calling for special comment. Herniotomy -without Opening the Sac (Petit's Operation)__ This method w as employed in the early part of the last century by Petit, and has been particularly advocated by Aston Key, Luke, and other Brit- ish surgeons. It is upon the whole the most eligible procedure when the circumstances of the case allow a choice of operations. It is attended with the obvious advantage of not involving the peritoneum, and of therefore exposing to less risk of the occurrence of peritonitis; but, on the other hand, with the disadvantage of not allowing the surgeon to determine by inspection the condition of the protruded viscera, and of possibly permitting a continuance of strangulation by the occurrence of reduction in mass, or by leaving internal adhesions undivided, etc. It is of course only appli- cable to those cases in which the seat of constriction is external to the sac (li. 872); but as this point cannot always be determined beforehand, this mode of operating should be tried in every instance in which the duration of strangulation and the urgency of the symptoms do not contra-indicate its employment. A safe rule is that given by Birkett—to try this method in those cases, and those only, in which the taxis would be deemed justifi- 884 SPECIAL HERNLE. able. If, after exposing the sac and dividing the tissues external to the neck, the hernia be found still irreducible, or (in the case of an old irre- ducible hernia,, recently strangulated) the symptoms of strangulation still continue, it is easy to open the sac and complete the ojieration in the ordi- nary way. Petit's method is particularly applicable in cases of femoral and umbilical hernia, but should be attempted in those of inguinal hernia as well. It is especially desirable to avoid opening the sac in large hernia? which have been long irreducible, and in which strangulation is due to the protrusion of a fresh portion of gut. The statistics of this operation are very favorable, the mortality being, according to the figures given by Erichsen, but 23.5 per cent., as compared with a mortality of 47.7 per cent, after the ordinary operation. It must be remembered, however, that Petit's method is only resorted to in selected cases. Gay's Modification of Petit's Method consists in making a small opening near the neck of the sac, introducing the finger to search for the seat of constriction, and upon the finger a concealed bistoury, the point of which is cautiously insinuated between the neck of the sac and the stricture; by then jirotruding the blade of the instrument, division is effected. This method will be again referred to in speaking of femoral hernia, to which it is chiefly applicable. CHAPTER XLI. SPECIAL HERNLE. The following classification of the various forms of abdominal hernia, according to their locality and anatomical peculiarities, is based upon that given by Birkett, in his excellent monograph in Holmes's System of Sur- gery, but is modified and slightly extended, in the hope that it will thus be more readily understood by the student. CLASSIFICATION OF HERNIA. Hernia in the Epigastric Region. 1. Diaphragmatic. 2. Epigastric. Hernia in the Mesogastric Region. 1. Ventral. [This form may also occur in other regions.] 2. Umbilical. 3. Lumbar. I. Inguinal, 1. Hernia in the Hypogastric Region. Hernial of sudden development. (a.) Into the vaginal process of peritoneum. (b.) Into funicular portion of vaginal process. (1.) In the male. -j (c.) Inguino-crural, etc. Hernia, of gradual development. (a.) Inguino-scrotal. [ (6.) Encysted. /•o \ t i\. e i / (a.) Into the canal of Nuck. {Z.) In the female. < ;, / T . i„u:„i ' \ (b.) Inguino-labial. 2. Direct. VENTRAL hernia. 885 II. Femoral or Crural. III. Pelvic. 1. Anterior. Obturator. ( (1.) Perineal. 2. Inferior. \ (2.) Pudendal. ( (3.) Vaginal. 3. Posterior. Isehiatic. The pathology and treatment of each of these forms of hernia are now to be briefly considered. Diaphragmatic Hernia. In this rare form of hernia, some of the abdominal viscera protrude into the thoracic cavity. The protrusion may occur through one of the dia- phragmatic orifices w'hich has undergone dilatation, through an aperture resulting from congential defect of development, or, which is most com- mon, through a laceration or wound of the part. The affection is seldom recognized during life, the symptoms being necessarily of a very equivocal nature; even if strangulation should occur, the diagnosis from other forms of intestinal obstruction could rarely* be established. The treatment, if strangulation of a diaphragmatic hernia were believed to exist, would consist in laparotomy; if the condition of the patient should permit, an attempt might properly be made to close the diaphragmatic opening with sutures. Epigastric Hernia. In this variety* of the disease, the protrusion occurs in or near the linea alba, between the ensiform cartilage and the umbilicus. Reduction is usually easy. The treatment consists in the application of a pad and elastic bandage. If strangulation occur, and herniotomy* be required, care must be taken to divide the stricture by an incision made in the direction of the long axis of the body, and exactly in the median line, so as to avoid wounding the epigastric artery. This variety of rupture may be properly- considered as a form of Ventral hernia, though the latter term is here applied more particularly to similar hernial in the mesogastric region. Ventral Hernia. This mav occur in the linea alba or linea? semilunares, or indeed in any part of the abdominal wall. It may result from rupture of the abdominal muscles (p. 399), from wounds, or from stretching of the fibrous tissue in the median line—due to over-exertion, to distention from pregnancy, etc., or to weakening of the part by the discharge of an abscess. The diagnosis can readily be made if the hernia be reducible, but under other circum- stances the affection may be mistaken for a cold abscess, an enlarged lym- phatic gland, or a cystic or fatty tumor, from any of which, however, it may be distinguished by careful palpation and inquiry into the history of the case. The treatment consists in the application of a suitable truss or bandage. Strangulation rarely occurs in this form of hernia. For the radical cure of hernia of the linea alba, Simon, of Heidelberg, freshened the edges of the opening, and united them by deep and superficial sutures, relieving the tension of the parts by making incisions on either side. 886 SPECIAL HERNIA. Umbilical Hkhnta. (Exomphalos, Omphalocele, Ruptured Navel.) In this variety of hernia, the protrusion occurs through, or in close proximity to, the umbilical ring or navel. Occasionally congenital, it is more commonly acquired, appearing usually during the early months of infancy, but sometimes not until adult life; it is probable, however, that in many, if not most, of the latter cases, the umbilical ring has been patu- lous since birth, or at least never firmly closed. In congenital cases, the hernia has, it is said, been strangulated by the application of tlie ligature to the umbilical cord. In infancy both sexes are equally liable to this form of hernia, but in adult life it is much more common in women, owing to the influence of pregnancy in distending and stretching the walls of the female abdomen. The sac of an umbilical hernia is always of the acquired variety* (see page 863). Symptoms__In infancy, the hernia appears as a smooth, tense, rounded tumor, varying in size from that of a marble to that of a small orange, easily* reducible, and reappearing sjiontaneously when the child struggles or cries. In adult life, the hernia often attains a very large size, is irregular in shape, and, in parts at least, doughy to the touch ; it usually contains both bowel and omentum, the latter being often indurated, hyjier- trophied, and adherent to the sac. The hernial tumor varies in shajie in different cases, but most commonly tends to hang downwards in front of the abdomen ; in a remarkable case which was under my care some years ago, the tumor, when the patient w7as in a sitting posture, rested on the chair between her thighs. The coverings of an umbilical hernia are in most cases very thin (consisting merely of skin, fascia, and sac), and are often closely connected together. The fascia sometimes presents jierfora- tions, through which a knuckle of intestine may protrude and become strangulated. Umbilical hernia in the adult is usually irreducible, or at least not comjiletely reducible, often becomes incarcerated, and is not rarely subject to strangulation, this accident being comparatively infrequent in the case of children. In some instances, double and even triple umbilical herniae have been observed in the same individual. Treatment.—In infants, it is usually possible to effect a cure by the use, for some months, of a comjiress of cork or metal, held in place by means of a suitable bandage ; or, as suggested by Archambault, by the use of a plug of wax, moulded to fit the umbilicus; or, which I prefer, by the simple application of a couple of broad strips of adhesive plaster, as advised by Fergusson. The strips should be renewed from time to time as they become detached by washing. If the umbilical aperture be very large, and particularly in the case of adults (if the hernia is reducible), the ring pad devised by J. Wood may be advantageously employed. For irreducible umbilical hernia, a concave pad or bag-truss, held in place by an elastic bandaire, will afford the best means of retention. Radical Cure___Various operations for the radical cure of umbilical hernia have been suggested and practised by Desault, Barwell, Heath, Lee, and other surgeons, the method which has attained most favor being jjro- bably that recommended by J. Wood, of London. This operation consists in approximating subcutaneously the tendinous margins of the aperture, through which the protrusion hasoccurred, by means of pins bent at a right angle, which are introduced in opposite directions and then twisted together, or by means of one or more wire sutures introduced with a curved needle, and 'secured over a superimposed roll of lint. The operation is more likely INGUINAL HERNIA. 887 to succeed in children than in adults, but, even in them, is believed by Mr. Wood to be of service, if not in obliterating, at least in diminishing the size of the hernial ajierture, and thus facilitating subsequent retention with a truss. J. M. Barton has operated successfully for the radical cure of um- bilical hernia in a child 33 hours old. Herniotomy.—It is very important in the operation for strangulated umbilical hernia, to relieve the constriction without opening the sac, jiar- ticularly if this be of large size—its implication in the wound being, under these circumstances, apt to be followed by a fatal result; hence, as the coverings of the hernia are commonly very thin, the surgeon should pro- ceed with great caution in their division. The hernia being drawn down and thus made tense, an incision two or three inches long is to be made over the neck of the tumor at the upper part, and usually* in the median line; the skin and fascia being divided, the finger-nail or director is slipped under the margin of the ring, wrhich is then nicked in an upw*ard direction. Wood jirefers an incision over the lower part of the hernial tumor, and divides the ring in a downward direction. If the symptoms of strangula- tion persist, the hernial sac must be opened, and any internal source of constriction divided. The omentum, if closely- adherent to the inner surface of the sac (as is often the case), should be left undisturbed, the gut being carefully returned, and the wound closed with sutures. The after-treat- ment consists in the application of a broad compress and bandage, and (if the sac have been opened) in the adoption of means to combat the perito- nitis which may be expected to follow. Fergusson advises, instead of the median incision above described, one at the side of the tumor's neck, as in Gay's method of ojierating for femoral hernia. Demarquay* also recommends a small lateral incision, on the left side of the sac, but forbids any* subsequent attempt at reduction, believing it safer to leave the parts in situ, and to rely* solely ujion the division of the neck of the sac to relieve the strangulation. Lawson Tait, on the other hand, advises that the sac should be freely laid open, the omentum cut away, and the edges of the ring pared and stitched together. He re- ports eleven cases thus treated, w-ithout a single death. Lucas, Golding- Bird, and Walsham recommend that the sac itself should be excised. Lumbar Hernia. In this very* rare form of hernia, which appears to have been first de- scribed by Petit, in 1783, the protrusion occurs in the loin, between the crest of the ilium and the last rib. In 9 of 29 cases collected by Braun, of Heidelberg, the hernia is said to have been of traumatic origin. Two were cases of double hernia, 12 occupied the left, and 7 the right, side, w-hile the side affected in 8 cases was not noted. Additional examjiles have since been recorded by Gosselin, Currier, Owen, Hutchinson, and Hume. Her- niotomy was required in but two cases (Ravaton's and Hume's), in the first of which it was successful. In Owen's case a radical cure was obtained. Inguinal Hernia. This is the most common variety of rupture, inguinal constituting about two-thirds of the whole number of herniae observed in both sexes. In oblique inguinal hernia, the protruding viscera pass through both the internal and external abdominal rings, traversing thus the whole length of the inguinal canal; in direct inguinal hernia, the viscera pass only through the external abdominal ring. The oblique variety is sometimes called external, because in it the neck of the hernial sac is placed to the outer SPECIAL HERNIiE. Fig. 519.—Inguinal hernia; on the right side ob- lique, on the left direct, a. The hernial sac. 6. The epigastric'artery. side of the internal epigastric artery, the direct inguinal hernia receiv- ing the name of internal, because in it the neck of the sac is to the inner side of the same vessel. An oblique inguinal hernia, in which the protrusion is still within the limits of the inguinal canal, iscalled a bubonocele, or an incomplete or interstitial hernia ; while one in which the protrusion has jiassed the external ring is called a com- plete hernia, and when it occupies the scrotum, an oscheocele, or scro- tal hernia. I. Oblique Inguinal Hernia in the Male. Of this we may recognize five varieties, three of which are sud- denly developed, as the result, usually, of violent exertion, and in which a congenital defect allows the production of the hernia, while the other two are gradually developed. The distinction is of importance, as the former offer a better jirospect of radical cure, while, at the same time, if strangulated, they are less apt to yield to the taxis than the other. 1. Hernia into the Vaginal Process of the Peritoneum__This is the variety ordinarily sjioken of as congenital. As a matter of fact, how- ever, the hernia, though most com- mon in infancy, is occasionally not developed until late in life—it being not the disease, but the anatomical peculiarity which allows its occur- rence, that iscongenital. The vaginal process of peritoneum remaining jia- tulous (pp. 861, 862), the hernia (which is suddenly developed) de- scends at once into the scrotum,where it lies in contact with and surrounds the testicle. In some cases, however, the hernia may descend into a patu- lous vagina] process, while the testis itself is retained in or immediately outside of the inguinal canal, or even within the abdominal cavity; in the former instances the hernia would, but in the latter instance would not, be in contact with the gland. The sac, in this variety of hernia, is the vaginal process itself, its mouth cor- responding with the position of the internal abdominal ring, and its neck occupying the inguinal canal, which is not shortened by the approximation of the internal and external rings, as in the ordinary oblique inguinal hernia of slow formation. A sub-variety of the hernia into the vaginal process is the hour-glass-shaped hernia, in which a constriction or narrowing of the Fig. 520.- -Hernia into vaginal process of perl- toneum. (Pirrie.) OBLIQUE INGUINAL HERNIA IN THE MALE. 889 Fio. 521.—Herniainto funicular por- tion of vaginal process. hernial sac (vaginal process) exists at some point between the position of the testis and that of the external abdominal ring. 2. Hernia into the Funicular Portion of the Vaginal Pro- cess.__This variety of hernia (which is sometimes called "infantile," in contradistinction to the last-mentioned, or so- called "congenital" hernia), is of frequent oc- currence. It is suddenly developed, and, though common in infancy, often does not make its appearance until adult life. The sac is the funicular portion of the vaginal process of peritoneum (pp. 861, 862), and the hernia, when it reaches the scrotum, lies above and separate from the testis, which is inclosed in its own proper tunic. I have shown, diagram- matically, the structure of this form of hernia in Fig. 521. 3. Inguino-Crural Hernia—This is the name proposed by Holthouse for cases of sud- denly developed oblique inguinal hernia, in which, owing to the non-descent of the testicle, or to other causes, the hernia, instead of passing down into the scrotum (or labium, in the case of a woman), protrudes outwards along the fold of the groin, presenting somewhat the appearance of a femoral hernia. Similar to these are the cases in which prolongations of the hernial sac (vaginal process) extend in various directions within the abdominal walls, constituting the inter-parietal or inter-muscular herniae of English authors, the uhernies en bissac" of French surgeons, and the inguino-properitoneal herniae of Kronlein, of Berlin, who has collected 23 cases of the kind, only one having been recognized during the life of the patient.1 4. Inguino-Scrotal Hernia of Slow Formation.—This is the common form of oblique inguinal hernia in persons past the middle period of life; the hernia "points" at the internal ab- dominal ring, forming a small circumscribed swelling, which is most prominent when the patient is erect, and which transmits an impulse when he coughs. As the hernia descends through the inguinal canal, it pushes before it the parie- tal layer of peritoneum, thus forming its own sac by a process of gradual distention. In this situation, it forms a somewhat elongated tumor (Bubonocele), lying parallel tothe line of Pou- part's ligament, and usually in front of the spermatic cord. When the hernia makes its appearance at the external abdominal ring, it forms a tumor of a somewhat globular shape, which, however, becomes more or less pyriform as the protrusion descends into the scrotum. Scrotal hernial often attain an enormous size, hanging perhaps as low as the knee; in such cases the hernia is commonly irreducible. In the 1 In 22 of the 23 cases the patients were of the male sex ; in 15, the hernia was originally of the so-called "congenital" variety; and in 9 cases it was complicated by the presence of an undescended testicle. The affection was found 13 times on the right, and 7 times on the left side, the side in the other 3 cases not being mentioned. An additional case, occurring in a woman, has recently been reported by Mr. Golding- Bird, and still another, in a man, by Dr. Oberst, of Halle. Dr. Dulles has added 6 cases to Kronlein's collection, including 1 of his own. Fig 522.—Common inguino-scrotal hernia. (Pirrie.) 890 SPECIAL HERNIJ1. descent of the hernia, the internal and external rings are approximated, thus shortening the inguinal canal, through which, when the hernia is reduced, the finger may be readily* passed (invaginating the covering of the hernia) within the abdominal cavity*. This is not usually jiracticable in the sud- denly* developed herniae, in which the inguinal canal maintains its normal length. 5 Encysted Hernia__This is the " encysted hernia of the tunica vaginalis" of Cooper, and the "infantile hernia" of Hey, of Leeds. It is a hernia of slow formation, and is therefore to he distinguished from the ordinary "infantile hernia" into the funicular portion of the vaginal jirocess. The peculiarity of this form of hernia consists in the persistence, of the testicular orifice of the, funicular portion of the vaginal jirocess of peri- toneum, the ventral orifice being closed (|>. siil); as a consequence of this congenital defect, the tunica vaginalis testis extends up to the external abdominal ring, and the hernia, forming its own sac from the parietal jieritoneum, protrudes into the tunica vaginalis, which is therefore first cut into when an operation is required in a case of this kind. This variety of hernia is very rare, and is seldom recognized before the parts are exjiosed in herniotomy. Coverings of Oblique Inguinal Hernia. Fio. 523—Encysted hernia. —These are (1) the skin, (2) the superficial fascia, (Liston.) (3) the external spermatic or intercolumnar fascia, (4) the cremasteric fascia, containing fibres derived from the internal oblique muscle, (5) the fascia propria, internal spermatic, or infundibuliform fascia, corresponding to the fascia transversalis, and (6) the sac, which may* consist of a dilatation of the parietal peritoneum, or of part or all of the vaginal process. In the encysted hernia there is apparently a double sac, the true sac being surrounded by both layers of the tunica vaginalis testis ; hence, in laying open the sac of an encysted hernia, three layers of serous membrane are divided. Though the six coverings above mentioned are properly described by systematic writers, it is seldom in practice that they can be individually recognized, the third, fourth, and fifth being commonly blended together so as to be indistinguishable. Relations of Oblique Inguinal Hernia__The spermatic cord is almost invariably behind the hernia, its component parts being commonly together, but occasionally separated ; more rarely the various structures of the cord may be spread out in front of the hernia. The position of the testicle corresponds with that of the cord, lying below and behind the hernia, or very rarely in front of it; the hernia and testis are in con- tact in the so-called congenital hernia (into the vaginal process) and in the inguino-crural variety, but in all others are separate. The epigastric artery lies to the inner side of and behind the neck of the hernia ; it is, in ingu'ino-scrotal herniae of long standing, somewhat deflected from its nor- mal oblique course, by the shortening of the inguinal canal, and then jiasses upwards and slightly inwards beneath the outer border of the rectus abdominis muscle. DIRECT INGUINAL HERNIA. 891 II. Oblique Inguinal Hernia in the Female. Of this we may recognize two varieties—one of sudden development, in which the hernia descends into the canal of Nuck, this variety correspond- in"-with the hernia into the vaginal process of the male ("congenital" hernia), and one of gradual development, the inguino-labial, corresponding to the ordinary inguino-scrotal hernia of the male. When, in a case of hernia into the canal of Nuck, the protrusion extends obliquely outwards in the line of Poupart's ligament, the hernia may be properly called inguino- crural. The coverings and relations of these hernial are the same as in the corresponding hernise of the male, substituting merely round ligament for spermatic cord, and labium pudendi for scrotum. Hernia into the Canal of Nuck is the commonest form of hernia met with in girls, and, with the exception of umbilical hernia, is the only form which occurs in female infants. It is in these cases, according to Kingdon, not unusual to find the ovary in contact with the hernia. Inguino-Labial Hernia, contrary to the commonly received notion, is almost as frequent in women as femoral hernia. The symptoms are very much those of the inguino-scrotal hernia of the male, except that the tumor rarely attains as large a size, and is less jiyriform in shape. The neck of the hernia is, besides, longer and narrower than in the correspond- ing hernia in the male. III. Direct Inguinal Hernia. This occurs in both sexes. The direct inguinal hernia is always gradu- ally developed, except in the contingency of a traumatic laceration of the structures immediately behind the external abdominal ring, when a hernia may suddenly protrude. The hernia "points" behind the external abdomi- nal ring, and escapes through the space known as Hesselbach's triangle, usually pushing before itself, or separating the fibres of, the conjoined ten- don, but occasionally passing to the outer side of the latter. Leaving the external ring, the hernia reaches the upper portion of the scrotum, where it forms a tumor which is more globular in form than that of an oblique inguinal hernia. The long axis of the sac, moreover, is parallel to the median line of the body, and its neck close to the outer border of the rectus muscle—not curving outwards in the line of Poupart's ligament, as in the case of a hernia which has traversed the entire length of the inguinal canal. Coverings of Direct Inguinal Hernia.—These vary according to the particular part of the triangle of Hesselbach through which the hernia protrudes. In the common form of direct inguinal hernia the coverings are (1) skin, (2) superficial fascia, (3) intercolumnar fascia, (4) fibres of the conjoined tendon, (5) transversalis fascia, and (6) the sac. In the comparatively rare instances in which the protrusion occurs to the outer side of the conjoined tendon, the latter does not furnish any part of the investments of the hernia, which then carries with it a portion of the cre- masteric fascia, as in the case of the oblique inguinal hernia. Relations.—The spermatic cord (or round ligament) passes almost invariably along the outer and posterior side1 of the hernial sac, while the epigastric artery also courses along the outer side of the sac, arching above the neck of the latter to reach the sheath of the rectus muscle. 1 Todd met with a case in which the cord passed in front of the sac, and B. Wills Richardson with one in which the cord passed on its inner side. 892 SPECIAL HERNIJE. Anomalous Inguinal Hernise.—It occasionally, though very rarely, happens that an inguinal hernia escajies, not through the external abdomi- nal ring, but through an abnormal opening in the aponeurosis of the ex- ternal oblique muscle, close to the ring. In such a case the sjiermatic cord would not be in direct contact with the hernia. Diagnosis of Inguinal Hf,rnia. From Femoral Hernia, an inguinal hernia may be distinguished by ob- serving (1) that it invariably protrudes above the line of Poupart's liga- ment, and (2) that the external abdominal ring (through which an ingui- nal hernia escapes) lies to the inner side of the pubic spine. Hence, if the neck of the sac be found outside of this prominence, it may be inferred that the hernia is not inguinal. The Differential Diagnosis between the var- ious forms of inguinal hernia may usually be made by investigating the history of the case, and by attention to the symptoms which have been described as characterizing the several varieties of the affection. In other instances, however, and particularly in cases of strangulation, the surgeon may be unable to say* positively even whether the hernia is oblique or direct. Inguinal Hernia -which has not descended into the Scrotum is to be distinguished from abscess, hydrocele or hematocele of the cord, tumor of the cord, adenitis, and undescended testis. (1) Abscess arising within the jielvis and pointing in the course of the inguinal canal is reducible, and may transmit an impulse when the jiatient coughs, but can be distinguished from hernia by its fluctuating character, and by the absence of gurgling in reduction. (2) Hydrocele of the Cord, may be distinguished by its elastic, semi- fluctuating character, its transluency if low down, the impossibility of complete reduction within the abdominal cavity, and the absence; of gur- gling. The same signs may, in the female, serve for the diagnosis, from hernia, of a serous cyst, which sometimes occupies the canal of Nuck (Hydrocele of the Round Ligament). (3) Haematocele of the Cord may be recognized by the existence of fluc- tuation and ecchymosis, by the impossibility of complete reduction, and by the absence of gurgling. (4) Tumors of the Cord have a well-defined outline, transmit no im- pulse on coughing, and are irreducible. (5) Enlarged Lymphatic Glands are commonly situated below Pou- part's ligament; but when a single gland is above, and inflamed, the case may be mistaken for one of strangulated hernia, the diagnosis perhaps being only cleared up by an exploratory incision. In a case of supposed hernia which came some years ago under my care, I found the inguinal tumor to be glandular, and to be dependent upon cancer of the vagina which had not been detected. (6) An Undescended Testis occupying the inguinal canal may be distin- guished from hernia by* the imjiossibility of reduction, the absence of gur- gling, the peculiar sickening sensation caused by pressure, and the fact that there is no testicle in the scrotum of that side. The difficulty in greater when the undescended testis is inflamed, but here (unless a stran- gulated hernia coexists) the diagnosis may be made by attention to the points already* mentioned, and by noting the character of the vomiting, which in the'ease of an inflamed" testis is not persistent, and never sterco- raceous. treatment of inguinal hernia. 893 Scrotal Hernia is to be distinguished from hydrocele of the tunica vaginalis, haematocele, varicocele, and tumors of the testis. (1) Hydrocele is to be distinguished by its translucency, its tense and semi-elastic cnaracter, its irreducibility, and the absence of impulse on coughing; it begins at the bottom of the scrotum, instead of at the top, as is the case with hernia, and is distinctly circumscribed, the cord being readily perceptible above it. If a hydrocele of the cord coexist, the diag- nosis is more difficult. Congenital hydrocele, in which the communication between the tunica vaginalis and peritoneum persists, though reducible by pressure, may be distinguished by the absence of gurgling, and by the gradual manner in which the tumor reappears when the pressure is removed. Hernia and hydrocele may coexist, in which case the hydrocele is usually in front, and each tumor presents its own characteristic"peculiarities. (2) Haematocele may be distinguished by its history (of traumatic ori- gin), its irreducibility, the absence of impulse and gurgling, and the dis- tinctness with which the cord may be felt above. (3) Varicocele may be distinguished from hernia by making the patient lie down and by elevating the scrotum, when the tumor, if a varicocele, will disajipear slowly and without gurgling; if now the surgeon press gently on the external abdominal ring, and direct the patient to rise, the tumor, if a varicocele, will be slowly reproduced, beginning at the bottom of the scrotum, but if a hernia, will not reappear ; if, on the other hand, moderately firm pressure be made upon the cord below the external ring^ so as to take off the weight of the superincumbent column of blood, and thus prevent distinction of the spermatic veins, the tumor, if a varicocele, will not be reproduced, whereas a hernia will slip down alongside of the' finger. (4) Tumors of the Testis may be distinguished by their rounded shape and solid feel, by the absence of impulse or gurgling, by their irreducibility, and by the non-implication of the cord and inguinal canal. Treatment of Inguinal Hernia. The Palliative Treatment of oblique inguinal hernia consists, when the rupture is reducible, in the application of a truss, the pad of which should be of an elongated shape, and should press upon the whole extent of the inguinal canal and upon the internal abdominal ring. In applying a truss for hernia into the vaginal process, in a child, great care must be taken not to press injuriously upon the testis, if this have not fully de- scended. For direct inguinal hernia, a truss is required which shall sup- port the abdominal parietes behind the external abdominal ring ; a good instrument for the purpose is that with an "ovoid-ring pad," as employed by Mr. John Wood. For irreducible inguinal hernia of either form, a hollow pad, or suspensory or bag-truss is to be applied. For inguinal hernia in infants, Coates, Lund, and Pye recommend the application of a thick skein of wool or worsted, passed around the pelvis and under the thigh, with a loop over the hernial ojiening. Radical Cure.—Of the numerous ingenious operations which have been advised for the radical treatment of inguinal hernia, I shall describe but seven, viz : 1, Wutzer's ; 2, Syme's and Fayrer's (which are essentially the same); 3, Agnew's; 4, Buchanan's; 5, J.Wood's; 6, McBurney's; and 7, Macewen's. Modifications of Wood's method have been devised by Mr. Spanton, of Hanley, by Prof. Annandale, and by Dr. Greensville Dowell, of Texas, the latter of whom applies subcutaneous sutures by means of what he calls a " shuttle-needle," and reports 60 at least tern- 894 SPECIAL HERN I.E. porary successes in a total of 6S operations. A similar ojieration is per- formed by Mr. Fitzgerald, of Melbourne. Mr. Spanton pins together the sides of the inguinal canal with an instrument resembling a corkscrew. 1. Wutzer's Method consists in invaginating a plug of scrotum in the inguinal canal, and endeavoring to fix it there by exciting inflammation in the neck of the sac. The patient is placed in a supine posture, the rectum and bladder being empty, the aflected part carefully shaved, and the hernia thoroughly reduced. Invagination is effected by pushing up a cone of the scrotal tissues with the left forefinger, which is introduced within the internal ring; an oiled, hollow, boxwood cylinder (Fig. 524) is carefully introduced as the finger is withdrawn, so as to maintain invagination; L c C i: Fio. 524.—Wutzer's apparatus for radical cure of hernia. along the inner surface of this cylinder, a flexible needle (A), gilt to prevent corro- sion, is passed by means of a movable handle, and thrust through the scrotum, her- nial sac, anterior wall of the inguinal canal, and tissues of the groin, the operation being completed by the application externally of a concave boxwood ease or roof (B), the curve of which corresponds to that of the cylinder, and which passes over the point of the needle and is held in place by means of a screw at the other end. The apparatus is kept in place for about a week, the invaginated plug being subse- quently supported by a roll of lint and a sj>ica bandage; the patient is kept in bed about three weeks, and should wear a light truss for several months afterwards. 2. Syme's Method is a modification of the above, and is thus descrihed by its author:— " Instead of a complicated machine for distending the invaginated integument, I employed a piece of bougie or gutta-percha, to one end of which was attached a strong double thread. The plug, thus prepared and smeared with cantharides oint- ment, was drawn into its place by the threads, which, by means of a curved needle guided on the finger fairly within the ring, were passed, at a distance of rather more than an inch from each other, through all the textures to the surface, where they were tied firmly together on a piece of bougie, to prevent undue, pressure on the skin." The plug is left in position ten days, and the patient kept in bed a fortnight longer. Prof. Fayrer's Method differs from Syme's, merely in the substitution of an oiled wooden plug for that of gutta-percha; in the fact that the ligatures (which are of silk), though introduced at different points, are brought out through the same aperture in the groin, where they are tied over a piece of wood or ivory; and in the withdrawal of the plug in from two to six days. Thirty-eight cases operated on in this way by Fayrer gave twenty-four cures (the permanence of which was, however, not ascertained), while twenty-five cases operated on by Wutzer's plan gave the smaller proportion of fourteen cures. 3. Agnew's Method.—For this operation a special instrument is required, which resembles a bivalve speculum, and consists of two semi cylindrical blades with handles, with two grooves on the inner or concave surface of each blade, and a rod and screw to regulate the degree to which the blades are separated. An incision 2£ inches long is made over the scrotum, passing downwards from a point three-fourths of an inch below the external abdominal ring; the subjacent ti»- RADICAL CURE OF INGUINAL HERNIA. 895 sues are separated from the skin of the scrotum by the finger, introduced through the incision, and then invaginated, the '' speculum" being made to replace the finger, as in Wutzer's operation. The blades of the instrument are then separated, and a long- handled needle, armed with silver wire, is passed along one of the grooves of the lower blade, thrust through the interven- ing structures, and brought out on the surface of the body over the internal ring; the needle is then unthreaded and with- drawn, rethreaded with the Other end of Fm Wi.-Agnew'ii instrument for the radical the wire, and passed along the second cure of hernia. groove, to be brought out at nearly the same point as before. Both ends of the wire are then drawn tight and firmly twisted together. A short needle is next armed with silk or wire, and passed across the in- guinal canal between the blades of the speculum at three points, near the summit, at the middle, and just above the external ring; these sutures are tied over a roll of lint, the speculum is removed, and the operation is completed by the application of a compress and bandage. The sutures are removed on the eighth day, and the patient is kept in bed, in all, for about three weeks, and subsequently furnished with a light truss. "With reference to my own operation," says Prof. Agnew, "the suc- cess obtained has not been sufficiently uniform to justify me in speaking of it in any other way* than with distrust," An operation similar in principle, though somewhat differing in details from Prof. Agnew's, is employed by Mr. Croly, of Dublin. 4. Prof. Buchanan, of Glasgow, in cases of congenital hernia, in chil- dren, employs an operation somewhat resembling that just described, except that he divides the sac transversely, invaginating the upper portion, and turning the lower part downwards to form a tunica vaginalis. 5. Wood's Method.—The most important feature of Mr. Wood's various operations consists, as has been already mentioned, in applying sutures in such a way as to effect compression and closure of the tendinous sides of the hernial canal in its whole length. The instruments required are, (1) a strongly-curved needle, eyed near the point, and mounted in a firm handle ; (2) a knife somewhat resembling a tenotome ; (3) a strong, hempen thread, or silvered copper wire; and (4) a compress, which if the thread be used, is to be made of boxwood, glass, or porcelain. (1) Operation with Thread.—The patient being anassthetized, and the rupture thoroughly reduced, a small scrotal incision is made over or below the fundus of the hernial sac, and the skin and fascia are separated over an area two or more inches in diameter, by means of the knife introduced flatwise. The knees of the patient are then brought together, and elevated so as to relax the structures of the groin, and the detached fascia is invaginated with the forefinger, which is pushed well up into the inguinal canal with the nail directed backwards. The finger being hooked forwards, so as to raise the lower border of the internal oblique muscle, and with it the con- joined tendon, the unarmed needle, well oiled, is jiassed up on the pubic side of the finger, pushed deeply through the tendon at its most salient part, made to traverse the internal pillar of the superficial ring obliquely upwards and inwards, and finally brought through the skin, which is first drawn inwards and upwards as much as its deep attachments will allow. One end of the thread is then passed through the eye of the needle, which is quickly withdrawn, leaving the other end of the thread in the puncture. The finger is next placed behind the external pillar of the super- ficial ring, close to Poupart's ligament, opposite the internal hernial opening, in the groove between the spermatic cord and the ligament. The finger is again raised, stretching the aponeurosis, and the needle (which is now armed) passed between the point of the finger and Poupart's ligament, pushed through the latter, and brought out at the same opening as before ; a loop of the thread is this time left in the punc- ture, and the needle carrying the free end again withdrawn. The finger is now placed on the inner side of the si>erniaticcord, just above the pubic spine, and pressed 896 SPECIAL HERNIA. firmly upon the conjoined tendon, pushing this backwards and the cord outwards, so as to feel the border of the rectus tendon. Into the tendinous layer of the trianqular aponeurosis covering this part of the rectus, the needle is then deeply thrust, turned obliquely towards the surface, and a third time brought out through the original puncture, which now contains both ends of the thread and an intermediate loop; two portions of thread thus cross the hernial canal, invaginated fascia, and sac, closelv embracing but not including the spermatic cord, and joining together the front anil back walls of the canal. The compress is placed obliquely over the canal, the free ends of thread and the loop crossed and firmly drawn in opposite directions, and the whole then secured by passing one end of the thread through the looj) and tving it back to the other end in a " bow-knot." The ojiera- tion is completed by the application of pads of lint and a spica bandage. The knot is untied and the com- press removed from the third to the seventh (lav, the threads being allowed to remain as setons as long as may be deemed necessary. (2) Operation with Wire.—The preliminary steps arc the same as when the thread is used, but in passing tin; needle for the second time it is unarmed, and with- drawn armed with the other end of the wire, thus leaving a loop above and bringing both free extremi- ties out at the scrotal incision below ; the hernial sac and the fascia covering it opposite the scrotal aperture are then pinched up with the finger and thumb, and the cord slipped back as in the ojieration for varico- cele, when the needle is passed (entering and emerging through the scrotal wound) from without inwards and W—-2 v a little upwards, immediately in front of the spermatic f "'■ cord; it is now armed with one of the ends of wire Fig. 526—Wood's operation for (either will answer the purpose) and withdrawn ; the radical cure of hernia. next step is to straighten and draw down the ends of wire until the loop is near the skin, where it is held while the ends are twisted together with three or four turns, the inclosed sac and fascia being thus twisted and held between the ends of wire. The loop is now drawn upwards, so as to effect complete invagination of" the twisted sac and scrotal fascia, and in its turn twisted down into the groin puncture; the ends of the wire are then cut off about three inches from the surface and bent into a hook which is carried up- wards to meet the loop, both being locked together over a compress of lint, and the whole covered with a spica bandage. The wire may be untwisted about the eighth or tenth day, and removed about the fourteenth. This is the form of operation which Mr. Wood now considers most desirable. (3) Operation with Pins.—For small ruptures in children, particularly for rup- tures into the vaginal process, Mr. Wood resorts to the use of pins bent at a right angle; these are passed in opposite directions, one through the conjoined tendon and internal pillar, and the other through the external pillar of the ring, the hernial sac being transfixed by both pins, which are then twisted together. The pins are with- drawn from the second to the tenth day. (4)- Operation by Removal of Sac.—In a few cases Mr. Wood has, with antiseptic precautions, cut away the sac after tying its neck, and then brought the sides of the canal and rings together with wire, or with kangaroo or ox tendon. Of 28 cases treated in this manner, 3 have proved fatal. Mr. Wood's statistics of the operation by his first three methods, up to the year 1885, have already been given on page 868; it may be added that 30 operations by one or other of these methods, recorded in the Reports of the Boston City Hospital, gave only 8 recoveries, 3 " fair results," 2 deaths, and 17 failures. 6. McBurney's Method.—This differs from Wood's fourth method in that after splitting the sac, tying or stitching its neck at the highest point so as to obtain a perfectly smooth surface on the peritoneal asjiect of the abdominal wall, and cutting away the remainder, the tissues of the sides of the wound are stitched together separately, so as to keep the wound HERNIOTOMY FOR INGUINAL HERNIA. 897 below. its side " Tension sutures' come into contact. itself open from its base, and iodoform gauze is then packed in, in such a wav as to make sure that healing shall be entirely by granulation from are used to narrow the wound without letting Dr. McBurney believes that, contrary to the ordinarily received opinion, strength is gained by securing a large amount of cicatricial tissue. 7. Macewen's Method.—In this operation, the sac, after reduction of the hernia, is separated both from the inguinal canal and from the abdominal surface of the internal ring; it is next transfixed by a suture and pushed within the abdominal cavity, where, by tightening the suture, it is thrown into a series of folds, constituting a pad which is then fixed with stitches on the inner aspect of the ring. The canal itself is then closed by a suture, which is made to transfix the border of the conjoined tendon above and below, and to secure it to Poupart's ligament and the aponeurotic structures of the abdominal muscles. The patient, as a rule, does not require to wear a truss after the operation. Taxis for Inguinal Hernia__In employing the taxis, in a case of inguinal hernia, the pressure must be applied strictly in the direction of the inguinal canal, i. e., obliquely upwards and outwards. It must, how- ever, be remembered that in a case of inguino-scrotal hernia of long stand- ing, the direction of the canal itself becomes changed, by the approximation of the abdominal rings. Bernays recommends, as an aid to the taxis, a subcutaneous section of Poupart's ligament. Herniotomy___An incision of from two to four inches in length is made in the direction of the long axis of the tumor (Fig. 527), so that the position of the external ring will be a little above the middle of the wound; the various cov- erings of the hernia are then carefully* divided, until the director or tip of the finger can be in- sinuated beneath the edge of the ring, when, if this be found to exer- cise any constriction, it is to be incised in an upward direction, in a line parallel to the linea alba. The taxis may be then gently employed, when it will occasion- ally happen that reduction can be effected without further trouble, but if such is not the case, the internal ring is to be explored and similarly dealt with; in the majority of instances, however, the stricture is in the neck of the sac itself, and an opening must then be made of sufficient size to allow the introduction of the finger, which is passed up to the seat of obstruction, a hernia-knife following and nicking the stricture in the way described at Jiage 881. It is a well-established rule that the incision in this part of the operation should be made directly upwards, in a line parallel to the linea alba, so that whether the rupture be of the oblique or direct variety (and this cannot always be determined beforehand), the epigastric artery may escape injury. 57 527.—Incision for strangulated inguinal hernia. (Fekocsson.) 898 SPECIAL HERNIAS. Femoral or Crural Hernia; Merocele. Fio. 528.—1, Femoral hernia; 2, femoral vein ; 3, femoral artery, giving off 4, common trunk of epigastric and obtu- rator arteries; 5, epigastric artery ; 6, spermatic cord. (Erich- sen.) In this form of hernia, which is more common in women than in men (in the proportion, according to Croft, of nearly five to one), the protru- sion takes jilace beneath Poupart's ligament, and al- most invariably to t he inner side of the femoral vein. Descending through the fe- moral ring, the hernia pushes before it the parietal layer of jioritoneum (thus forming its own sac), with the dense layer of areolar tissue which normally closes the ring and is known as the septum crurale; pass- ing downwards along the crural canal, in the inner compartment of the sheath of the femoral vessels, the hernia changes its course ujion arriving at the snjihe- nous opening, and, turning forwards, pushes before it the cribriform fascia, and curves upw*ards on to the falciform process of the fas- cia lata and lower portion of the external oblique tendon, lying at this point beneath the superficial fascia and skin. Varieties.—Several varieties of femoral hernia are described by sys- tematic writers. Thus, when the rupture is still within the crural canal it is called incomplete, being complete when it has jiassed the saphenous opening. Another division is founded upon the relations of the sac to the internal epigastric and obliterated umbilical arteries, the common form, in which the mouth of the sac lies between these vessels, being called middle crural hernia, and the rare varieties in which it lies to the outer side of the epigastric, or to the inner side of the umbilical artery, being called, respec- tively*, external and internal crural hernia. LeGendre has described four rare varieties, to which Birkett has added a fifth: these are, (1) the pecti- neal crural, or hernia of Cloquet, in which, after passing the femoral ring, the hernia turns within and behind the femoral vessels, resting on the pec- tineus muscle; (2) the hernia, through Gimbernat's ligament, or hernia of Laugier, the anatomical peculiarities of which are sufficiently exjiresscd by its name; (3) the hernia with a diverticulum through, the cribriform fascia, or hernia of Hesselbach, in which the hernia protrudes through several openings in the cribriform fascia, getting thus a lobulated appear- ance; (4) the hernia with diverticulum through the superficial fascia, or hernia of Cooper, which, mutatis mutandis, is similar to that last men- tioned; and (5) the hernia external to the femoral vessels, or hernia of Partridge. Tessier has recorded a case, to which Kronlein gives the name of cruro-properitoneal hernia, in which an additional sac existed between the peritoneum and abdominal wall, in the cellular tissue of the jxlvis and side of the bladder. A similar case has been successfully submitted to an operation for radical cure by C. J. Rossander, and Golding-Bird has TREATMENT OF FEMORAL HERNIA. 899 reported a case in which the additional sac passed downwards into the right labium. Other cases have been recorded by Baron and Tansini. Coverings__The coverings of an ordinary complete femoral hernia are (1) skin, (2) superficial fascia, (3) cribriform fascia, (4) crural sheath, (5) septum crurale, and (6) sac. The septum crurale and adjacent portion of the crural sheath are commonly matted together, constituting the fascia propria of Cooper. The coverings of an incomplete femoral hernia are the same, substituting the falciform process of the fascia lata for the crib- riform fascia. Relations—The femoral vein lies close to the outer side of the hernia, and separated from it merely by a septum of the crural sheath, the epigas- tric artery is above and to its outer side, while the spermatic cord or round ligament passes almost immediately above it on the inner side. The obtu- rator artery, when, as not unfrequently happens, it arises from the external iliac, common femoral, or epigastric, instead of from the internal iliac artery (as in the normal condition), usually descends on the outer side of the crural ring to reach the obturator foramen, but occasionally skirts along the free border of Gimbernat's ligament, when it would almost completely encircle the neck of the hernial sac. In the rare cases in which the hernia escapes externally to the femoral vessels, the circumflex ilii artery would lie to the outer side of the sac. Diagnosis—Femoral hernia seldom attains a large size, appearing usually as a firm, tense, rounded tumor, on the inner side of the femoral vessels, and invariably originating below Poupart's ligament—though it frequently jiasses above that structure, as it curves upwards after emerging from the saphenous opening. When of large size, the appearances are somewhat different, the tumor then being often soft and doughy, even though strangulated. The diagnosis of crural from inguinal hernia, can always be. made by observing the relations of the neck of the hernia to Poupart's ligament and the spine of the pubis, as pointed out at page 892. Obturator hernia can be distinguished by noting its deep situation and the freedom of the femoral ring. Enlarged lymphatic glands may be mis- taken for crural hernia, but can usually be distinguished by observing that there is more than one tumor, and that there is no impulse on coughing, and by attention to the history* and progress of the case. As, however, a strangulated femoral hernia may exist behind an enlarged gland, in any case of doubt an exploratory incision should be made. The same course may be necessary if symptoms of strangulation occur in a case in which a fatty or cystic growth occupies the region of the femoral ring. For the diagnosis of crural .hernia from psoas abscess, see page 712. A dilated and varicose condition of the saphena vein may be distinguished by the absence of gurgling on reduction, and by the return of the tumor when the patient stands up, even though pressure be made at the crural ring. Treatment of Femoral Hernia__The Palliative Treatment consists in the application of a well-fitting truss, which, in ordinary cases, should be furnished with a small and convex pad, made to press just below Poujiart's ligament and a little to the outside of the pubic spine, in the line of the crural canal. If, however, as is sometimes the case, the whole crural arch be much relaxed, a large and rather flat pad is preferable, in order to press Poupart's ligament against the bodv of the pubis, and thus approximate the walls of the canal. A hollow-pad or bag-truss must be employed if the hernia is irreducible. Radical Cure—Mr. Wood has described an operation in which wire i* used in the same manner as in his second method of treating inguinal hernia, and by which " that part of the tendinous crural arch whichever- 900 SPECIAL HERNIA. rides the neck of the sac is drawn backwards and downwards, and he- conies adherent to the pubic portion of the fascia lata." Cheever, of Bos. ton, has recorded one case in which this plan was resorted to without anv permanent benefit, but no extended statistics of the ojieration have, I he lieve, as yet been jiublished. Taxis.—In applying the taxis in a case of femoral hernia, the thigh of the affected side should be strongly flexed, rotated inwards, and carried well across the ojiposite limb, so as to relax the crural arch. Pressure is to be made in accordance with the direction of the descent of the hernia, viz., first downwards, so as to clear the falciform process, then backwards, and finally upwards in the line of the crural canal. The taxis is less likely to succeed in femoral than in inguinal hernia, and the proportion of cases requiring herniotomy is therefore greater. Moreover, there is less time for delay, as strangulation in crural rupture is commonly of the acute variety (see p. 875). Roux reports a case of strangulated femoral hernia successfully reduced by taxis applied through the vagina. Herniotomy___The external incision may vary according to the fancy of the operator, some surgeons preferring a single longitudinal incision, others one which is oblique and jiarallel to Poupart's ligament, while still others combine both, thus TT or make a slightly curved cut over the pubic side of the neck of the tumor, reaching one inch above and one or two below the crural arch. The superficial coverings having been divided, the condensed layer formed by the septum crurale and crural sheath (fascia propria) is cautiously opened, so as to expose without wounding the sac. The finger is then passed up below the fascia jiropria, and the nail, or the extremity of a grooved director, insinuated under the sharp edges of Gimbernat's ligament and the falciform jirocess at their point of junction (Hey's ligament), the hernia-knife being then introduced and made to cut upwards and inwards for a sjiace not exceeding two lines. If reduction cannot now be effected, any constricting fibres of the fascia propria which may have been left are to be carefully* severed, when, if the hernia be still irreduci- ble, the sac must be opened, and the stric- ture sought for and divided, with the pre- cautions described on a previous jiage. It is sometimes possible to relieve the strangula- tion by nicking Gim- bernat's and Hey's ligaments outside of the fascia jiropria. In the majority of in- stances, however, the stricture is in this structure itself, requir ing it to be laid open in the manner above described. The fascia propria, when much thickened and congested, may be mistaken for the hernial sac, or for a mass of omentum. It has not, however, the arborescent arrangement of vessels which characterizes the former, and is more rounded and uniform in ap- pearance than the latter. The direction in which the stricture is to lie Fig. 529.—Incision for strangulated femoral hernia. (FERntrssoN.) OBTURATOR HERNIA. 901 divided, whether the sac be opened or not, is invariably* upwards and in- wards. An outward incision might wound the femoral vein, one upwards and outwards the epigastric artery, and one directly upwards the sjiermatic cord, while an inward incision would divide Ginibernat's ligament only, and therefore probably fail to relieve the constriction. The only possible risk in the incision upwards and inwards, is of wounding the "obturator artery, in the rare cases in which this vessel winds around the neck of the sac (page 899). This danger may be obviated by employing a knife with a concealed blade, as advised by Corley and Hayes, or by slightly blunting the edges of the hernia-knife, which will then push the vessel before it, while it will still be sharp enough to divide the fibrous bands which im- pede reduction. Wyeth advises that the point of the knife should be kept firmly pressed against the pubis during this step of the operation, as, if the cutting edge does not pass beyond the ligament, the artery cannot be wounded. As already mentioned, a very limited incision is sufficient. Should the obturator artery be accidentally* wounded, hemorrhage from either end must be arrested by torsion, or, if this fail, by the application of a ligature. Herniotomy by Gay's Method.—An incision about an inch in length is to be made on the inner side of the tumor, near the neck of the sac, and the various tissues cautiously divided until a concealed bistoury can be introduced flatwise between the neck of the sac and the inner margin of the erural ring. The edge of the knife is then turned towards the pubis, when, by projecting the blade, the stricture is readily divided. The small lateral incision which is practised in this mode of operating, was highly commended by the late Sir William Fergusson, who declared that he rarely employed any other. This distinguished surgeon, however, apparently completed the operation with the ordinary hernia-knife, instead of with the Ustouri cache, as originally advised by Gay. Obturator Hernia. In this rare form of hernia, which was first described bv Garengeot, the protrusion takes place through the obturator foramen, forming in some cases a well-marked tumor in Scarpa's triangle, though, in other instances, not even the slightest fulness of the part has been perceptible. The affec- tion is commoner in women than in men, and the hernial sac (which is one of gradual development) is always small, not unfrequently containing a portion only of the calibre of the bowel. Obturator hernia is occasionally complicated by the coexistence of femoral or inguinal hernia, and, in a case recorded by Hilton, the sac of an obturator hernia was found on either side of the body. The position occupied by an obturator hernia is in Scarpa's triangle, behind and somewhat to the inner side of the femoral vessels, and to the outer side of the adductor longus tendon; the hernial tumor is covered by the pectineus muscle. Zoja, an Italian surgeon, has recorded a case of obturator cystocele. Diagnosis—When the protrusion is perceptible, the case may be diagnosticated from one of femoral rupture by observing the position of the tumor in relation to the femoral artery and body of the pubis—these structures lying behind the tumor in the case of a crural, but in front of it in the case of an obturator, hernia. When no swelling is observable, the symptoms of strangulation being at the same time present, the diagnosis of obturator hernia may be made, according to Birkett, by attending to the following particulars: (1) there is often a history of colicky pains pre- viously felt in the pelvic region, sometimes relieved with an accompanying sensation of something having slipped back into the abdomen; (2) the 902 SPECIAL HERNIiE. evidences of strangulation may have been preceded by a sudden and violent pain at the inner and upper part of the thigh; (:>) cramp in the abdominal muscles, rather than pain within the abdomen, may be complained of, obviously due to reflected irritation from the cutaneous filaments of the obturator nerve; (4) pain in the course of the distribution of the obturator nerve—a very significant symptom, the value of which was first pointed out by Howship—may be induced or increased by rotating the thi.yh out- wards, and thus putting the obturator muscle on the stretch; (5) jiain may be elicited by making pressure over the external outlet of the obturator canal, comparing the effect on either side of the body; and (6) jiain may be elicited by pressing on the pelvic outlet of the canal with the linger introduced into the vagina or rectum. Griinberg considers pain and tender- ness over the pectineus muscle a sign of much value. Treatment___If the hernial tumor be perceptible, an attempt may bo made to effect reduction by means of the taxis; but if this fail, or if there be reason to suspect the existence of strangulated obturator hernia, though no swelling can be recognized, an exploratory operation should at once be resorted to. A longitudinal incision about three inches in extent may be made, beginning a little above Poupart's ligament, and passing downwards on the inner side of the femoral vessels. The pectineus muscle being divided, and the fibres of the obturator separated with the director or handle of the knife, the sac of the hernia, if there be one, will be exposed. The taxis should now be tried again, when, if still unsuccessful, the sac should be opened, and the stricture cautiously divided in an upward di- rection. Birkett has collected twenty-five recorded cases of strangulated obturator hernia, in fourteen of which the nature of the affection was not discovered until after the patient's death, while in one the symptoms dis- appeared spontaneously without treatment. Of the ten cases recognized during life and submitted to treatment, four recovered and six died. The taxis was employed in two cases with one recovery, and herniotomy in six cases with three recoveries. In one case (Hilton's) the diagnosis was not made until after the performance of laparotomy (the jiatient dying), and in another, in which the integuments were becoming gangrenous when the case was first seen, the patient died the day after the establishment of a fecal fistula. Additional fatal cases of obturator hernia have been re- corded by Griinberg, Thring, Coulson, and Rehn—the patients of the two last-named surgeons having submitted to laparotomy. B. Schmidt has collected 25 cases in which obturator hernia was diagnosed during the life of the patient; the taxis was employed in 8, and operative measures in 17 cases, but only 5 out of both categories ended successfully. Successful operations for obturator hernia have recently been recorded by Hassel- wander and Morrant Baker. Perineal Hernia. In this form of rupture, the protrusion occupies the perineum, and is placed usually between the rectum and prostate in the male, and between the rectum and vagina in the female, but, occasionally, on one or other side of the anus. Perineal hernia, which is more common in women than in men, is readily reducible, and may be kept within the pelvic cavity by the use of a pad and T" bandage. Pudendal or Labial Hernia. In this variety, the hernia occupies one of the labia majora, descending between the vagina and the ramus of the ischium. Pudendal hernia is to INTESTINAL OBSTRUCTION. 903 be diagnosticated from inguino-labial and from femoral rupture, and from cysts of the labium and of the canal of Nuck, the so-called hydrocele of that part. From inguino-labial hernia, it may be distinguished bv the parallelism of its axis with that of the vagina/by the non-implication of the inguinal canal, by its rounded, rather than pyriform shape, and by its positiou alongside of the ramus of the ischium instead of over the body of the pubis; from femoral hernia, by the position of the neck of the hernial sac as regards the ramus of the ischium, this bone lying externally in the case of pudendal, and internally in the case of crural rupture; and from cystic growths, by their irreducibility, their tense and resisting character, their gradual increase in size, and, in many instances, the possibility of completely isolating them with the fingers. The treatment consists in the introduction of a suitable pessary, or in the application of an elastic band- age. Should strangulation occur, and herniotomy be required, the stricture should be divided in an inward direction. Vaginal Hernia. The protrusion occupies either the anterior or posterior wall of the vagina, and may produce discomfort by compressing either the rectum or urethra. The treatment consists in the use of a suitable pessary or elastic bandage, and in the employment of the catheter, if there is any difficulty in evacuating the contents of the bladder. Ischiatic or Sciatic Hernia. The hernia protrudes through the sciatic notch, usually below, but some- times above, the pyriformis muscle, and projects beneath the gluteus maxi- mus. The treatment consists in the apjilication of a pad and elastic bandage; should herniotomy be required, the stricture should be divided, as recommended by Sir Astley Cooper, in a forward direction. An inter- esting example of this rare form of hernia has been recently reported bv Crossle, of Dublin. CHAPTER XLII. DISEASES OF INTESTINAL CANAL. Intestinal Obstruction. Obstruction to the passage of fecal matter along the intestinal canal may be due to various causes, some of which produce acute symptoms and often terminate life in the course of a few days, while others act compara- tively slowly—the obstruction in these cases not unfrequently yielding spontaneously, and, even when proving fatal, not doing so for a consider- able period; hence the customary division of cases of intestinal obstruction into two classes, the acute and chronic, a division which is convenient for purposes of study, and will, therefore, be retained, though in practice, cases will often be met with which are on the border line between the two varie- ties, the acute forms of obstruction sometimes, as well remarked by Pol- lock, subsiding into the chronic, while, on the other hand, the chronic cases may at any moment become acute. Acute Intestinal Obstruction—The most frequent causes of this 904 DISEASES OF INTESTINAL CANAL. form of obstruction are (1) congenital malformations; (2) the impaction of foreign bodies, gall-stones, etc. ; (3) invagination or intussusception—the up. per segment of bowel commonly slipping within the grasp of the lower, like the finger of a glove when it is taken from the hand, though occasionally the lower segment is invaginated into the upper, constituting retrograde intussusception ; (4) twisting of the bowel ujion itself— volvulus—commonly connected with ab- normal elongation of the mesenteric at- tachment of the affected gut; and (5) infernal strangulation, due to the binding down of the bowel by a diverticulum, or by a band of organized lymph, to the jiro- trusion of the gut through an aperture in the mesentery or omentum, etc. Symp- toms of acute obstruction may also occur in the course of in flammatorij affections of the abdomen, such as enteritis, jierito- nitis, or typhlitis, or (as already men- tioned) in cases of chronic obstruction, esjiecially from cancerous disease of the bowel. Spasm, without organic change, no. 53o.-intemai ^angulation by a di- is considered by some authors to be capa- verticuium. (Pirrib.) ble of producing acute obstruction; but though the possibility of such an event may not be denied, its occurrence must be extremely rare. F. Jordan be- lieves that either acute or chronic obstruction may result from fatty degeneration of the muscular wall of the bowel.1 Symptoms of Acute Obstruction.—These are usually well marked ; the patient commonly experiences intense pain,2 often referred to a particular spot, accomjianied with great vital depression, and occasionally absolute syncope. Vomiting, at first of the gastric and subsequently of the intesti- nal contents, and complete constipation, quickly supervene, the abdomen at the same time becoming tender, swollen, and tympanitic, and the inter- ference with normal peristalsis causing the bowels to roll over each other with loud borborygmus and gurgling; the motions of the intestine, if the abdominal parietes be thin, may be felt or even seen externally, and may sometimes be observed to cease suddenly at some particular point which corresponds to the seat of obstruction. Unless relief be speedily obtained, death ensues—either from simple exhaustion, or, more commonly, from peritonitis, gangrene, or both—the duration of the case rarely exceeding a week or ten days; in cases of intussusception, the invaginated portion of gut is occasionally separated by sloughing, and discharged per anum, the 1 Strangulated hernia, which is perhaps the most frequent cause of acute intestinal obstruction, is treated of in Chap. XL., and is therefore omitted here. 2 According to Mr. Treves, the pain of absolute strangulation, as by a band, is sud- den and intense, localized, continuous, often relieved by pressure, and apt to lessen in severity after its first onset; the pain due to disordered peristalsis, as in stricture of the bowel, is somewhat intermittent; the pain of distention, as in volvulus, is con- tinuous, but very diffuse ; while from peritonitis, the absolute pain is less marked than the excessive tenderness. Sudden cessation of pain in unrelieved intestinal obstruction indicates the occurrence of collapse or of gangrene. DIAGNOSIS OF INTESTINAL OBSTRUCTION. 905 continuity of the bowel being maintained by previously formed adhesions, and spontaneous recovery thus following. Chronic Obstruction—The most common causes of this variety of obstruction are (I) fecal accumulations; (2) stricture of the bowel, often of a malignant character ; (3) inflammatory changes in the bowel, result- ing from injury; (4) chronic peritonitis (often tuberculous), or abdominal abscesses; and (5) abdominal tumors of various kinds, which may com- press and thus obstruct the adjacent portions of intestine. Symptoms.—In the case of chronic obstruction, constipation is the most prominent symptom ; there is seldom any* acute pain, and comparatively* slight constitutional disturbance, while the vomiting is not constant and does not assume a stercoraceous character until much later than in cases of the acute variety. Abdominal distention, though ultimately well marked, is slowly* developed, and life may* be prolonged for six weeks or more, recovery* even being sometimes obtained after the persistence of complete obstruction for this period of time. Statistics of Intestinal Obstruction.—The statistics of intestinal obstruction were particularly-investigated by the late Dr. W. Brinton, who found, from an analysis of 12,000 post-mortem examinations taken pro- miscuously, that, excluding hernia, intestinal obstruction caused death in one out of 280 cases. Of the fatal cases of obstructed bowel, about 43 per cent, were due to the existence of intussusception ; 3H per cent, to inter- nal strangulation (by bands, etc.) ; lHper cent, to strictures, or to tumors implicating the intestinal wall; and 8 percent, to twisting of the gut upon itself. The figures given by Leichtenstern and Fitz differ somewhat from these, the former giving the proportionate numbers of cases of intussuscep- tion and strangulation as 38 per cent, and 26 per cent, respectively, and the latter as 32 per cent, and 34 per cent. The locality of the lesion, according to Brinton's statistics, is (in the case of intussusception) the junction of ileum and caecum in 56 per cent., the ileum, alone in 28 per cent., the jejunum in 4 per cent., and the colon 12 per cent, of the whole number of instances. The corresponding per- centages derived from Bulteau's statistics of 763 cases show for the ileo- csecal junction 51.4 jier cent., for the small intestine 28.8 per cent., and for the large intestine 19.8 per cent. In obstruction from internal strangu- lation (by bands, etc.), Brinton found the part affected to have been the small intestine in 95 per cent, of all cases ; while, on the other hand, stric- tures and twistings involved the large intestine in 88 per cent, of all cases. Essentially similar results are obtained from Bulteau's and Leichtenstern's statistics. The sexes are almost equally liable to most of the causes of intestinal obstruction, but impacted gall-stones arefourtimes as common in women as in men, while, on the other hand, according to Leichtenstern and Fitz, intussusception is nearly twice as common in the male as in the female. Diagnosis—It is of the utmost importance, in undertaking the treat- ment of a case of intestinal obstruction, to ascertain (1) whether it belongs to the acute or to the chronic variety, and (2) to what cause the obstruc- tion is due. From Dr. Brinton's statistics, quoted above, it will be seen that the acute (fatal) cases rather more than half (43 to 39^) are due to intussusception, while of the remainder about four-fifths are due to internal strangulation ; and as the treatment of these conditions is not the same, their diagnosis becomes a matter of great interest. Intussusception is by far the most frequent cause of obstruction met with among infants and young children, and is sometimes traceable to the disturbance created by polypi of the bowel, by intestinal worms, or even by masses of undigested food; it is especially characterized by a constant 906 DISEASES OF INTESTINAL CANAL. desire to go to stool, and by the discharge from the rectum of mucus, with liquid or coagulated blood. The perpetual desire to defecate is considered by Pollock almost pathognomonic of invagination. Stercoraceous vomit- ing is not as uniformly present in this as in other varieties of acute oli- struction. In many cases, if the abdominal wall be thin, an elongated tumor, the shape of which has been compared to that of a sausage, may be distinctly felt by jialpation, usually at the left side, and, in children at least, the invaginated gut may often be felt by the introduction of the finger into the rectum. The tumor of fecal accumulation is usually felt, at the right side, and may be made to pit by firm external pressure—a pathog- nomonic sign, according to Sawyer, of Birmingham. Internal Strangulation is most common in the periods of adolescence and early adult or middle life. Its most characteristic symptom is the occurrence of intense prostration or syncope. Twisting of the Bowel is usually an affection of advanced life, and com- monly* involves the sigmoid flexure of the colon, its next most frequent seat being in the neighborhood of the ileo-caecal valve. True knotting of the bowel has been observed in at least three cases, recorded by Parker, Gruber, and M. W. Taylor. In obstruction from twisting, the abdomen is often unevenly distended; one side (usually the right) being flattened, while the other is tympanitic. The flattening of the right side in volvulus is known as "Dance's symptom," from the name of the surgeon who first pointed out its significance. Strictures or Tumors (causing chronic obstruction) affect the lower bowel much more commonly than the upper, and the diagnosis can usually be made by inquiring into the history of the case, and by an examination per anum. The history of the case will likewise serve for the purpose of diagnosis, should acute symptoms suddenly supervene under these cir- cumstances. In order to determine what part of the intestinal canal is the seat of obstruction, it is to be borne in mind that when the symptoms are acute, the lesion (unless the case be one of twisting of the gut) is usually situated in the upper bowel, while chronic obstruction commonly involves the large intestine. Obstruction below the descending colon can generally be recog- nized by careful exploration of the rectum. The period at which vomiting occurs is earlier in proportion to the greater proximity of the seat of ob- struction to the pylorus ; moreover, the higher the point at which peristal- sis is arrested, the less, as a rule (according to Hilton, Bird, and Barlow), is the amount of urine secreted, though it is quite possible, as main- tained by Habershon, Leichtenstern, Treves, and others, that this is because high obstruction is usually of an acute character, and that the anuria really* depends rather upon the tightness than upon the locality of the con- striction. Finally, careful palpation of the abdomen may, if the parietes be thin, serve to point out more or less exactly the point at which the bowel is obstructed. Treatment of Intestinal Obstruction. Certain indications are common to all cases of intestinal obstruction.1 Bearing in mind that the most desperate cases sometimes terminate in spontaneous recovery, the surgeon should in the first place endeavor to obviate the tendency to death by relieving pain, diminishing peristaltic action, preventing distention, and maintaining the patient's strength. The 1 It is perhaps scarcely necessary to say that, in every case of intestinal obstruction, the surgeon should make a careful examination of all the localities in which hernia is apt to occur. LAPAROTOMY FOR INTESTINAL OBSTRUCTION. 907 first and second objects are best accomplished by the free administration of opium (which may be advantageously- combined with belladonna), and preferably in the solid form. From half a grain to a grain of the Extractum opii of the IT. S. Pharmacopoeia may be given every three or four hours, or at such intervals as may be thought proper. The third and fourth objects are to be accomplished by the administration of concentrated food in small quantities and at frequent intervals. It is obviously desirable that, in order to prevent distention, the bulk of the food, and especially of liquid, introduced into the stomach, should be as small as possible ; and for the same reason the exhibition of purgatives by the mouth should be strictly interdicted. Kussmaul, Cabn, Senator, Hasenclever, Chantemesse, Faucrie, Kuhn, Whitaker, and others, advise washing out the stomach^ so as to lessen the amount of fluid above the seat of obstruction. Large and repeated enemata of warm water, or, which Head prefers, warm oil,1 administered through a long tube, are, moreover, of the greatest value, serving in different cases to effect disintegration of fecal accumulations, to alter the position of the bowel and thus cause the disappearance of a twist, or even possibly to relieve intussusception by pushing up the invaginated gut; the last-mentioned result could, however, only be obtained in very- recent cases, on account of the rapid formation of adhesions between the two portions of intestine which are involved. Inflation of the large intes- tine with, air, introduced through the rectum by means of a long tube and stomach-pump, has occasionally proved successful in relieving the obstruc- tion when all other measures have failed, and should certainly, I think, be resorted to in such cases. The application of electricity has also proved successful in cases recorded by Finny, Giommi, and others. Boudet reports 61 cases treated in this way with 44 recoveries and only 17 failures. The administration of calomel, in combination with opium, might be proper in case peritonitis should be develojied at an early period; but under other circumstances should be avoided, as tending by its cathartic action to increase the distention of the bowel. External manipulation by gently rubbing and kneading the abdomen (abdominal taxis), has occasionally proved of service, and may be aided, as may the administration of enemata, by placing the patient upon the knees and elbows, or, in the case of an infant, by complete inversion. The external application of ice proved suc- cessful in some cases referred to by Habershon. The special treatment of congenital malformations of the anus or rectum, of stricture or tumor involving the large intestine, and of abdominal ab- scess or tumor, compressing, though not directly implicating the bowel__ any of which conditions may lead to intestinal obstruction—will be con- sidered in future pages. But supposing that the case is one of acute obstruction, resulting from either intussusception, internal strangulation, twisting, stricture of the small intestine, or the impaction of a foreign body! and that the course of treatment which has been recommended has been tried and failed, what is to be done ? There is no time for delav, for these cases as a rule soon terminate fatally, and if any operation is to be done, it should not be postponed until the patient is at the point of death. Laparotomy, or, as it was formerly though less accurately called, Gastrotomy;1 the laying open of the abdominal cavity in order to search 1 Cases have been recorded by Libur and .late, in which cures were effected by the successive injection of solutions of bicarbonate of sodium and of tartaric acid. Mur- ray, of Newcastle-on-Tyne, and others, recommend enemata of ox-gall. An enema of iced water proved successful in a case recorded by Kormann, of Coburg. It is better, I think, to reserve the term qaslrotomy for the operation of opening the stomach to remove a foreign body (page 413), designating the operation of abdominal. fctwn m general, by the word laparotomy (from Xawi?a, the soft part of the body below Me ribs). 908 DISEASES OF INTESTINAL CANAL. for and if possible remove the source of obstruction, has been resorted to in these cases, and is, I think, justifiable under certain circumstances. If, however, the case be one of intussusception (and this is, as has been seen, the cause of obstruction in the majority* of acute cases), the surgeon will, in my judgment, usually best consult the interests of his jiatient by declin- ing operative interference.1 My reasons for this opinion are, that (1) the tender age of many of the subjects of invagination renders them peculiarly ill adapted to support so grave an operation ; (2) the ojieration, which is always one of a very serious nature, is particularly so in these cases, on account of the frequent existence of peritonitis as a complication ; (3) the attempt to dislodge the invaginated bowel is very apt to fail; and (4) there is a fair probability of spontaneous recovery after sloughing of the invaginated gut. The latter point may be illustrated by Leichtonstern's statistics, which show that of 551 cases of which the termination is known, sloughing occurred in 149, of which 88 ended in recovery and 61 (41 per cent.) in death, while of the 408 in which sloughing did not occur, only 63 terminated favorably and 345 (85 per cent.) in death. The only cases of intussusception in which laparotomy seems to me to be justifiable, are the rare instances in which the symptoms are those of obstruction merely, and not of strangulation. The operation has, I believe, been emjiloyed in 95 cases, 26 of which terminated successfully. The earliest ages at which the operation has been successful are six months (Sands), and eight months (Snowball). In cases of acute obstruction due to causes other than, intussusception, there can be no doubt, I think, that lajiarotomy is justifiable, should other measures fail to give relief in the course of two or at most three days. There is, under such circumstances, no reasonable prospect of sjiontaneous recovery, and the only hope of cure in a case of persistent internal strangu- lation, which, next to invagination, is by far the most common lesion found in cases of acute obstruction, is in the employment of operative measures before the occurrence of general peritonitis or gangrene. Even in these cases, however, it may be well, before resorting to the knife, to try, as advised by Brinton, the effect of one or more tobacco enemata, and the surgeon, I may* add, should take care not to mistake the constipation that attends enteritis or peritonitis for mechanical obstruction. Laparotomy is thus performed: The patient, thoroughly etherized, is placed in a recumbent posture, his buttocks being brought to the foot of the operating table, and the contents of his bladder evacuated by catheter- ization ; the temperature of the room should be previously raised to at least 10° Fahr. The surgeon may cut down directly upon the seat of obstruc- tion, if the point at which this exists has been accurately determined, but should, under other circumstances, make his incision strictly in the median line, the wound extending from an inch below the umbilicus, longitudinally downwards for about four inches. The dissection is cautiously carried down to the peritoneum, in which membrane a small opening is then made, and enlarged as much as may be necessary* with a probe-pointed bistoury introduced upon the finger as a director. Search is next to be made for the 1 Mr. Howse suggests that when the bowel protrudes through the anus it should be transfixed and held down with pins and then excised. This operation appears to have been first done unwittingly by an Italian surgeon (Nicoladoni), the patient re- covering, and Mr. Treves refers to similar instances. Successful operations of this kind have also been recorded by Mikulicz (seven cases), Willard, Fuller, A. E. Barker, and Raye. A case in the hands of Auffret, of Brest, ended fatally in a few hours, and two fatal cases are attributed to Verneuil; Kulenkampf, in excising an intussusception of the rectum, opened a coil of small intestine, but his patient ulti- mately recovered. ENTEROTOMY FOR ACUTE OBSTRUCTION. 909 seat of obstruction, by carefully tracing upwards that portion of the bowel which is found contracted. The source of strangulation having been dis- covered, the constriction is to be relieved, by the division or separation of bands or organized adhesions, or by withdrawing the strangulated gut from any pocket or fissure in which it may have been caught. If it should be found that the case is one of volvulus, the bowel may* be carefully untwisted and rejilaced in its normal position. If the obstruction be due to the im- paction of a foreign body or a gall-stone, the gut may'be opened and the offending substance removed, the case being subsequently treated as one of wounded intestine (see page 406). If a stricture of the intestine be found (very rare except in the lower bowel, when a different ojieration would be indicated), the best that can be done is to lay open the gut above the stricture, and attach the margins of the aperture thus made to the edges of the external wound, in hope that the patient may recover with a fecal fistula. The same course should be pursued if the case be found to be one of intussusception, and if the firmness of the adhesions should prevent the relief of the invagination. Ruata advises that in any case, if the cause of obstruction cannot be discovered without allowing the bowels to escape from the abdominal cavity, an artificial anus should be at once established. In order to facilitate closure of the wound, if the bowels are distended, Rehn recommends washing out the stomach. Unless it be designed to attempt the establishment of a fecal fistula, the external wound should, after thorough irrigation of the abdominal cavity with hot water (105°-110° F.), be immediately closed ; the after-treat- ment consists in the adoption of means to combat the peritonitis which may be expected to rise. The statistics of lajiarotomy for intestinal obstruction have been investi- gated by several writers, including Adelmann, Whitall, Sands, Schramm, and myself. I have collected in all 539 cases,1 of which only 183 appear to have ended favorably. Operation for Cases. Result not ascer-tained. Recov-ered. Died. Mortality per ceut. of termi-nated cases. Volvulus ...... Strangulation continuing after herni-otomy or taxis .... Invagination ..... Foreign l>odies, impacted feces, gall-stones, etc. ..... Strangulation by bands, adhesions, or diverticula .... Obstruction from tumors, strictures, ulcers, etc. ..... Various forms of hernia and " ileus" Obstruction from other causes . Causes of obstruction not ascertained 46 28 95 36 180 67 39 13 35 l" "i 1 4 5 1 1 14 9 26 13 67 22 14 5 13 31 19 68 22 109 40 24 8 21 68.8 67.8 72.3 62.8 61.9 64.5 63.1 61.5 61.7 Aggregate .... 539 U 183 342 65.0 Enterotomy for Acute Obstruction.—The operation which has just been described, is that which I would ordinarily recommend in cases of acute intestinal obstruction in wbich interference is deemed necessary. Other surgeons, however, including the late Mr. Maunder, have preferred 1 In the International Encyclopaedia of Surgery, vol. vi , I have tabulated 346 cases, to which I am now able to add 193 since reported. 910 DISEASES OF INTESTINAL CANAL. a resort to Enterotomy, making an incision, usually in the right iliac region, and opening the first coil of intestine which presents itself, so as to establish a fecal fistula. This operation involves much less interference with the peritoneal cavity* than laparotomy, and may therefore be ju-eferred in sonic cases as a palliative or euthanasial measure, but it could not be expected to afford permanent relief in cases of internal strangulation, while in cases of intussusception, no operation should, as a rule, be performed, for the rea- sons already mentioned. Mr. Bryant, however, advises this ojieration in cases of intussusception in which it does not appear likely that lajiarotomy would succeed, as affording relief from the most urgent symptoms, and allowing time for the separation of the invaginated jiart by sloughing, and Czerny recommends it in all cases in which the jiatient is collajised, and the belly greatly distended. According to the statistics of Dr. B. F. Curtis, the mortality of enterotomy is about 15 per cent, less than that of lapa- rotomy*. Puncture of the Bowel with a delicate trocar or aspirator is recommended by Gross, Demarquay, Wagstaffe. and Dozzi, as a means of affording relief by allowing the escape of gas from the distended bowel. This procedure, which has occasionally been followed by complete recovery, is, however, not free from risk, death directly traceable to the operation having ensued in three out of ten cases recorded by Frantzel, of Berlin. Operations for Chronic Obstruction ; Colotomy—In most in- stances, the cause of the obstruction in chronic cases can be detected by careful rectal exploration, when very simple treatment will often suffice to give relief; thus, if an accumulation of hardened and impacted,feces be found in the lower bowel, repeated enemata must be employed, so as to soften and disintegrate the mass, removal being, if necessary, aided by the use of the finger, or, which is certainly more agreeable to the operator, a lithotomy scoop, or the handle of a teaspoon. In cases of obstruction de- pendent on uterine or ovarian disease, the surgeon should address his treat- ment to the organs primarily implicated. The cases of chronic obstruction demanding operative relief are chiefly those dependent on stricture of the rectum, whether malignant or otherwise, and the operation employed in these cases consists in the establishment of an artificial anus by ojiening the colon (colotomy), the part of the gut usually selected for this procedure being the sigmoid flexure. The operation of colotomy may also be occa- sionally required in certain cases of malformation of the lower bowel, of ulceration or cancerous disease of the rectum (even if unattended by ob- struction), and of recto-vaginal or recto-vesical fistula. Colotomy may be performed by opening the sigmoid flexure in the left iliac region (as origi- nally suggested by Littre, in 1710), the caecum in the right iliac region (Pillore, 1776); the sigmoid flexure in the left lumbar region (Callisen, 1796); the transverse colon in the umbilical region (Fine, 1797); or, finally, the caecum, in the right lumbar region. Callisen's or Amussat's Operation.—The operation which is generally resorted to at the present day, and which is probably the best in most cases of chronic obstruction from stricture, etc., was suggested by Callisen and subsequently improved by Amussat, and consists in ojiening the colon in the left lumbar region—Left Lumbar Colotomy; the following directions for its performance are given by W. Allingham, and are founded ujion the experience derived from more than fifty dissections, and from a large number of operations performed bv that surgeon. Anaesthesia having been induced, the patient is fixed in the prone position with a slight inclination towards the right side, a hard pillow being placed under the left side, so as to render the loin tense and prominent. To determine the exact jiosition of the colon, COLOTOMY. 911 a point on the crest of the ilium, midway between the anterior superior and posterior superior spinous processes, is marked with iodine paint, the colon in the normal condition being always situated half an inch behind the point thus marked. The surgeon then, standing in front of the patient, makes an incision of at least four inches, midway between the last rib and the crest of the ilium, the centre of the wound corresponding exactly with the point which has been marked. Thje wound may be transverse, as recom- Fig. 531.—Result of lumbar colotomy, showing line of incision. (Bryant.) mended by Amussat, or, which is better, oblique, downwards and forwards in the course of the ribs, as advised by Bryant. The various tissues are carefully divided to the full extent of the external wound, until the lumbar fascia and edge of the quadratus lumborum muscle have been reached ; the former being cut through, the colon usually presents itself, and may com- monly be recognized, even if undistended, by the appearance of one of its longitudinal bands. Care must be taken not to open the peritoneum,1 which is sometimes inflated with gas, and simulates the appearance of the bowel. The operation is completed by introducing with a curved needle strong silken sutures, by means of which the gut is drawn to the surface, when it is incised in the direction of its long axis, to the extent of about an inch ; the margins of the intestinal aperture are then stitched to the edges of the external wound, the sutures being retained until they begin to cut their way through by ulceration. Costallat divides the operation into two stages, not opening the bowel until several days after its exposure. Madelung advises that the gut should be completely cut across, the upper end fixed in the wound, and the lower end closed with sutures and returned. The advantage of this operation over Littre's, is in the fact that the abdominal cavity is not opened, the colon being approached on that side which is uncovered by peritoneum ; the operation is comparatively easy when the bowel is distended with feces, but under opposite circumstances (as when performed for stricture without obstruction) may be attended with considerable difficulty; it is a good plan in such a case to distend the gut with air before beginning the operation, so as, if possible, to render the position of the colon more apparent. Some inconvenience is usually at first experienced from prolapse of the bowel2 through the artificial anus, but, as 1 Herbert Allingbam, however, recommends that, in case the colon is not readily found, the peritoneum should be deliberately opened, and its edges stitched to the skin, the bowel being similarly secured before it is cut into. 2 To prevent protrusion, Dr. Maclaren employs an " enterotomy tube" somewhat resembling Sir Henry Thompson's supra-pubic vesical tube for prostatic hypertrophy. 912 DISEASES OF INTESTINAL CANAL. the tissues contract, the tendency* to protrusion diminishes, and it may be ultimately necessary* to adopt means to jirevent the orifice from closing. To avoid the escape of fecal matter at inconvenient times, the jiatient should wear an obturator of ivory or other suitable material, attached to a gutta- percha plate, and held in position with a truss or bandage. If the disease for which the operation is performed be situated above the sigmoid flexure (which may commonly be ascertained by noting the quan- tity of fluid which can be injected),1 the caecum should be ojiened in the right lumbar region by a similar procedure to that which has been described. Littre's Operation, which is preferred by Studsgaard, Reeves, H. Ailing- ham, Cooper, Cripps, and several other surgeons, is a more simple proce- dure than Amussat's, particularly in children. It consists in making an incision from two to three inches in length, parallel to and a little above the line of Poupart's ligament, and midway between the anterior sujierior spinous process of the ilium and the spine of the pubis. The various tis- sues, including the peritoneum, are cautiously divided upon a grooved director, when the colon is drawn forwards and opened as in Amussat's method. This operation is usually performed on the left side, opening the sigmoid flexure, but may also be practised on the right side, ojiening the cueum. II. Allingham recommends that several inches of the bowel should be drawn out and excised (after an interval of from twelve hours to three days), so as to insure the formation of a sufficient spur and to jirevent subsequent protrusion. With regard to the statistics of these operations, it may be said that, although the drift of surgical opinion is at present unquestionably in the direction of preferring the inguinal operation, yet Amussat's method has hitherto given the best results. This clearly appears from the annexed table, compiled from those constructed at my suggestion by Dr. W. R. Batt, who has succeeded in collecting no less than 351 cases of colotomy by various methods. H. A. Reeves has recorded 53 colotomies occurring in his own practice, with only 7 deaths; and Allingham, in 69 cases, had only* 2 deaths as the result of the operation. Cripps records 15 lumbar and 22 inguinal colotomies, with only one death in each series. Operation. Amussat's method Littre's Callisen's Fine's Not stated do. do.2 do. Aggregate Cases. Deaths. 244 78 82 43 10 7 4 11 5 351 133 Undeter- mined. 2 1 1 Mortality per cent. 32.2 53.1 77.7 0.0 45.4 37.9 When colotomy is performed for malignant disease of the rectum, per- manent recovery cannot, of course, be anticipated, but, even as a means of affording temporary comfort, the operation should, in my judgment, be unhesitatingly resorted to in suitable cases. I would advise its perform- ance (provided that there were no special contra-indications) in any case 1 Mr. T. P. Teale recommends laparotomy as an exploratory operation to ascertain on which side the colon should be opened, a preliminary measure which seems to me as dangerous as it is unnecessary. 2 Callisen's differed from Amussat's operation merely in the fact that the external incision was longitudinal instead of transverse. PARTIAL OCCLUSION OF THE ANUS. 913 of chronic obstruction from disease of the lower bowel, in which no benefit had resulted from a fair trial of judicious medical treatment. Enterectomy" and Colectomy-, or resections respectively* of the small and large intestine, have been practised in cases of intestinal ob- struction, but have been more frequently resorted to after the operation for strangulated hernia, or in cases of artificial anus and fecal fistula. I have collected1 in all 255 cases of these operations, of which 131 are said to have terminated in recovery and 113 in death, the results in 11 not having been ascertained. The mortality of terminated cases would appear from these figures therefore to be over 46 per cent. When the lesion which requires enterectomy is in the upper part of the small intestine, an attempt should be made to restore the continuity of the gut by immediate suture, but under other circumstances an artificial anus should be temjiorarily established, and suture of the bowel (enterorraphy) postjioned until a future occasion. Rydygier, Treves, and Gibson have devised special clamps to prevent fecal extravasation during the operation of enterorraphy, and Mudd advises that Lembert's sutures (see Fig. 225) with long loops should be introduced before the bowel is resected, and an additional line of the continued suture applied after these are tightened. If only a small portion of the bowel is removed, the corresponding portion of mesentery is simply tied with a transverse ligature, about half an inch from the line of the intestine, but if a large segment is excised, a triangular portion of the mesentery is usually likewise exsected. The risk in this mode of treat- ing the mesentery is that the blood supply of the intestine may be inter- fered with, and perhaps gangrene result; hence, unless the puckering be too great, it is better, I think, not to resort to excision, but simply to cut the mesentery about half an inch from the gut and ligate it in sections. Senn recommends, as preferable to circular enterorraphy, that the ends of the bowel should be separately closed, and a longitudinal opening made between their approximated sides (lateral anastomosis). He facilitates the operation by introducing plates of decalcified bone within the segments of bowel which are to be approximated, these plates serving as temporary splints by which the portions of intestine are firmly tied together, and which are ultimately dissolved and spontaneously disappear. Abbe em- ploys for the same purpose rings of catgut, and advises that the parts of bowel should be adjusted with their ends pointing in opposite directions, so that the peristaltic wave may* be continuous through both. C. B. Pen- rose employs rings of India-rubber. Before tightening the plates or rings, the serous surface of the gut is slightly scratched with a needle, to en- courage adhesion, and the operation is completed by the introduction of a few Lembert's sutures, or, which Abbe prefers, a continued suture. Malformations of the Anus and Rectum. The surgeon is not unfrequently called upon to attempt the relief of congenital malformations of the lower bowel, which, unless remedied by operation, will inevitably lead to fatal intestinal obstruction. Partial Occlusion of the Anus.—In this condition the anus, though not entirely occluded, yet presents so minute an orifice as not to permit the free escape of feces. The diagnosis of this from the more serious con- ditions which will be presently described, can be made by careful inspec- tion, which will reveal a passage admitting the introduction of a probe. 1 In the International Encyclopaedia of Surgery, vol. vi., I have tabulated 186 cases, to which ti9 are now added. 58 914 DISEASES OF INTESTINAL CANAL. The treatment consists in enlarging the orifice by making radiating incisions with a probe-pointed knife, dilatation being subsequently maintained by the occasional use of a bougie. Complete Occlusion of the Anus—In this variety of malforma- tion the anus is closed by a membrane of greater or less thickness, through which the meconium may be seen, and which bulges when the child strug- gles or cries. The treatment consists in making a crucial incision, excising the flaps thus formed, and bringing the skin and mucous membrane to- gether with fine stitches—a bougie being passed from time to time to maintain the opening in a patulous condition. Imperforate Anus.—Here the anus is completely absent, its normal position being occupied by a dense fibro-cellular mass, from a quarter of an ' inch to an inch in thick- ness, behind which the rectum terminates in a blind pouch. The treat- ment consists in making an incision of about an inch in length, forwards from the coccyx, in the direction of the raphe of the jierineum. The wound is then cautiously deep- ened in the median line, following the curve of the sacrum until the gut is reached, when a free open- ing is to be made, and the meconium evacuated. The mucous lining of the rec- tum is then to be drawn downwards (if jiossible) to the external wound, and attached to the skin with sutures. The use of bougies is subsequently required to maintain dilatation. Occlusion of the Rectum.—The anus is well formed, and the nature of the ease is, therefore, probably not suspected until after the development of symptoms of intestinal obstruction, when the diagnosis may be readily made by the introduction of the finger or a probe, the in- strument coming in contact with a bulging membranous septum, from half an inch to an inch above the anal orifice. The treatment consists in making a small incision to evacuate the meconium, the wound being sub- sequently dilated with dressing-forceps or enlarged with a concealed bis- toury. The use of the bougie must be continued daily for some months. If the operation is attended with much bleeding, plugging of the rectum should be resorted to. Pearce-Gould has reported a curious case of con- genital occlusion of the rectum by an inspissated plug of mucus, in which enterotomy was resorted to with a fatal result. Imperforate Rectum__In this condition the whole rectum is want- ing, the anus being usually likewise imperforate. The colon terminates in a dilated pouch, in the iliac fossa, or opposite the promontory of the sacrum. The diagnosis of this condition from that of imperforate anus, is always difficult, and often impossible. It may in some cases be facilitated by careful palpation of the abdomen, or (as suggested by Holmes) by introducing a sound into the bladder (or vagina, if the patient be a female), when, if the instrument impinge indirectly on the posterior wall of the Fio. 532.—Imperforate anus. (Ashton.) IMPERFORATE RECTUM. 915 pelvis, it may be inferred that the rectum is totally absent. In the treat- ment of these cases, the surgeon has four operations to choose from, viz., (1) puncture with an aspirator, over the needle of which a small canula may be afterwards pushed in, and the passage thus gradually dilated, as advised by Grimes, of Liverpool, (2) cautious dissec- tion upwards from the perineum (as recommended for imperforate anus), (3) Littre's operation of opening the colon in the iliac region, and (4) lumbar colotomy by the method of Callisen and Amussat. In case of failure to reach the gut by means of the as- pirator, the perineal operation should be chosen, unless it is evi- dent that the bowel cannot be reached in this direction. It is performed in the manner already described, great care being taken not to wound the bladder, vagina, peritoneum, or iliac vessels. If the gut can be reached, its mucous liningshould, if possible, be drawn downward and attached to the edges of the external wound—as otherwise, apart from the danger attending the passage of the me- conium over a raw surface, the artificial canal will be apt to contract into a narrow and troublesome sinus. Verneuil recommends that the coccyx itself should be excised in these cases, as a preliminary to searching for the bowel; he has himself adopted this plan in several cases with a successful result. If, however, it be evident that no attempt to reach the bowel from the perineum can succeed, or if the attempt have been made and have failed, the only remaining course of treatment is to open the colon by one or other of the methods already described. I cannot subscribe to the doctrine that it is more merciful to abandon a child to certain death than to strive to save his life by the formation of an artificial anus ; on the contrary, it is, in my judgment, the surgeon's duty, in these cases, to urge the perfor- mance of this operation, on the same principles as those Avhich guide him to recommend tracheotomy in a case of occlusion of the larynx, or ampu- tation in one of hopeless disorganization of a limb. With regard to the particular mode of opening the colon to be adopted, some difference of opinion exists. Amussat's operation in the left lumbar region has been usually preferred, but is less apt to succeed in these cases than in those of chronic obstruction in adults, on account of the frequent existence in infants of a long meso-colon, which, by allowing the bowel to float, as it were, may render it impossible to complete the operation with- out opening the peritoneum; hence Erichsen is disposed to think that it may be better in these cases to open the caecum on the right side, instead of the descending colon on the left. Mr. Holmes, whose opinion on all subjects relating to the surgery of childhood is of the greatest value, gives Fig. 533.—Imperforate rectum. (Ashton.) 916 DISEASES OF INTESTINAL CANAL. a decided preference to Littre's operation, because (1) the ojieration is easier, the abdominal wall in the infant being thin, while the fat and other tissues of the loin are very deep; (2) the colon often cannot be reached from the loin without opening the peritoneum, and (3) the descending colon, in cases of imperforate rectum, is often so short that it might not be reached at all by Amussat's operation, unless the incision were made so high as to endanger the kidney ; hence Mr. Holmes recommends colotomy from the left groin, and similar advice is given by Mr. Curling.1 Finally, Huguier advises that the colon should be opened by an incision in the iliac region of the right side. Upon the whole, I think that the weight of evi- dence is in favor of Littre's operation, and it is that which I should re- commend in any* case in which it was found imjiossible to reach the bowel from the perineum. Should the child survive, in a case of this kind, it would be proper to attemjit the restoration of the natural passage by De- marquay's plan of passing a thread carrying a leaden ball through the artificial anus and out at the perineum, so as gradually to draw the gut downwards. A similar operation, using, however, an elastic bulb instead of a leaden ball, has been successfully emjiloyed by W. A. Iivrd, of Illinois. Congenital Malformations -with Abnormal Openings in other Parts.—The several varieties of malformation which have been described, may be complicated by the existence of an abnormal communi- cation between the gut and other parts; thus the bowel may open into the bladder or urethra, or into the vagina, according to the sex of the infant, or upon the surface of the body, sometimes at a considerable distance from the natural jiosition of the anus. The treatment of such cases consists in restoring the natural jiassage (if possible), when the abnormal ojiening will usually heal of itself, or, if not, may be closed at some future time by a plastic ojieration. When the gut opens into the vagina, the treatment may be facilitated by introducing a director through the fistulous orifice, and carrying it downwards towards the perineum ; its point may then be cut down upon, and the skin and mucous membrane stitched together in the way* already described. I suc- cessfully* adopted this plan some time ago, in a case brought to me by Dr. Logan, of Scranton. Should the bowel communicate with the bladder or urethra,"1 the case may be one of greater difficulty; if, in such a case, the natural passage cannot be restored, a free perineal incision should be made, as in the operation of lithotomy, laying open the neck of the bladder or membranous portion of the urethra, whichever may be involved, so as to afford a direct outlet for the meconium and feces. If the gut open on the, surface of the body, the question of ojierative interference turns on the position of the abnormal opening; if this be in a situation in which no particular inconvenience will result from the deformity (as immediately in front of the coccyx), or, on the other hand, in such a locality as to render it probable that a great part of the large intestine is absent (as in the iliac or umbilical region), the safest plan will be to decline an operation, merely dilating the abnormal aperture so as to prevent fecal accumulation ; if, however, the gut open in the anterior part of the perineum, or in the scro- 1 A case successfully treated in this way has recently been recorded by Dr. W. H. Haynes, of New York. Dr. Brewer, of the same city, has analyzed 56 cases of Littre's operation, 21 ending in recovery and 35 in death, a mortality rate of 62.5 per cent. On the other hand, 17 operations by Amussat's method gave 8 recoveries and 9 deaths, showing a mortality of only 53 per cent. 2 In a case of this kind recorded by Mr. F. Page, the patient was operated on suc- cessfully when he had reached the age of 54 years, having during all this time passed both feces and urine through the urethra. STRICTURE AND TUMORS OF RECTUM AND ANUS. 917 turn, the rectum will be found at a short distance beneath the integument, and may be readily reached by an incision in the ordinary position of the anus. In a case recorded by Miss Susan Dimock, in which, after the ope- ration, fecal incontinence continued, the normal and abnormal openings were found to be both within the limits of the sphincter, and a cure was effected by simply dividing the tissues by which they were separated. Before operating in any of the more complicated cases of rectal malfor- mation, it may be well, if the symptoms of the case are not urgent, to wait a day in order to allow the gut to become distended, as it will then be more easily reached than if it were in a flaccid condition. Stricture and Tumors of the Rectum and Anus. Any jiart of the large intestine may be the seat of stricture, but it is by far most commonly met with an inch or two above the anus, or just below the junction of the rectum and sigmoid flexure of the colon. Three forms of rectal stricture may be described, viz., the simple, the warty, and the malignant. Simple or Fibrous Stricture—The constriction (which appears to be due to the presence of an adventitious structure of a fibrous character) is usually seated in the submucous areolar tissue, but more rarely in the muscular coat, or even in the mucous lining of the bowel. The extent of the stricture varies from a few lines to an inch or more, the whole calibre of the gut being commonly involved, though not unfrequently the indura- tion and thickening are most marked on one side. The causes of this form of stricture are chiefly* inflammation or ulceration of the part, whether arising from chronic dysentery, from previous prolapsus, from wounds, from the irritation caused by fecal accumulations or foreign bodies, or from the contact of gonorrhoeal or leucorrhceal discharges. In other in- stances, stricture of the rectum may follow the cicatrization of a chan- croid, or may occur as a syphilitic lesion, almost invariably, in this case, as a secondary or tertiary phenomenon. The fibrous stricture ajipears to be more common in women than in men. Symptoms.—The symptoms of stricture of the rectum are difficult and painful defecation (the feces being flattened and ribbon-like, or, more com- monly, passed in the form of scybala, mingled with mucus and perhaps blood), followed by* various dyspeptic phenomena, and ultimately by the evidences of intestinal obstruction. Abscesses not unfrequently form in the areolar tissue around the gut, and communicate with the bow*el either above or below the stricture, opening into the vagina, in the perineum, or in the gluteal region, and giving rise to intractable fistulae. which contribute much to the discomfort and exhaustion of the patient. In other cases, the formation of fistulae is due to the escape of fecal matter through ulceration of the bowel above the seat of stricture. The more solid portions of the feces are detained above the stricture, the gut at this point becoming dilated into the form of a pouch ; while the more liquid portions mingled with mucus or muco-pus find their way through the contracted part, leading the patient not unfrequently* to complain of diarrhoea. When intestinal obstruction occurs, its symptoms may be gradually* develojied, or may be suddenly manifested, owing to the complete occlusion of the gut bv the lodgment of a fish-bone or other foreign body. Diagnosis.—The diagnosis of stricture of the rectum, when the seat of constriction is within three or four inches of the anus, can usually be readily made by digital examination, the finger being well oiled, and passed with the utmost gentleness. When the stricture \s at a higher point, it 918 DISEASES OF INTESTINAL CANAL. may often be brought within reach by directing the jiatient to bear down, or "by making the examination while he is in the upright posture, or, as advised by Simon, the whole hand may be introduced while the patient is in a state'of anaesthesia, and exploration thus carried as high as the sigmoid flexure. The last-mentioned mode of exploration is, however, as jiointcd out by Dittel, Weir, and Dand- ridge, not free from risk, and the latter surgeon has collected four cases, including one of his own, in which lacerations of the bowel were thus pro- duced. Fatal peritonitis from rupture of a splenic cyst has followed the same jiroeedure in the hands of Dr. Briddon. The introduction of a bougie is not of much value for diag- nostic purjioses, as it is apt to catch in some of the folds of the rectum, or to strike the promontory of the sacrum, and thus lead to error, while the subjective symptoms noted by the patient are extremely deceptive, many cases which the late Dr. Van Buren well described as "phantom stric- tures" being no strictures at all, but simply cases of de- ficient tone and action of the lower bowel. In making a digital examination, the sur- geon should bear in mind that the rectum may be com- pressed by objects external to itself, such as an enlarged prostate, a retroverted uterus, various forms of tumor, enlarged lymphatic glands, abscesses, etc. Treatment.—The treatment of rectal stricture is both general and local. The general treatment consists in maintaining the state of the jiatient's health, in keeping the bowels in a soluble condition by regulation of the diet and the administration of mild laxatives or emollient enemata, and in relieving pain by the use of opium, particularly in the form of supposi- tories. Iodide of jiotassium would be indicated in a case of syphilitic origin. The local treatment consists in endeavoring to restore the part to its normal calibre by the cautious employment of oiled bougies of gradually increasing sizes ; and in obstinate cases, especially if of traumatic origin, by making slight radiating incisions with a blunt-pointed bistoury. Bectal bougies are ordinarily best made of India-rubber, or of a material similar to that employed in the "English" flexible catheters, and should invaria- bly be used with the greatest caution, lest laceration, or even perforation, of the bowel ensue. Dr. Wales emjiloys a hollow bougie, so arranged that a stream of water can be directed through the instrument against the seat of obstruction. A bougie, of such a size as to be firmly grasped by the stric- ture, should be chosen, and may be introduced every third or fourth day, Fio. 534.—Fibrous stricture of the rectum. (Ashton.) MALIGNANT STRICTURE. 919 being left in for a few minutes on each occasion. After its withdrawal an opium suppository should be inserted, if possible above the stricture. If incisions are required, the knife should be introduced, guided and guarded by the left forefinger, the stricture being simply notched at several points, though AVhitehead, Lente, and Beane prefer free incisions in the median line, posteriorly in the case of a male, and both posteriorly and anteriorly in that of a female. A bougie may then be passed, and followed in a few minutes by* an opium suppository, the patient being kept at rest for a day or two subsequently*. In the after-treatment, Whitehead employes an India-rubber bag (such as that used by Bushe in cases of rectal hemor- rhage), distending it with warm water after its introduction ; a similar apparatus is employed by Wales. Various ingenious modes of effecting rapid dilatation have been proposed by surgeons, but are, I believe, more dangerous, and not more satisfactory, than the use of the simple bougie, which, though it may perhaps never accomplish an absolute cure of rectal stricture, affords in many instances very decided relief. Verneuil has in- troduced an operation, under the name of linear rectotomy, which consists in freely dividing the stricture together with the lower part of the rectum, including the sphincter. The section is effected with either the knife or the ecraseur (the chain of the instrument being introduced through a fistula, if there be one extending above the stricture), and the division is made by preference at the posterior part of the gut and in the median line ; the wound should not extend more than ten centimetres (about four inches) above the anus, for fear of wounding the peritoneum. Kelsey has collected 19 cases in which this operation has been resorted to, and in most instances with decided benefit to the patient; it is a mode of treatment only applica- ble, of course, to cases of constriction situated within a short distance of the anus, and even in them should, it seems to me, be looked upon as a last resource. Trelat has modified this operation by employing the gal- vanic cautery, and in other cases by using an elastic ligature. Excision of the contracted portion of bowel has been practised by Lowson, of Hud- dersfield, but with somewhat doubtful advantage. Should symptoms of intestinal obstruction come on, an attempt should be made to relieve the patient by the administration of copious enemata, etc. (p. 907), or, if necessary, by rectotomy, or by opening the colon, either on the left or right side, according to the seat of constriction. Warty Stricture___A peculiar form of rectal stricture, which might be appropriately called warty, has been described by Brodie, Curling, H. Lee, and others, in which numerous excrescences, resembling condylomata, occupy the margin of the anus and the interior of the gut, below the seat of stricture. These cases are believed by Gosselin to be of syphilitic ori- gin. The profuse muco-purulent discharge, which is the most annoying complication of this form of stricture, may be somewhat controlled by the use of astringent injections and the application of a solution of nitrate of silver. Malignant Stricture___In this form of stricture, the obstruction is due to a cancerous (usually scirrhous or encephaloid) growth, which may originate as an independent tumor, or as an infiltration in the tissues of the bowel.1 The symptoms do not at first materially differ from those of simple stricture, though the diagnosis can be made by digital examination, the induration of the malignant growth being of an irregular and nodulated 1 According to Cripps and Holmes, however, many cases called cancer of the rectum are really of an adenoid character. Bryant gives the proportion of non-cancerous to cancerous strictures as one in three. 920 DISEASES OF INTESTINAL CANAL. character. When ulceration occurs, the act of defecation is commonly attended with great pain and a burning sensation, extending to the loins and thighs, the discharges containing a con- siderable quantity of pus and blood. Digital examination at this time reveals a. soft, fung- ous mass, and the finger is withdrawn, smeared with blood. As the cancerous tumor grows, it frequently involves neighboring parts, as the vagina or bladder, giving rise, perhaps, to vesico-rectal or vagino-rectal fistula, and thus rendering the jiatient addi- tionally miserable. By comjiressing the iliac veins, the tumor causes oedema of the lower extremities. Death may ensue from gradual exhaustion, at the end, jierhajis, of three or four years, or at an earlier period from the occurrence of intestinal obstruction. The treatment must in most cases be merely palliative, any attempts to excise or tear away the malignant growth being, as a rule, unjustifiable, and usually leading to a sjieedy death from peritonitis or hemorrhage. Pain is to be alleviated by the free use of anodynes (by suppository* or otherwise), and fecal ac- cumulation to be prevented by the occasional use of laxatives. Emollient enemata may sometimes afford relief, but great care must be taken, in their emjiloyinent, not to inflict injury on the bowel. Bougies may be cau- tiously employed before ulceration has begun, but at a later period could only be produc- tive of mischief. Linear rectotomy is re- commended by Verneuil and Kelsey, but, I confess, seems to me not a very promising mode of treatment, though it may sometimes be properly employed as a jialliative measure; and I must exjiress even a less favorable opinion ofVolkmann's and (Jay's projiosal, to remove the growth with a circular portion of the rectum, and stitch together the divided portions of the bowel.1 Finally, lumliar or inguinal colotomy maybe projierly resorted to, either to relieve obstruction or to obviate the suffering caused by the passage of feces over the ulce- rated surface. Malignant Disease of the Anus.—This, when primary, is com- monly of an epitheliomatous character, though the anus may become secondarily involved in cases of cancer of the rectum. Epithelioma of the anus, if recognized at an early period, may occasionally be excised with advantage, the diseased part being held up by two tenacula, which are then freely dissected out, as advised by H. Lee ; but in a more advanced stage of the affection, palliative treatment is alone justifiable. Here, as in Fig. 535.—Malignant stricture of the rectum. (Ashton.) 1 Nicolaysen reports a similar operation (successful) for malignant tumor of the colon, the growth being forced by the patient's efforts into the rectum, and then drawn out through the anus. NON-MALIGNANT TUMORS OF THE RECTUM. 921 cancer of the rectum, great comfort may be occasionally afforded by a resort to colotomy. Extirpation of the lower end of the rectum has been jiracti>ed by Verneuil, Billroth, Levis, Agnew, Briddon, J. R. Wood Keyes. Moore, Vanderveer, Post, and numerous other surgeons, myself included; in some instances with at least temporary advantage, but in a considerable proportion of cases with a fatal result, 140 cases collected bv Kelsey having given 22 deaths as the immediate result of the ojieration, and only about the same number of permanent recoveries. Piechaud's statistics are still less favorable, 149 cases having given 36 deaths, a mor- tality of over 24 per cent., while Andrews, of Chicago, gives the mortality as 140 out of COS cases, a death rate of 23 per cent. On the other hand, Heuck reports 44 cases with only one death. Kraske facilitates the ojiera'- tion by removing a portion of the sacrum. It is usually advised to bring the resected gut down and attach it to the surrounding integument by means of sutures, but, according to Cripps and Vanderveer, this is unne- cessary, it being better to rely upon frequent syringing to prevent irrita- tion of the wound by the contact of fecal matter. Volkmann's plan of re- moving circular portions of the rectum without sacrificing the sphincter, has already been mentioned. Levy facilitates the operation by an osteo- plastic resection of the coccyx and lower jiart of the sacrum, turning down the sejiarated bones, and after removal of the rectal mass replacing them. and holding them in jiosition with sutures. Non-Malignant Tumors of the Rectum__These are commonly of a fibrous, fibro-cellular, or adenoid character, occasionally sessile, but more often pedunculated, constituting the affection known as polypus of the rectum. Rectal polypus is most common in children (though rare at any age), and may, unless the examination is made with care, be mistaken for a hemorrhoidal tumor, or for a prolapse of the mucous coat of the bowel. The polypus often protrudes through the anus at the time of defecation, and is frequently attended with hemorrhage; it mav exist as a complica- tion of the painful ulcer or fissure of the rectum, the treatment consists in the application of a firm ligature, so as to strangulate the growth, which may then be cut off below the point of ligation, or, which is safer, may be jiushed above the sjihincter, an opium suppository being then administered to prevent straining and to relieve pain. The strangulated mass becomes detached, and is passed at stool in the course of a few days. Excision, without previous ligation, should be avoided on account'of the risk of hemorrhage. Sessile growths may be treated in the same way (the base being trans- fixed by a double ligature and tied in two halves), or mav be more speedily removed by means of the ecraseur. A vascular tumor'of a papillary or villous character has been described as occurring in the rectum by Qu'ain, H. Smith, Allingham, and other writers. It is usually attended with con- stant, and sometimes with profuse, hemorrhage, which gradually exhausts the patient. Repeated applications of strong nitric acid effected a cure in the case observed by Mr. Smith, but in most instances the ligature would probably be a surer mode of treatment, A dermoid cyst in the rectum has been met with in one instance recorded bv Danzel. Enterotomy has been advantageously employed bv Sklifosovski in a case of multiple polypoid excrescences of the rectum and colon. 922 DISEASES OF INTESTINAL CANAL. Rectal Fistil.e. The rectum may communicate with the bladder or urethra in the male, and with the vagina in the female. Recto-Vesical and Recto-Urethral Fistulae may depend ujion congenital malformation, or may be caused by ulceration, usually of a ma- lignant character, or by wounds accidentally inflicted, as in the ojieration of lithotomy. Recto-urethral fistula may also be due to the careless use of a bougie, or to the bursting of a prostatic abscess. The symptoms are suffi- ciently* evident; urine escapes into the gut, and, by flowing over the nates, produces excoriation; while, if the opening be large, fecal matter may enter the bladder, giving rise to cystitis and vesical tenesmus. When the fistula is due to the ulceration of a malignant growth, little can be done in the way of treatment, beyond the adoption of mere palliative measures, co- lotomy* being justifiable when the feces escape into the bladder. In other cases, however, an attempt may be made to close the fistula, if small, by occasionally touching the part with nitrate of silver or with tho galvanic cautery, while, if more extensive, a plastic operation may be tried, the fistula being exposed by means of a duck-billed speculum, and its edges pared and brought together in a transverse direction ; the bladder should be subsequently- kept empty by* the frequent use of a gum-elastic catheter, and the bowels locked up by means of opium suppositories. The patients in these cases should be taught, before the operation, to introduce the catheter for themselves, so that there may be no occasion for urine to flow over the wound until cicatrization is completed. Advantage may be some- times derived from keeping the jiatient in the prone position, and in one instance Sir H. Thompson succeeded in effecting a cure by this alone. As a last resort, a large staff may be introduced into the urethra, and the sphincter ani divided upon this so as to lay the parts freely ojien ; the patient should then be placed in the prone position, and a catheter retained in the bladder while the wound is allowed to heal by granulation. Recto-Vaginal Fistula may depend upon congenital deformity, or upon abscess or ulceration affecting the recto-vaginal septum, sometimes in connection with rectal stricture; but its most frequent cause probably is injury received during parturition. The treatment consists in cauterization (if the fistula be small), or in the closure of the opening by means of a plastic operation, which is thus performed: The contents of the rectum and bladder having been evacuated, the patient is thoroughly etherized and secured in the lithotomy position ; the fistula is next exposed by drawing upwards the anterior wall of the vagina with a duck-billed speculum, and the edges are obliquely pared, the vaginal mucous membrane being dissected off in an extent of four lines around the aperture; a sufficient number of deep and superficial sutures are then introduced to bring the freshened edges of the fistula accurately together in a transverse direction. ('o|»eland, Brown, and Erichsen advise that the sjihincter ani should be divided, so as to prevent the contraction of this part from interfering with the healing process. The sutures may be of silk, or (which is better) of silver or flexible iron wire; if of silk, they should be removed about the sixth day, but if of metal, may be allowed to remain several days longer. The bowels should be locked up with opium for nearly a fortnight. Other modes of treatment consist in laying open the recto-vaginal septum below the fistula by incision, the parts being allowed to heal by granulation, or in introduc- ing a ligature which is daily tightened until it cuts its way through. The late J. R. Barton, of this city, and, more recently, Taylor, of New York, have recommended simple division of the sjihincter ani, as in the treatment FISTULA IN ANO. 923 of fistula in ano ; this mode of treatment is also applicable to cases in which the gut communicates by a fistulous track with one of the labia majora, constituting Recto-labial Fistula. When recto-vaginal fistula follows upon stricture of the rectum, this must be fully dilated before any ojieration upon the fistula is attempted. Entero-Vaginal Fistula, in which the small intestine ojiens into the vagina, its communication with the lower bowel being interrupted, is a rare condition which could only be dealt with by abdominal section. Fistula in Ano. This common and distressing affection consists in an abnormal communi- cation between the rectum and some point on the external surface, usually in the space between the anus and the tuberosity of the ischium. Causes.—Fistula in ano may originate in ulceration and perforation of the mucous membrane of the gut, as the result of the irritation produced by fecal accumulations (as in rectal stricture), or by* foreign bodies, such as fish-bones or grape-seeds; it may also be traceable to an abscess which occurs externally to the bowels, in the ischia-rectal fossa, and is caused by injuries, such as blows or kicks upon the anus, or by exposure to cold, as from sitting upon wet grass or stones, or which arises from suppuration around the jirostate, or in a lymphatic gland. Varieties.—Three forms are recognized by systematic writers, viz., (1) the complete fistula, in which there are two openings, one in the gut, and one on the surface of the body*; (2) the incomplete external fistula, in which there is no inner opening, though the fistulous track can usually* be traced to just beneath the mucous membrane; (3) the incomplete in- ternal fistula, in which the sinus communicates with the gut, but not with the external surface. The second and third varieties are also spoken of as blind fistulae. Symptoms—The position of the external orifice is usually* marked by a prominent papilla or granulation, while the internal opening can be felt by the finger in the rectum, or may be seen by* the aid of the rectal sjieculum (Fig. 536). There is a discharge of thin pus from the fistula, producing excoriation of the surround- ing parts, which are commonly thickened and indu- rated. The fistula sometimes runs a pretty straight course, but is often tortuous and bent upon itself, being superficial from the external orifice to the margin of the sphincter, and then passing up deeply by the side of the bowel. There may be several sinuses opening exter- nally, but all communicating with the same principal track; or there may be two or more independent fistulas in the same case. Occasionally a slight form of fistula is met with, which opens at the margin of the anus within the position of the sphincter; but in the true " fistula in ano,'' the external orifice is an inch or more distant from the anus, while the track of the fistula passes through or more frequently quite outside of the sphincter. Diagnosis.—This can be readily made by introducing a probe through the external ojiening, while the finger is placed in the rectum ; the track of the fistula can thus be traced with a little trouble to its internal opening, which will almost invariably be found just above the internal sphincter, though a sinus may extend some distance further up the bowel. 536.—Rectal spec- ulum. 924 DISEASES OF INTESTINAL CANAL. If there be no internal opening, the jirobe can be felt in the same locality, immediately beneath the mucous lining of the gut. In cases of blind in- ternal fistula a bent probe may be introduced through the inner opening (which may be brought into view by the aid of the sjieculum) and carried downwards in the direction of the fistulous track; in these cases, too, pressure on the external surface will cause an escajie of jms into the bowel. It must be remembered that every sinus in the neighborhood of the aniin is not necessarily a fistula in ano ; it may, for instance, be connected with caries or necrosis of the tuber ischii; may depend upon the presence! of a tuft of hair (pito-nidal fistula) as in curious cases1 observed by J. M. Warren and other surgeons, including Lamadrid, Gaston, Wyeth, and myself; or may* communicate with an abscess arising within the pelvis, or proceeding from the hip-joint. Treatment___The formation of a fistula in ano may sometimes be prevented by the dilatation with bougies of any rectal stricture that may exist, and by the jirompt treatment of inflammation or abscess in the ischio- rectal space. If the surgeon be called in before suppuration has actually occurred, the formation of an ischio-rcctal abscess may perhaps be arrested by* the assiduous use of poultices or warm fomentations, but if matter be present, it should be at once evacuated by a sufficiently free and dee|i inci- sion, when the part may possibly heal without forming a communication with the gut. The treatment of fistula in ano may consist (1) in the employment of stimulating a judications, such as nitrate of silver or the tincture of iodine; (2) in the use of a ligature, tied so as to strangulate the tissues interven- ing between the fistula and the surface of the body, and tightened every few days until it cuts its way through by ulceration ; and (3) in incision, or the " operation for fistula." The first and second methods are chiefly ajijilicable to those cases in which, from the constitutional condition of the patient, or from his fear of the knife, any cutting operation is contra-indi- cated. The elastic ligature, as recommended by Dittel, Courty, and Allingham, is much preferable to the ordinary form, cutting its way through more rapidly, and giving less pain to the patient; Allingham has devised an ingenious instrument to facilitate its introduction. There is some difference of opinion among surgeons as to the projiriety of operating for fistula in ano in the case of phthisical patients, many writers deprecating interference under these circumstances, on the ground that the fistula acts a useful part as a source of revulsion or counter-irrita- tion, while others advise the operation, in the belief that every additional drain upon the system must be injurious. It seems to me that this ques- tion should be decided, in each individual case, according to the stage and extent of the constitutional affection, and the degree of annoyance caused by the local disease. In a case of advanced phthisis, unless the discomfort produced bv the fistula were unusually great, it would doubtless be more prudent to decline an operation—but under other circumstances, a different course may* be proper. The mere existence of tubercle is not in itself a contra-indication, and there is in many instances reason to hope that by curing the local affection, the progress of the constitutional disease may be retarded, if not completely arrested. Even in advanced cases, the opera- tion does no particular harm, though the wound is apt not to heal. When fistula in ano is dejiendent upon stricture of the rectum, no ojiera- tion for the relief of the fistula should be performed until the stricture has 1 See an admirable paper on " Coccygeal Fistula," by Heurtaux, in Bull, et M6m. de la Societe de Chirurgie, 5 Avril, 1882. FISTULA IN ANO. 925 been properly dilated, and if the stricture be of a malignant character, the operation is positively contra-indicated, the disease, under these circum- stances, being apt to spread outwards in the line of the incision, thus add- ing to the patient's discomfort. The Operation for Fistula in Ano consists in dividing the sphincter, with the tissues between the external orifice of the fistula and the anus. The rectum having been emptied by an enema, the patient is placed on the side corresponding to that of the fistula, with his buttocks at the edge of the bed or table, and held apart by an assistant. If there be several sinuses communicating with one fistula, these should be laid open on a grooved director ; but in the majority* of instances there is but a single ex- ternal opening. Through this the surgeon introduces his director, slightly bent at the extremity, and passes it up in the track of the fistula until it projects through the internal ojiening into the gut, where it can be felt by the fore- finger1 inserted into the rectum. The internal opening of the fistula will almost invariably be found just above the sphincter ani, even though the fistula itself extend some distance further along the bowel; if, however, no opening be found here, one should be made by thrusting the director through the rectal mucous membrane, it being quite unnecessary and not very safe to extend the incision higher up. The point of the director being felt in the rectum, is to be hooked down by the finger and brought out through the anus, thus raising the sphincter and other parts to be divided upon the groove of the instrument, which is then cut loose by a few strokes with a sharp scalpel. Any branching sinuses should then be slit up, all loose flaps or tags of integument cut away with scissors, and the whole surface of the wound wiped with the solid stick of caustic potassa, so as to check oozing, and, by making a superficial eschar, to prevent premature adhesion of the edges. A strip of gauze or oiled lint is finally* laid in the wound, which is allowed to heal by granulation, a probe being occasionally- passed between its edges to prevent their uniting superficially and thus reproducing the fistula. The patient should be kept in bed for about a week after the operation, the bowels being locked by* opium for five or six days. I have never met with troublesome hemorrhage either during or after this operation, but if it should occur (as it may, if the incision be carried too high, from wound of the hemorrhoidal vessels), it must be controlled by compressfon or bv styptics, or, if a bleeding vessel can be found, by the application of a liga- ture. If the fistula be of the blind internal variety, an external opening may- be made by cutting upon the point of a director introduced from within, the subsequent steps of the operation being conducted in the way already described. Other modes of operating are frequently resorted to, but the principle is the same in all. Gross and Allingham, after passing the director, cut from within outwards with a curved bistoury introduced along the groove of the instrument, while many other surgeons, and perhaps the majority, employ a jirobe-pointed bistoury, and dispense with the director altogether. Brodie, and more recently- W. Cooke, have preferred to divide the sphincter with scissors, while Hewson and others used the " syringotome," or as Syme not inaptly called it, the " probe-razor." Mr. Reeves, after dividing 1 In making digital examinations of either rectum or vagina, the finger should be well oiled, and the depressions around the nail filled with soap, or simple cerate, so as to prevent the adhesion of any offensive substance. In examining a fistula in ano without etherization, the probe should be introduced before the finger is placed in the rectum. 926 DISEASES OF INTESTINAL CANAL. the sphincter and freshening the fistula, closes the latter with sutures, somewhat as in the operation for ruptured perineum. If there should be more than one fistula, there would be reason to fear that a multiple division of the sphincter might entail subsequent fecal incontinence. Hence, in such a case, the elastic ligature should be used in preference to the knife, or the knife might be used on one side and the ligature on the other. Felix, of Brussels, employs a ligature drawn rapidly* backwards and forwards so as to cut its way through, in the manner of the hemp-saw recommended for uterine polypi by McClintock, of Dublin. Fissures and Ulcers of the Anus. Several distinct affections are often included under these names. 1. Fissures, Chaps, or Cracks, may exist in the thin skin around the anus, without at all implicating the mucous membrane. These mav follow upon herpetic or eczematous eruptions of the part, or may* be pro- duced by the acridity of the intestinal discharges, want of cleanliness, etc. In their worst form, these fissures or chajis constitute the rhagades often seen in prostitutes, and therefore commonly supjiosed to be of syphilitic origin, though it is probable that, in many instances, they are due rather to the irritating contact of vaginal discharges, and to a neglect of ablutions. Though these fissures are productive of a great deal of annoyance by the itching and smarting which they occasion, they are not attended by the intense burning pain which characterizes the affection which will next be described, and though they may, like it, cause suffering during the act of defecation, this suffering is of comparatively brief duration. The treat- ment consists in the enforcement of scrupulous cleanliness, and in the appli- cation of stimulating and slightly astringent washes or ointments, with attention to the state of the bowels, and the administration of arsenic or other alteratives, as indicated by the general condition of the jiatient. Among the most useful local applications are solutions of nitrate of silver (gr. v-x to f|j) or borax, the oxide of zinc or tar ointments of the U. S. Pharmacopoeia, and the citrine ointment diluted to an eighth of its officinal strength. If mucous patches or vegetations exist, they must be treated as directed ifi previous chapters (pp. 489, 504, 548). 2. The True Fissure of the Anus, or, as it should, in many in- stances, rather be called, the Painful Ulcer of the Anus, is a small ulcer situated at or within the margin of the anus, and in the grasp, as it were, of the sphincter. It appears, when at the margin of the anus, as a linear ulcer or fissure (whence its name), but, when within the gut, may be seen by dilating the sphincter with the speculum to be of an elongated oval shajie, rarely exceeding half an inch in length by a quarter of an inch in breadth. The fissure is not unfrequently concealed by a small reddish pile, or fold of skin, while the painful ulcer may be comjilicated by the existence of rectal polypus. Symptoms.—The symptoms of this affection are sufficiently character- istic. The patient experiences an intense burning pain, beginning at the time of or shortly after the act of defecation, and continuing without alle- viation for several hours subsequently. The severity of the pain induces the patient to postpone going to stool as long as possible, thus causing an artificial costiveness which only aggravates his condition. The feces themselves may be streaked with blood or pus on the side corresponding to the seat of the ulcer. There is always a spasmodic contraction of the sphincter ani, attended with tenesmus, and often with a discharge of slimy HEMORRHOIDS. 927 mucus, and there is frequently great sympathetic disturbance of the urinary apparatus, or of the uterus, occasioning an error in diagnosis by directing attention to those organs. The true nature of the ease may, however, always be detected by digital or ocular examination, aided, if necessary, by anaesthesia and the use of the speculum. The fissure or ulcer may occupy any part of the circumference of the anus, but is commonly found posteriorly. This is essentially an affection of adult life, though Houghton, of Dudley*, has seen a well-marked case in a child one year old. Treatment.—In slight cases, a cure may sometimes be effected by the apjilication of chloral, iodoform, or nitrate of silver, and by the use of ano- dyne and astringent lotions, ointments or suppositories, but in the majority of instances, at least in adults, a trifling operation will be necessary. Boyer, who first accurately described this affection, divided the whole sphincter, thus effectually putting the part at rest and allowing the ulcer to heal; but this procedure is now known to be unnecessarily severe, and the practice of modern surgeons is simply to divide the floor of the ulcer and the muscular fibres immediately beneath it. The rectum being emptied by an enema, the surgeon introduces upon his left forefinger, which serves as a director, a straight, narrow, probe-pointed knife, and, beginning above the upper margin of the ulcer, cuts quickly downwards, fairly dividing in a longitudinal direction the whole ulcerated surface through its centre. In some cases it may* be more convenient to expose the ulcer by means of a fenestrated speculum, the incision being made through the aperture of the instrument in the way* described, or a sharp-pointed knife being introduced below the floor of the ulcer and made to cut its way outwards. The pa- tient may be etherized if thought necessary, but chloroform should not be used, as death has, according to Ducamp, followed its employment sev- eral times in these cases. The after-treatment consists in the application of a little oiled lint and the introduction of an opium suppository. Recamier, and more recently Van Buren, of New York, have recom- mended, instead of the incision of the ulcer, forcible dilatation or partial rupture of the sphincter, accomplished by* introducing both thumbs, or both forefingers, back to back into the rectum, and then widely separating them. I do not know that this procedure is any less painful than the in- cision, while it is, I think, less certain to effect a permanent cure. 3. Chronic Ulcer of the Rectum.—Extensive ulceration of the rectum, above the sphincter, may result from dysentery, from the irritation caused by foreign bodies or hardened feces, or from the incautious use of bougies or enema-tubes. The symptoms are pain, not, however, usually very severe, w*ith a muco-purulent discharge. The ulcers may be felt by digital examination, or seen by the aid of the speculum. The treatment consists in the employment of anodyne and astringent lotions or supposi- tories, with attention to the state of the digestive functions. Advantage may be sometimes derived from the internal use of the confection of black pepjier, which has acquired a reputation under the name of Ward's paste. 4. Tuberculous Ulcer of the Anus.—Under this name MM. Mar- tineau and Fereol have described an affection resembling that met with by Trelat in the tongue (see p. 817). They advise the topical use of a weak solution of chloral. Grosselin suggests the application of bismuth. Iodo- form has also been recommended. Hemorrhoids. Hemorrhoids, or piles, are tumors met with at or within the verge of the anus, consisting essentially of a hypertrophy and infiltration of the mucous 928 DISEASES OF INTESTINAL CANAL. or muco-cutaneous and subjacent areolar tissues, with a varicose dilatation of branches of the hemorrhoidal veins ; in some instances rupture of a vein occurs, with extravasation of blood into the subcutaneous lis.-ues, while in other cases there appears to be a new development of arterial capillaries, the pile being then of a vascular, sjiongy, and almost erectile character, and its mucous covering having an ulcerated, granular, or somewhat villous apjiearance. Piles are classified, according to their situation, into external and internal, and, according to the presence or absence of hemorrhage, into open or bleed- ing, and blind piles. The ordinary bleeding pile is that form of internal hemorrhoid in which the arterial element predominates, and is sometimes called from its shape the globular pile, in contradistinction to the longi- tudinal or fleshy pile, which is rarely attended by hemorrhage. Causes of Hemorrhoids.—Any circumstance which impedes the returning current from the hemorrhoidal plexus of veins, or which encour- ages a flow of blood to the rectum, tends to promote the formation of jiiles ; hence a sedentary life, luxurious habits, occupations which require much standing (as that of a barber), disorders of the alimentary canal, or of the liver, the presence of abdominal tumors, the pregnant state, constijiation, the straining due to urethral stricture or prostatic enlargement, inordinate sexual indulgence, etc., may all act as causes of hemorrhoids. Piles may occur at any age, but are most common during the periods of adolescence and later adult life. They occur with about equal frequency- in either sex. The first steji in the formation of a pile, either external or internal, is dila- tation of a hemorrhoidal vein, soon followed, if the disease persists, by hypertrophy and infiltration of the superincumbent tissues; when the pile is unirritated or indolent, it mav appear to consist merely of a fold of skin or mucous membrane and areolar tissue, but when from any cause the hemorrhoid is inflamed, it becomes swollen and tense, and is evidently filled with fluid or coagulated blood. After a succession of such attacks, the pile forms a distinct tumor, sometimes of considerable size, which, even in its indolent state, gives a good deal of annoyance by its bulk and by the sensation of weight which it occasions. External Piles—In the indolent state these ajipear as small tumors or radiating folds, occupying the verge of the anus external to the sphincter, and covered with the thin integument of the part. They give rise to a feel- ing of heat and fulness about the anus, particularly after defecation, and may* be attended with some itching, but do not usually cause a great deal of inconvenience. When inflamed, however, they become excessively pain- ful, the pain radiating in various directions and being much aggravated by exercise, or even by the assumption of the erect posture ; they are often accompanied by an intolerable itching and burning, with violent tenesmus, depriving the patient of sleep, and for the time being rendering life almost a burden. If examined in this condition—which constitutes an " attack of the piles"—the hemorrhoidal tumors will be found tense and swollen, ex- tending up within the grasp of the sjihincter, and thus becoming partially covered with mucous membrane (extero-internal piles). Their color, which in the uninflamed state was nearly that of the surrounding integument, is now of a deep purplish-red hue. The hemorrhoidal tumor occasionally suppurates, but more commonly returns gradually to its previous indolent state, becoming, however, larger and more indurated with each successive attack of inflammation. When piles are large and numerous, the skin between them may* undergo maceration, giving rise to a sero-purulent dis- charge which sometimes produces troublesome excoriation. External piles are rarely attended by bleeding, but Syme and others have recorded cases INTERNAL PILES. 929 of profuse rectal hemorrhage, in which no internal piles could be found, and in which entire relief was afforded by the removal of pendulous flaps of skin which surrounded the anus. The diagnosis of external piles is made with little difficulty; the only affections with which they are liable to be confounded are vegetations and mucous patches, but these can be distinguished by observing that they are not, like piles, solely confined to the anal region. External hemorrhoids often coexist with the painful ulcer of the anus, or with fistula in ano. Internal Piles—These are situated entirely within the sphincter, and are therefore covered with mucous membrane. As already mentioned, there are two principal varieties, the longitudinal or fleshy pile, which in structure corresjionds pretty closely with the external hemorrhoid, except that the venous element is more promi- nent, and the globular, vascular, or granular pile, which is characterized by the develop- ment of a congeries of arterial capillaries. The former variety* has a broad base, is firm and elastic to the touch, and of a reddish- brown color; the latter may be either sessile or pedunculated, is at first of a bluish hue (resembling a varicose vein), but ultimately assumes its characteristic red color and villous or strawberry-like appearance. Internal piles may exist just within the sphincter, or an inch or two higher up; occasionally the hemor- rhoidal tumors form a double circle, one above the other. The symptoms of internal piles are similar to those of external hemorrhoids, but there is more distress, from the tumors frequently protruding during defecation and being caught or grasped by the sphincter, thus causing great pain and tenesmus. The frequent protrusion of the piles ultimately leads to general prolapse of the mucous coat of the rectum, while the constant irritation of the part gives rise to a dis- charge of thin mucus, which excoriates the skin around the anus, and is often sufficiently abundant to soil the patient's clothes. Bleeding from the Rectum, or the Hemorrhoidal Flux, is a most char- acteristic symptom of internal piles; it may accompany either form of. the disease, though by far most common in connection with that in which there are isolated tumors with a granular, strawberry-like surface. In most instances, blood of an arterial hue appears to issue directly from the surface of the pile, but occasionally there is general oozing from the con- gested mucous membrane, or a copious stream may be poured from an ulcer- ated opening in a dilated vein. The amount of blood varies, in different cases, from a few drops to many ounces—enough in some instances to pro- duce excessive and even fatal anaemia and exhaustion. The bleeding may be continuous, or intermittent—recurring sometimes at regular intervals. The occurrence of the hemorrhoidal flux is not unfrequently preceded for some days by an increase of the ordinary symptoms of piles, constituting what the older writers called the Hemorrhoidal Effort: in these cases, the loss of blood seems often to act beneficially both by giving local relief and by acting as a derivative, and perhaps preventing serious visceral conges- tions. The hemorrhoidal flux sometimes alternates vicariously with the 59 Fig. 537.—Protruding hemorrhoids. (Ashton.) 980 DISEASES OF INTESTINAL CANAL. menstrual flow. The pain in a sever*1 case of internal piles is not limited to the rectum, but radiates to the loins, sacrum, hijis, and thighs, and marked sympathetic irritation is frequently developed in the genitourinary organs. Internal, like external, piles may become inflamed, and ultimately subside into an indolent condition, jiersisting as hard and incomjiressible tumors containing clotted blood ; the clot occasionally undergoes a calcare- ous change, and becomes converted into a phlebolite or veinstone. In other instances, the piles protrude, and are strangulated by the sphincter, eventually sloughing off, and thus undergoing a spontaneous cure. Internal hemorrhoids are to be diagnosticated from prolapsus, and from polypus of the rectum : in complete prolapsus of the rectum (a very rare affection in adults), the smooth character of the mucous membrane and the cylindrical form of the protrusion will enable the surgeon to make the diagnosis, while the common form of prolapsus, in which the mucous membrane alone is implicated, may usually be distinguished from piles by its annular form, and by the absence of distinct tumors. The two affec- tions, however, often coexist in the same patient. Bectal polypus may be recognized by its being solitary and of comparatively large size. The diagnosis of bleeding piles from other sources of intestinal hemorrhage may be made by observing that the blood in the hemorrhoidal flux is bright, liquid, and spread over, rather than mingled with, the feces, whereas blood entering the bowel at a higher point will be dark, partially (dotted. and mingled more or less intimately with the other contents of the intes- tinal canal. Internal hemorrhoids sometimes exist in cases of fistula in ano, and may prove a troublesome complication in the treatment of that affection, by* protruding in the wound after the operation. Treatment op Hemorrhoids. Constitutional Treatment.—This consists in endeavoring to im- prove the general health, by the administration of nutritious food and tonics if the patient be of relaxed or debilitated frame, or by regulating the diet and partially- cutting off the supply of animal food under ojijiosite circumstances; highly seasoned dishes and alcoholic stimulants should be particularly avoided. Any habits that predispose to the disease should be given up, and the jiatient should daily take moderate, but not fatiguing, exercise in the open air. If any special cause of the affection can be de- tected (as urethral stricture), this must, of course, be appropriately treated. In every case the bowels should be kept in a soluble condition by the ad- ministration of mild laxatives, such as castor oil, the compound rhubarb pill, copaiba, the confection of black pepper or senna, the mineral waters of Saratoga or Kissingen, etc. Glycerin, as recommended by G. B. Powell, D. Young, and others, may be employed with advantage. Ene- mata of cold or tepid water, as most agreeable to the patient, are some- times of service. Local Treatment—The local treatment may be palliative or radi- cal: the former will, in many* instances, suffice to give very great comfort to the patient, and may in mild cases even effect a permanent cure; it is often the only plan which is applicable in the later stages of pregnancy, or in extreme old age. The radical cure, or that by operation, should, bow- ever, usually be advised whenever the hemorrhoidal tumors have become permanent, leading to more or less constant inconvenience and suffering, and particularly in cases of bleeding piles, in which the amount of blood lost tends to render the patient anaemic. If, on the other hand, the hemor- rhoidal flux be slight and not productive of much annoyance, it may, in OPERATIVE treatment of hemorrhoids. 931 some instances, be wiser not to interfere, for, as already mentioned, there is reason to believe that the loss of blood in these cases sometimes acts beneficially as a derivative. The Palliative Treatment consists in the topical use of various astringents and anodynes, and in the practice of frequent ablutions, so as to insure perfect cleanliness. Sjionging with cold water, or the employ- ment of the cold douche, should be resorted to night and morning, and after each fecal evacuation. For internal piles, weak astringent injections (as of alum, or of the tinct. ferri chloridi, ten drops to the ounce) may* be ajiplied, and are particularly useful in cases complicated with prolajisus. Enemata of the fluid extract of ergot (f5^s to f.^ss of water) are highly recommended in these cases bv Dr. Semjile, of Virginia, and Drs. Orr and Conner, of Cincinnati, while Langenbeck advises the injection of ergotin beneath the rectal mucous membrane. Enemata of bismuth (in the form of the liquor bismuthi) are recommended by Cleland, and simple enemata of hot water by Dr. J. L. Powell and Dr. G. T. Welsh. Whenever the piles protrude, they should be carefully replaced. In other cases, great comfort may be derived from the use of opium combined with acetate of lead or tannic acid, in the form of suppositories. The same or similar re- medies may- be used for external piles, in the form of ointments. A good combination is one containing equal parts of the gall and stramonium oint- ments of the U. S. Pharmacopoeia. To relieve the itching which attends either form of piles, the best remedy, according to my* experience, is the ung. hydrargyri nitratis, diluted in the proportion of one part to seven. When piles become inflamed, the patient should be put to bed and the part constantly fomented or poulticed, while the bowels are moved with mild laxatives. Leeches may sometimes be applied around, but not over, the hemorrhoidal tumors, and if a pile be tense and evidently filled with coagu- lated blood, a puncture may be made with a lancet or sharp bistoury, and the clot turned out. An ice-bag may be substituted for the warm applica- tions, if more agreeable to the patient. Forcible dilatation of the sphincter ani is recommended by Verneuil, Fontan, and Cristofori. As a rule, no operative treatment should be instituted while the piles are in a state of inflammation, though, as the operation can be rendered painless by anass- thesia, it need not be postponed if there be any reason to the contrary. The Radical or Operative Treatment of Hemorrhoids may consist in excision, ligation, torsion, the application of caustics or the cau- tery, or the injection of coagulating fluids. i. Excision is chiefly adapted to the treatment of external piles. For the removal of these, it is sufficient to seize each pile with broad-bladed ring-forceps (Fig. 539), and cut it off with scissors curved upon the flat, treating in the same way any loose folds of skin that may exist around the anus. If the piles be altogether external (covered with skin only), there is no risk of troublesome hemorrhage, and any bleeding that may occur can be readily controlled by pressure or torsion. If, however, as is often the case, the piles be partly covered with mucous membrane (extero-in- ternal), the hemorrhage may be quite profuse, and it is then much better to use the ligature in the way which will be presently described, notching first with the scissors the cutaneous surface of the hemorrhoidal tumor, and applying the ligature in the groove thus made. Care must be taken, in the excision of external piles, not to remove too much skin, lest the con- traction which occurs in the healing process should result in the formation of a troublesome anal stricture. In order to render excision a safe mode of treatment for internal piles, a plan wbich originated with Cusack, of Dublin, may be employed. In 932 diseases of intestinal canal. this, which is called the Operation by Clamp and Cautery, the base of the hemorrhoidal tumor is closely comjiressed between the blades of clamp- forceps, and, the pile being then cut off with scissors, bleeding is prevented by applying to the stump or pedicle strong nitric acid or the hot iron. Instruments for this operation have been devised by II Lee, Wood, and others, the best, probably, being that introduced by H. Smith, of King's College Hospital. The blades of this ajiparatus (Fig. 538) fit accurately Fig. 538.—Smith's clamp for piles. together with a tongue and groove, and the comjiression of the pedicle is effected by means of a screw which unites the handles. Plates of ivory are fixed to the outer surface and edges of the blades, so as to prevent the heat of the cautery-iron from reaching the surrounding parts. This opera- tion, which Mr. .Smith also employs in cases of prolapsus of the rectum, is said to be attended with very little pain, and to be followed by* quicker con- valescence than the operation of ligation. In his more recent cases, Mr. Smith has employed a cautery with a cutting or a serrated edge, thus re- moving and cauterizing the hemorrhoid at the same time, and dispensing with the use of scissors. Whitehead, of Manchester, excises internal piles, removing the tissues in a complete ring between the anal margin and the sphincter, and then bringing the skin and mucous membrane together with stitches. This plan has also been successfully adopted by Weir, of New York, and by Packard, of this city. 2. Ligation is the method usually employed for the treatment of in- ternal piles, and it is that which I myself am in the habit of adopting. The patient should take a dose of castor oil the night before, and have the lower bowel thoroughly washed out by means of an enema on the morning of the operation. Though it is not absolutely necessary, it is better for him to be etherized. If the piles do not protrude, they may be made to do so by administering a warm-water enema, which will bring them down as it is ejected from the rectum ; or, if the patient is etherized, they may be brought down with the finger. The patient being placed on his side and turned slightly over on his belly, while the nates are widely separated by an assistant, the surgeon begins by thoroughly stretching the sphincter ani, introducing both thumbs and pressing them in opposite directions, or, which Pick prefers, by divid- ing the sphincter subcutaneously with a narrow-bladed bistoury ; he then seizes each tumor with the ring-forceps and transfixes its base with a double ligature, introduced by means of a naevus-needle, or, which is better for the purpose, the needle known as Bushe's (Fig. 540). The needle being detached, the pile is effectually strangulated by tying the ligatures on either side. The ends of the ligatures are then cut short, when the bulk of the strangulated pile may be lessened by cutting off its summit at a safe distance from the point of ligation. If, however, the hemorrhoid arise from some distance up the rectum, it is safer not to use the scissors, but to push the whole strangulated mass above the sphincter. When all the internal piles have been thus ligated, and any external ones that may exist OPERATIVE TREATMENT OF HEMORRHOIDS. 933 Fig. 539.—Ring for- ceps for piles. Fio. 540.—Bushe's nee- dle and needle-car- eXClSed, an opium suppository should be placed in the rectum, and the patient returned to bed, with cold water dressing constantly applied to the anus. The bowels should be kept locked up for six or seven days, after which a free evacuation may be se- cured by the administration of castor oil. The ligatures become detached, usually within a week, leaving small granulating surfaces, which soon heal under the occasional application of ni- trate of silver. The operation is some- times followed by strangury, or even by retention of urine, requiring the administration of a warm bath, or pos- sibly the use of the catheter. In cases of internal piles complicated with pro- lapsus, the ecraseur may be occasion- ally used with advantage, as it pro- duces more contraction than the liga- ture. The instrument should be very slowly worked, as otherwise its em- ployment is apt to be followed by he- morrhage. Dr. Xott has emjiloyed with success a form of clamp which he calls a rectilinear ecraseur, to com- press the base of the pile, then remov- ing the instrument and applying a liga- ture in the groove which it has left. The ligation of piles is not entirely free from danger, being, in some cases, followed by peritonitis, erysipelas, pyaemia, phlebitis, or tetanus. I have seen but one fatal result from the operation in my own practice, though I nearly lost another patient by erysipelas. In two cases which occurred at the Episcopal Hospital, in the wards of my colleagues, some years ago, tetanus ensued, with a fatal termination. 3. Torsion is recommended by Allingham for small and particularly for single hemorrhoids, situated near the median line; the base of the jiile is grasped with a clamp applied in a longitudinal direction, and the strangu- lated mass then seized with broad forceps and slowly twisted off. This mode of treatment is said to be almost painless, but, I confess, seems to me less safe, and therefore less desirable, than the application of a ligature. The same may be said of the operation with tooth-edged scissors suggested by Richardson, of Dublin, and that with clamp-forceps advised by Pol- lock, Benham, Allingham, and others. 4. The Application of Caustic is particularly suited for those piles in which the arterial element is predominant, and w-hich may be recog- nized by their granular or strawberry-like appearance. This mode of treat- ment, which was introduced by Houston, of Dublin, has been since advocated by- H. Lee, Fergusson, and H. Smith ; it is more apt to succeed when the piles are sessile than when they are pedunculated. The caustic used is strong nitric acid, which is conveniently applied with a piece of wood or a glass brush through a fenestrated glass speculum ; as soon as the pile is well coated with the acid, it should be wiped with a piece of lint dipped in oil, or in a paste of prepared chalk and water. A thin slough is formed, the detachment of which leaves a healthy granulating surface which soon heals. The great advantage of this mode of treatment is, according to H. 934 DISEASES OF INTESTINAL CANAL. Smith, that it does not require the patient to keep the house after the operation. If the acid be carefully applied, so as not to touch the skin, it causes very little pain; but its use is not absolutely free from risk, one case referred to by Erichsen having terminated fatally from orysijiolas. 5. Puncture of the pile with the conical tip of Paquelin's Gas Cau- tery is recommended by H. A. Reeves, and by Gosselin. 6. The Injection of the Tincture of Chloride of Iron, or of Carbolic Acid, has been successfully resorted to, in the treatment of internal piles, the former being employed by Colics, of Dublin. The instrument used is the ordinary hypodermic syringe, and about 20 minims of the tincture are injected into each hemorrhoid. The ojieration is said to be painless, but I should fear would expose the patient to the risk of embo- lism. Carbolic acid injections, of a strength varying from a 15 jier cent. solution to the pure acid, have been employed in the same way by Drs. Pooh-y, Andrews, Kelsey, and other surgeons. They undoubtedly may afford relief in mild cases, but are, in my judgment, far inferior to the lig- ature in cases which really require operative treatment. Prolapsus of the Rectum. This occurs under two forms—the partial and the complete. In partial prolapsus of the rectum, the mucous membrane of the gut is alone involved in the protrusion, though the submucous areolar tissue is commonly thick- ened and elongated. In complete prolapsus, all the tissues of the gut are involved, the bowel being actually invaginated, and protruding sometimes to the extent of several inches. Causes.—The causes of prolapsus of the rectum are, (1) a relaxed and weakened state of the tissues in general, such as is met with in feeble children or in debilitated adults; (2) chronic irritation of the rectal mucous membrane, such as results from dysentery or from the presence of internal piles; and (3) reflected irritation dependent upon diseases of other organs, such as urethral stricture, prostatic enlargement, vesical calculus, or ex- strophy of the bladder. Fig. 542.—Section of complete prolapsus of rectum. (Dkcitt.) Symptoms—The protrusion occurs, at first, only after defecation, and perhaps only when the bowels are unduly relaxed; but as the disease pro- gresses, the prolapsus becomes more constant, the gut coming down when the patient stands or walks, and being with difficulty kept in place. In the Fio. 541.—Partial prolapsus of rectum. PROLAPSUS OF THE RECTUM. 935 partial form, the mucous membrane forms a red or purplish ring, some- what elongated in shape, and continuous with the mucous coating of the sphincter; in the complete prolapsus the gut is invaginated through the sphincter, between which and the protruded bowel a distinct groove may always be recognized. The complete prolapsus forms an elongated cylin- drical tumor, of the ordinary color of mucous membrane, 'presenting a smooth and even surface in the child, but being usually somewhat convo- luted and rugose in the adult. When the protrusion is down, there is a sensation of weight and dragging, with some pain (not, however, very intense), and sympathetic vesical disturbance. In a case of recent prolapsus of either form, strangulation may occur, leading perhaps to sloughing, and possibly spontaneous cure; but in cases of long standing the sphincter is commonly much relaxed, facilitating both the descent and the reduction of the protrusion. According to Lannelongue, infantile prolapsus is not an unfrequent cause of rectal stricture in later life. Diagnosis.—The diagnosis of prolapsus of the rectum is usually made without difficulty; the complete form of the affection can, indeed, scarcely be mistaken for anything else, while partial prolapsus is only likely to be confounded with internal piles, with which it is very often complicated, but from which it may be distinguished by the annular character of the jiro- trusion, and by the absence of distinct tumors. Mr. Stocks has reported a case in which an ovarian cyst protruded through the anus, and was at first mistaken for prolajisus of the rectum. Treatment.—The first step in the treatment of prolapsus of the rectum is to effect reduction ; this may usually be accomplished by placing the patient on his side, and gently but firmly compressing and pushing up the gut with the band, protected with a Soft cloth dipped in oil. If the sphincter be much dilated, both hands may be required—one to fix the part, while comjiression is made with the other. When strangulation occurs, reduc- tion may, if necessary, be facilitated by incising the mucous membrane, if the prolapsus be of the partial variety, or by dividing the sphincter, if com- plete invagination have occurred. After reduction, the part may be sup- ported with a pad and bandage. In order to prevent a recurrence of the prolapsus, the bowels should be kejit in a soluble condition by the adminis- tration of laxatives, such as were recommended for piles. The descent of the gut while at stool should be prevented by avoiding straining, and by having the bowels moved while in the recumbent position, or even while standing—protrusion being less apt to occur in either of these than in the ordinary sitting posture. With children a kneeling posture is preferable, and the nurse may*, as advised by MacCormac and H. Smith, be directed to draw the skin of the anus forcibly to one side during the act of defeca- tion, so as to cause contraction of the sphincter, and thus prevent the gut from protruding. In mild cases, a cure may often be obtained by atten- tion to these points, and by the local use of bismuth or other astringents in the form of injections or supjiositories. Hypodermic injections of strychnia are advised by Lorigiola, W. H. Thomson, and L. Weber, and those of ergotine by Langenbeck, Henoch, and Vidal. The daily* use of the cold douche is highly recommended by Saint Germain. If the prolapsus be due to sympathetic irritation from stricture, calculus, etc., these affections must, of course, be properly treated, when the rectal complication will commonly subside of itself. Operative Treatment.—In cases of extensive and inveterate pro- lapsus, especially in adults, something more may* be required. 1. It may* be sufficient simply to cut off with curved scissors the radiating flaps of integument around the anal orifice, the subsequent contraction 936 DISEASES OF INTESTINAL CANAL. often sufficing to effect a cure ; if the incision involve the mucous mem- brane, a stitch or two should be inserted so as to guard against hemor- rhage. 2. Ligation is effected by seizing with ring-forcejis a jiortion of the pro- truded mucous membrane, and tying it firmly with a single ligature: it is usually sufficient to ajijily one ligature on either side, but more may be re- quired if the prolapsus be extensive. The parts should then be carefully returned through the sphincter, and an opium suppository introduced. 3. Caustic, the strong nitric acid being the best, may be ajiplied, through a fenestrated sjieculum, as directed in the case of piles, or to the protruded gut, before reduction, as advised by Allingham. This is the best operation in cases occurring in children, and I have fre- quently employed it with success. All of the protruded gut should be cauterized except the half inch nearest the anus, and the bowel should then be returned, and re-protrusion prevented by introducing a plug of oiled cotton and ajiplying a firm bandage. 4. The Clamp and Cautery method is an efficient mode of treatment. Longitudinal folds of mucous membrane are seized with Smith's clamp and cut off with scissors, the pedicle being then seared with a hot iron. 5. Excision of a \J-shaped Segment of the sphincter on one or both sides has been occasionally jiractised, but is a severe mode of treatment, and may be followed by fecal incontinence. (J. Narrowing the Rectum.—Lange makes an incision from the sacrum to the anus, removes the coccyx, and exposes the posterior wall of the rectum, the lumen of which he then narrows by introducing stitches which do not involve the entire thickness of the wall, but which cause this to project into the gut as a fold or ridge; the sphincter and levator ani are then stitched in the same manner, and the cavity left by removal of the coccyx lightly* packed with gauze. 7. Mikulicz's operation consists in cutting away the prolapsus, and stitching together the edges of the two portions of bowel; this method is rather ajijilicable to cases of invagination of the colon through the anus than to those of ordinary prolapsus of the rectum. (See note, page 908.) Finally, in cases in which operative interference is not deemed advisa- ble, great comfort may be afforded by the adaptation of a well-fitting anal truss or supporter, such as is shown in Fig. 543. Inflammation of the Rectal Pouches. The pouches or lacunae of the rectum are sometimes much enlarged, chiefly in old people, becoming distended with fecal matter, and, as a con- sequence, inflamed or ulcerated, and causing intense itching and often severe pain, unaccompanied, however, by spasm of the sphincter. This affection was first described by Physick, under the name of Preternatural Pouches of the Rectum, and was called by Gibson the Encysted Rectum, and by (iross, Sacciform Disease of the Anus. The diagnosis is readily made by exploring the rectum with a blunt hook or a probe bent at its end. The treatment consists in drawing down successively each pouch that is affected, and excising the mucous fold at its base with curved scissors. PARACENTESIS ABDOMINIS. 937 Neuralgia of the Anus. This usually occurs as a symptom of some local lesion (as painful ulcer of the rectum), but may exist independently. The treatment in such cases is very unsatisfactory ; the free use of quinia, and the local application of belladonna or stramonium, are perhaps the best remedies. Pruritus or Itching of the Anus. This is probably alway*s symptomatic, but occasions so much distress as to be worthy of special mention. It may be due to hemorrhoids, to the presence of intestinal parasites, to papular or other eruptions in the neigh- borhood of the anus, or to uterine displacement. The treatment consists in the removal of the cause, if this can be ascertained, in attention to the state of the bowels, in the use of frequent ablutions, and in the employ- ment (somewhat empirically, it must be confessed) of various washes or ointments. The dilute citrine ointment is, perhaps, the best remedy* for itching piles, while for the pruritus dejiendent on cutaneous eruptions of the part, the tar and iodide-of-sulphur ointments of the U. S. Pharmacopoeia will often be found useful. Curling speaks highly of an ointment contain- ing chloroform and oxide of zinc, and of a wash of sulphuret of potassium and lime-water (5j-f.lviij)- Chlorinated lotions or weak solutions of hydrocyanic acid may be employed, or a weak solution of carbolic acid (gr. v-f'3j). Camphor, chloral, and various preparations of mercury have also been advantageously* used as topical applications. Banks recommends a superficial application of the actual cautery. Arsenic is often of service as an internal remedy*, and may* be conveniently* given in the form of arsenious acid, combined in a pill with iron and quinia. CHAPTER XLIII. DISEASES OF THE ABDOMTNAL ORGANS, AND VARIOUS OPERA- TIONS ON THE ABDOMEN. Umbilical Tumors and Fistulje. It sometimes happens that after sejiaration of the umbilical cord, the navel does not retract and cicatrize in the usual manner, but remains the seat of a polypoid protrusion or excrescence, partially covered with mucous mem- brane. These protrusions may be caused by a patulous condition of the urachus, in which case the escape of urine from the umbilicus will reveal their nature, or may* present a structure analogous to the mucous mem- brane of the intestine, or even, as in a case recorded by Ball, to that of the stomach. In some cases, as pointed out by Dr. Holt, they appear to consist of the prolajised mucous membrane of Meckel's diverticulum. A cure may usually be effected by cauterization and strangulation with a ligature. Paracentesis Abdominis. Paracentesis abdominis, or "the operation of tapping," is not unfre- quently required in cases of ascites and ovarian dropsy. The circum- stances which in any* particular case indicate or contra-indicate this opera- 938 DISEASES OF THE ABDOMINAL ORGANS. tion are discussed in works on the Practice of Medicine or on the Diseases Peculiar to Women, and it will, therefore, only be necessary to describe in these pages the manual procedure itself. The bladder having been emptied, the patient sits on the edge of the bed, or lies on either side, a broad four-tailed flannel bandage being laid over the upjier part of the abdomen, and the ends crossed behind, and firmly- held by an assistant. The surgeon makes a short incision in the median line about an inch and a half below the umbilicus, dividing the sujierficial structures, and then with a quick motion thrusts in a full-sized trocar and canula; the trocar being withdrawn, the fluid is allowed to eseajie, and is collected in suitable basins or pails. While the flow continues, the bandage should be continually tightened, so as to compress the abdomen and pre- vent the occurrence of syncope. Should the canula become clogged, it may be freed from obstruction by introducing a director or flexible catheter. AVhen all the fluid has been evacuated, the canula is withdrawn and the wound closed with a broad adhesive strip, the abdomen being supported with a firm compress and bandage. Fio. 541.—Tapping the abdomen. (Fergusson.) The steps of the operation as above described may be occasionally va- ried ; thus, if the abdominal parietes be tense and thin, the trocar may be thrust in at once, without a preliminary incision, the instrument being hindered from penetrating too far by the operator's finger placed about half an inch from the point, while the canula may, if preferred, be provided with a stopcock and flexible tube, as in the operation of paracentesis thora- cis. The puncture in the median line is to be adopted in cases of ascites, and indeed in every instance, unless the unilateral character of the swell- ing should indicate the choice of another locality, when the puncture may be made in the corresponding linea semilunaris. When, as usually hap- pens, the operation has to be repeated, the second puncture should be made a few lines above or below the cicatrix of the first. The ojieration of tapping is rarely attended by any unpleasant results; it may occasionally, however, be followed by' the development of a low form of peritonitis, and, in cases of dropsy from malignant disease, the wound of puncture may become the seat of secondary* deposits. It might seem unnecessary* to caution the surgeon against mistaking pregnancy for abdominal or ovarian dropsy, but for the fact that tapping has occasionally been incautiously employed under such circumstances, with an unfortunate result that can be readily imagined. DIAGNOSIS OF OVARIAN TUMORS. 939 Ovarian Tumors. I do not purpose entering into any prolonged discussion of the symp- toms, diagnosis, and therapeutics of ovarian disease, for these subjects be- long more to the special domain of Gynaecology than to that of Surgery ; it will be sufficient to enumerate the principal affections with which ovarian tumors are likely to be confounded, and to describe briefly the various operative procedures which are emjiloyed in their treatment.1 Diagnosis.—Fecal Accumulations in the caecum or other parts of the large intestine have been mistaken for ovarian tumors ; the diagnosis may commonly be made by* digital examination per vaginam, the fecal tumor imparting a characteristic doughy sensation to the touch. Pregnancy, either normal or extra-uterine, is usually attended with such obvious symptoms as to prevent the possibility of mistake, and in any case of doubt, a brief delay will serve to clear up the diagnosis. Fibro-muscular Tumors of the Uterus can usually be distinguished from ovarian growths, by observing that in cases of the former there is com- Fig. 545.—Sims's uterine probe, smallest size. monlv uterine hemorrhage and leucorrhoea; the uterine sound or probe enters further than in the normal state : the tumor, which is often multijile, is usually* hard, and by* vaginal exploration is found to be irregular in out- line and continuous with the uterus; and, finally, if the uterus be moved by means of the sound, the tumor moves with it. On the other hand, in a case of ovarian tumor, there is neither menorrhagia nor leucorrhoea ; the uterine sound enters only to the normal distance ; the tumor, which is usually solitary, often fluctuates, and is smooth and not continuous with the uterus ; and finally, the uterus can be moved without the tumor mov- ing with it. It is to be noted, with regard to the last diagnostic point, that it is the uterus and not the tumor which must be movable ; for the upper part of the solid uterine growth may be movable, while its base is so tightly* wedged in the superior strait of the pelvis that no motion can be communicated to the mass through the uterine sound. Ascites can commonly be distinguished by the character of the tumefac- tion, which in abdominal dropsy is uniform, but in ovarian disease is loca- lized at first to one or other iliac fossa; by the flattening of the abdomen, in the recumbent posture, owing to the ascitic fluid gravitating to the sides of the jieritoneal cavity ; by the change in the line of dulness upon varia tion in the patient's position; by the resonance anteriorly when the patient lies on her back, owing to the intestines floating upward; by the promi- 1 For further information I would respectfully refer the reader to Prof. T. Gaillard Thomas's Practical Treatise on the Diseases of Women, of which I have made free use in tlie following pages, to Prof. Goodell's Lessons in Gynaecology, and to Dr. C. C. Lee's article on Ovarian and Uterine Tumors in the International Encyclopaedia of Surgery, vol. vi. 940 DISEASES OF THE ABDOMINAL ORGANS. nence of the recto-vesical pouch, in which fluctuation can be detected by the finger introduced into the vagina; by the jiresence of a distinct wave when the patient rolls in bed ; and by the coexistence of signs of disease of the heart, liver, or kidney, the skin being often harsh and jaundiced, and the feet cedematous at an early* period of the affection. In dropsy from disease of the ovary, on the other hand, beside the local character of the swelling in the early stages, it is found that, owing to the fact of the fluid being contained in a tense cyst, there is no flattening of the abdomen nor anterior resonance in the supine posture; little or no variation in the line of dulness; no prominence of Douglas's cul-de-sac; no abdominal wave when the patient rolls in bed ; and no evidence (except by a coincidence) of disease of other viscera. Finally, in a doubtful case, the diagnosis may be made by examining the fluid withdrawn by tapping, which, if the dis- ease be ovarian, will probably be found to contain altered blood-cells, epi- thelial scales, masses of granular matter, oil globules, and crystals of cho- lestearine. Hughes-Bennett, and, more recently, Dr. Drysdale, of this city, have described cell-forms which they believe to be peculiar to ovarian fluids, but their views have not been universally accepted by jiathologists. Foulis and Knowsley Thornton have described certain groups of cells as being peculiar to the fluid from malignant growths of the ovary or perito- neum. According to Spiogolberg, if the ovarian fluid be of low density and of a serous character, the cyst-wall has ceased to grow actively, and simple tapping may be advantageously substituted for ovariotomy. Cystic Disease of the Broad Ligament so closely resembles that of the ovary, that a diagnosis is frequently impossible, though if the fluid removed by tapping were found to be non-albuminous, and like that of ascites, there would be strong reason for believing that the ovary was not implicated. The fluid from Fibro-cystic Tumors of the Uterus is, according to Atlee and other authorities, remarkably free from morphological elements, while it coagulates spontaneously and comjiletely. Drysdale describes a peculiar cell which he believes to be characteristic of this form of tumor. Other abnormal conditions may be occasionally mistaken for ovarian tumors, such as hydatids, uterine distention from retention of the men- strual secretion, accumulation of fat in the omentum or abdominal walls, partial contractions of the recti muscles, hydronephrosis, and cysts of the kidney or spleen. Though the diagnosis of ovarian tumors can, in most instances, be made with tolerable certainty, by careful and repeated examination, yet cases occasionally occur which completely baffle the most cautious observer, and it has repeatedly happened that the operation of ovariotomy has been undertaken in eases in which no ovarian tumor could be found, the morbid growth being perhaps connected with the uterus, kidney, spleen, or omen- tum ; or more rarely there being no tumor at all (see Phantom Tumor, p. 525). The difficulty, and in some cases impossibility, of making a correct diagnosis, has been advanced as an argumeut against the propriety of ovari- otomy ; and yet the operation should not on this account be considered unjustifiable, any more than should the ligation of arteries for aneurism, on the ground that deligation has been occasionally performed when no aneurism existed. Treatment.—Solid tumors of the ovary do not, as a rule, call for operative interference, and the same may be said of those tumors which contain both solid and fluid elements, with the exception of the fibro- cystic tumor, or cystic sarcoma, which may projierly be removed by ovari- otomy*. Hence the remarks which follow are to be understood as applying to the treatment of cysts of the ovary, which are of much commoner occur- TREATMENT OF OVARIAN TUMORS. 941 rence than the other forms of tumor. The question whether or not a tumor of the ovary be cystic, can usually though not invariably be decided by noting the presence or absence of fluctuation, upon external, and especially upon vaginal palpation. In any case of doubt, an exploratory puncture or incision may be resorted to. There may be a single cyst, or the tumor maybe multilocular; in the latter case the secondary cysts may some- times be recognized by palpation, and the contained fluid is usually darker and more viscid than that of a cyst which is unilocular ; single cysts, moreover, rarely attain a very large size; the distinction is of importance as regards the prognosis of the case, single cysts being occasionally curable by milder measures than ovariotomy, and offering a better prospect of re- covery after that operation, than multilocular growths. Another point which is usually considered of great importance as regards the prognosis of ovariotomy, is the presence or absence of adhesions; these may some- times be detected by careful palpation and auscultation, but, on the other hand, may exist without giving any evidence of their presence; it is pro- bable, however, that, as remarked by Spencer Wells, the prognosis after operation is more influenced by the age and general condition of the patient than by the size and condition of the tumor. According to this writer, the prognosis is more favorable in patients under twenty or over sixty years of age, than in those at an intermediate period of life. The existence of pelvic adhesions is more to be dreaded than that of adhesions to the omen- tum or abdominal parietes. The occurrence of suppuration in an ovarian cyst is, according to T. Keith, an indication for immediate ovariotomy, and this surgeon reports twelve cases operated on under these circumstances with ten recoveries. The surgical procedures resorted to in the treatment of ovarian cysts, are tapping, drainage, incision, partial excision, injection of iodine, galvano- puncture, and ovariotomy. 1. Tapping, the mode of performing which has already been described, is chiefly resorted to as an aid to diagnosis, or with a view to palliation rather than to radical cure. It has been maintained by Spencer Wells, whose experience in cases of ovarian disease is probably greater than that of any other living surgeon, that the prospect of recovery after ovariotomy is not lessened by the fact of the patient having been previously tapped once or oftener, and that hence there need be no hesitation in employing this simple operation, either to assist the diagnosis in a doubtful case, or as a means of affording temporary relief before resorting to graver measures. Other surgeons, however, take an opposite view, and there can be no doubt 4f Fio. 546.—Siphon-trocar. that Lee correctly represents the general feeling of gynaecologists in de- claring that an exploratory incision is safer as well as more satisfactory than tapping. If the latter operation is employed, special care must be taken to prevent the escape of the cystic contents into the peritoneal cavity (an occurrence which might be followed by peritonitis), by using Thom- son's "siphon-trocar," an aspirator, or some similar instrument. Though in the large majority* of instances tapping acts only as a palliative, it has occasionally been followed by permanent recovery; according to Spiegel- 942 DISEASES OF THE ABDOMINAL ORGANS. berg, this result is most ajit to follow when the ovarian fluid is of low density* and of a serous character. Tapping through the vagina or rectum is occasionally* preferred to the ordinary operation through the abdominal parietes. 2. Drainage is effected by enlarging the puncture made in parietal or vaginal paracentesis, and introducing a tube which is fixed so as to allow the escape of fluid, and, if necessary, the washing out of the cyst with simple or medicated injections. This mode of treatment is chiefly* adapted to cases of unilocular cyst, in which ovariotomy is contra-indicated by the extent of adhesions. A more frequent resort to this method has been ably advocated by Dr. Stimson, of New York. 3. Incision consists in laying open the tumor through the abdominal wall or vagina; this plan, which may be considered a modification of that last mentioned, is best adapted for the treatment of firmly adherent multi- locular cysts, which do not admit of ovariotomy on the one hand, nor of simple drainage on the other. Bernutz advises incision as preferable to ovariotomy in cases of suppurating dermoid cyst. 4. Partial Excision consists in cutting away a small portion of the anterior wall of the cyst, and allowing the contents to escape into the peri- toneal cavity ; this mode of treatment is more applicable to cases of cystic disease of the broad ligament than to those in which the ovary is involved. 5. Injection of Iodine for the cure of ovarian cysts, appears to have been first successfully employed by Dr. Alison, of Indiana, in 1846, but was not brought jirominently before the profession until some years after- wards, through the writings of Boinet and other European surgeons. The formula recommended by Boinet is 100 parts each of tincture of iodine and water, with 4 jiarts of iodide of potassium. The operation consists in introducing through the canula (after tapping) a flexible catheter, by means of which from four to ten ounces of the solution are injected, the liquid being withdrawn again after ten or fifteen minutes ; the catheter is retained as long as may be thought necessary, the injections, the strength of which is gradually increased, being occasionally repeated. This mode of treat- ment should, according to Peaslee, be reserved for cases of unilocular cyst, with clear, serous contents, in which simple tapping has been previously employed at least once ; by so limiting its application, Dr. Peaslee believes that the mortality of the operation would be reduced to one in ten, and the proportion of cures increased to one in three. 6. Galvano-puncture is recommended by Semeleder, who reports three recoveries by this mode of treatment. 7. Ovariotomy, or the formal extirpation of a diseased ovary, was suggested by Wm. Hunter and recommended by John Bell ; but the first surgeon who actually resorted to the operation was McDowell, of Kentucky, who performed the first ovariotomy in the year 1809. This case was suc- cessful, the patient surviving thirty-two years. McDowell repeated the operation about a dozen times, with varying success, and his example was followed by* a few surgeons at home and abroad, but for many years the feeling of the profession at large was that ovariotomy was an unjustifiable procedure, and it is within a comparatively short period only that this operation has been generally accepted as a legitimate resource of surgery. Among those who have acquired most distinction as ovariotomists may be particularly mentioned Bird, Clay, Baker Brown, Tyler Smith, Wells, Thornton, Tait, Bantock, and Keith, among British surgeons; W. L. and J. L. Atlee, Kimball, Dunlap, Peaslee, Thomas, Homans, and Goodell, in our own country ; Schroeder, Martin, Billroth, and Spiegelberg, in Ger- many ; and Koeberle, in J" ranee. OVARIOTOMY. 943 The operation is not usually very* difficult, but is always one of consider- able gravity, the mortality in the hands of surgeons generally* averaging from 27 to 29 per cent.1 This is in itself no valid objection to the opera- tion, for the death-rate is less than that of many other operations which are universally recognized as legitimate ; but it is surely sufficient to render the surgeon very* cautious in his prognosis, and to induce him to neglect no means of satisfying himself both as to the accuracy of his diagnosis, and as to the applicability of the operation to the particular case with which he has to deal. As Sir Spencer Wells justly remarks, "it is seldom that a surgeon is called upon to perform ovariotomy in order to save a patient from imminent death. . . . There is generally as much time for dis- cussion as in the parallel case of lithotomy in the male adult. And in both cases, the responsibility* of operating, with the full knowledge that if the patient be not saved by the operation he or she is killed by it, must be fairly faced." This responsibility, moreover, is one which the surgeon has no right to throw upon the patient; every* woman knows that, after an operation like ovariotomy, she may die or she may get well, and it is to the superior knowledge and wide experience of the surgeon that she looks for advice as to whether the operation is or is not desirable in her particular case. The ultimate decision in this, as in every other case, must of course rest with the patient, but the surgeon should honestly and plainly express his opinion, whether it be favorable or unfavorable ; and if, after a full and careful consideration of all the circumstances of the case, he is brought to the conclusion that the operation is, upon the whole, not advisable, he should, in my judgment, simply* decline to operate. The Operation of Ovariotomy may be performed as follows: The patient's bowels should have been emptied by the administration of a dose of castor oil a day or two previously*, and by means of an enema on the morning appointed for the operation. The temperature of the room should be at least 10° Fahr., andthe table well covered with blankets ; the patient should be thoroughly anaesthetized, and at the last moment the contents of the bladder should be evacuated by means of the catheter. The first incision is made to correspond as nearly as possible to the position of the linea alba, and may reach from about an inch or an inch and a half below the umbilicus to within two inches of the pubes, though, in many instances, a smaller wound may be sufficient. Wells's statistics, however, go to show that, provided that the incision does not extend above the umbilicus, its exact length in inches does not affect the result of the operation. The dissection is cautiously- continued until the peritoneum is reached, when, all hemorrhage having been checked, this membrane is ojiened by picking it up with forceps, making a small cut, and then intro- ducing the left forefinger, upon which as a director the wound is enlarged to the full extent of the external incision. A small quantity of serum now usually makes its escape, when the cyst wall probably presents itself im- mediately below the wound; should a fold of omentum or a loop of intes- tine intervene, these should be carefully lifted off and put to one side. The surgeon then proceeds to investigate the extent of adhesions, if there be any*, by introducing first two or three fingers, then a curved steel sound, so as to sweep around the base of the tumor, and finally, if necessary, the 1 Sir Spencer Wells has published records of 1000 cases of which 231 proved fatal. His later have furnished a much less mortality than his earlier cases, and the same has been the experience of other ovariotomists, showing that a great deal depends upon the skill of the operator. Keith, Thornton, and other surgeons have had long series of successful cases, and Tait has reported one sequence of 139 operations without a single death. 944 DISEASES OF THE ABDOMINAL ORGANS. whole hand. Dr. Peaslee directed that the hand and sound should be dipped in an "artificial serum," consisting of an ounce of table-salt, six drachms of white of egg, and two quarts of water. If the adhesions be extensive,1 or if the tumor be ascertained to be chiefly or entirely solid, it may be necessary* to carry the incision above the umbilicus—this being done by a curve to the left side, so as to avoid wounding the round ligament of the liver. Should the adhesions be found so firm and extensive as to forbid the hope of removing the tumor, the surgeon may attempt the treatment by drainage, incision, partial excision, or injection of iodine, according to the character of the cyst—whether single or multilocular—and the nature of its contents, which may be ascertained by making an exploratory puncture with a small trocar. (See pp. 940, 941.) If the adhesions be less firm and extensive, those which are accessible may* be carefully sepa- rated by the fingers, thus completing what may be called the second stage of the operation. The third stage consists in turning the patient on her side, and then lessening the size of the tumor by tapping the cyst, or the principal cysts, if there be more than one—good instruments for the purjiose being-the winged trocar and canula of Sir Spencer Wells, that of Dr. Enimett, or the ingenious hollow trocars devised by Dr. Mears and Dr. Hodge, of this city, and Dr. Fitch, of New Brunswick (Fig. 547). The fluid may becon- Fig. 547.—Fitch's trocar and canula. veyed away through a flexible tube, while the cyst-wall is held forwards with vulsellum forceps, and compression of the abdomen kept up by the hands of an assistant. The sac having been sufficiently reduced in size, is now gently drawn out through the external wound, any remaining adhesions being severed by the hand, by a small cautery iron (or the galvanic cautery), by an ecraseur, or by scissors, according to the peculiar circumstances of the case. If any hemorrhage occur, it may be controlled by torsion, by styptics, by the cautery, or by the ligature; in the latter case carbolized catgut or fine silk may be used in preference to other materials. If the adhesions be inseparable, it may be necessary to leave a portion of the cyst-wall, which J. L. Atlee advises should then be secured with the clamp, the abdominal wound being carefully closed below the instrument. The next step is to secure the pedicle of the tumor, so as to prevent hemorrhage. This may be done by means of the ligature or the clamp; by dividing the pedicle with the ecraseur or the actual cautery ; by apply- ing torsion to each individual vessel as it is cut across; or by enucleating2 the tumor in the ingenious way recommended by Miner, of Buffalo, so as to avoid hemorrhage by tearing across the vessels at their peripheral terminations. If sufficiently long, the pedicle may be fixed between the lips of the wound, but most operators of the present day prefer that it 1 Stimson advises that the cyst should be fixed in the abdominal wound, and opened, the operator's hand being then passed into the interior to explore and search for adhesions from within. 2 Miner's method of enucleation has also been applied to uterine tumors by Spiegel- berg, and by Moore, of Rochester; the former surgeon, after enucleation, closes the peritoneum over the uterus by the introduction of sutures, while the latter brings the pedicle out and fixes it in the abdominal wound in the ordinary way. OVARIOTOMY. 945 should be returned into the abdominal cavity; or it may be " pocketed" in the deeper part of the incision (as suggested by Storer, of Boston), the external wound being accurately closed above it. When the stump is to be fixed in the external wound, the use of the clamp is proliablv the best method of securing the pedicle. Several varieties of clamp have been em- ployed, those devised by Wells, Koeberle, Atlee, and Dawson being per- haps the best. When it is thought better to return the stump to the abdominal cavity, a different plan must be adopted ; here the surgeon may choose between slow division of the pedicle and the application of torsion to each separate vessel, the use of the actual cauterv, and the employ*ment of the ligature. Torsion has not been resorted to sufficiently often to allow a positive opinion as to its merits. If the ligature be employed, as is usually done, the pedicle is transfixed and tied in two parts with strong carbolized silk, the ends being cut short and drojiped into the peri- toneal cavity. Hays, of Dublin, recommends the use of a catgut ligature applied subperitoneally, so as to close the vessels without endangering the vitality of the stump. If the cautery be used (as was done by Baker Brown), the surrounding parts may be protected by the use of the clamp- shield devised by Prof. Storer. The pedicle being secured, and the tumor removed, the surgeon examines the other ovary (excising it also, if it be diseased), and then, having cleansed the peritoneum by* careful sponging, closes the wound with numerous deep and superficial sutures, and applies an antiseptic dressing, with a large pad of sublimated cotton, and a broad flannel bandage. The deep sutures should be made of carbolized silk, and should pass through the whole thick- ness of the abdominal wall, including the peritoneum, which some surgeons advise should be separately* stitched with catgut; the superficial sutures may be of silver wire, as after ordinary operations. Sims recommends that, unless the antiseptic method be used, a puncture should be made from the vagina, through the recto-uterine fold of the peritoneum (Douglas's cul-de-sac), and a drainage tube introduced; or, if enucleation have been practised, two drainage tubes—one into the cavity of the pelvis, and one between the folds of the pedicle;1 these drainage tubes may, if thought proper, be brought out at the lower part of the abdominal wound, so as to facilitate the use of disinfecting injections, if these should become necessary. 1 Dr. A. Dunlap, of Ohio, recommends that the pedicle itself should be inverted through the vagina. 60 946 DISEASES OF THE ABDOMINAL ORGANS. Sims's plan has been successfully* followed by other surgeons, including Hahn and Spiegelberg, but it is thought unadvisable by Sjiencer Wells, who reserves puncture and drainage for excejitional cases. Most modern ovariotomists attach great importance to the observance of antiseptic jire- cautions, but others, including such successful ojierators as Keith and Law- son Tait, the latter of whom has, as already mentioned, reported l:>9 consecutive operations without a single death, rely exclusively* upon care and cleanliness in their cases. The after-treatment consists in adopting means to prevent the occur- rence of peritonitis, which is the cause of death in about one-fourth of the fatal cases. The patient should be kept perfectly* quiet and tranquil, and fed upon liquid diet for ten days or a fortnight after the operation. A Sims's catheter should be retained in the bladder during the first four or five days, and the bowels locked up by the moderate use of opium for about two weeks. If there be much tympanitic distention, a simple enema may be given on the eighth or ninth day. The chief sources of danger, beside shock and nervous pros- tration, are secondary hemorrhage, peritonitis, and septic poisoning; the latter is, indeed, according to Sims, the principal camse of death after the operation. Hemorrhage must be arrested by exposing or opening the wound, and securing the bleeding vessel in the pedicle, and peritonitis is to be treated in the way described in previous chapters. Koeberle applies an ice-bag on either side of the incision, as a prophylactic against both of these comjilications. Wells and Thornton apply cold to the head by Peti- gand's coil, as a means of reducing the temperature of the body. Boze- man lays great stress upon the administration of quinia and opium, in large doses, by the rectum. Should symptoms of septic poisoning super- vene, the lower part of the incision should be opened sufficiently to allow the introduction of an elastic catheter, through which disinfectant solutions may be injected and the peritoneal cavity washed out, as recommended by Dr. Peaslee. This surgeon reports several successful cases, in one of which no less than 135 injections were made in the course of 78 days. The best disinfectants for the purpose are probably the liq. sodse ehlorinatis and carbolic acid, either being, of course, very much diluted. Quinia should, at the same time, be freely given internally. The sutures may be removed a few at a time, from the fifth to the tenth day. Vaginal Ovariotomy, or the removal of an ovarian tumor through the jiosterior wall of the vagina, an operation which has been practised by Thomas, Wing, Davis, Gilmore, and Goodell, may occasionally be preferred to the ordinary operation, but is manifestly suited only to cases in which the tumor is small, and free from adhesions. Rectal Ovariotomy.—Mr. A. W. Stocks, an English surgeon, has recorded a remarkable case, in which an ovarian cyst protruded through the rectum, and was successfully removed through an incision in the ante- rior wall of that organ. Normal Ovariotomy; Oophorotomy ; Oophorectomy ; Bat- tey's Operation__These names have been applied to an operation in- troduced by Hegar, of Freiburg, and Battey*, of Georgia, and since repeated by numerous surgeons, both at home and abroad; it consists in the re- moval of one or both ovaries, even when not obviously diseased, as a means of hastening the menopause, when that may seem desirable. The glands are removed either by abdominal section or through the posterior CESAREAN SECTION, ETC. 947 wall of the vagina, as in Thomas's operation of vaginal ovariotomy*. Tis- sier has analyzed 170 terminated cases, and finds that 135 patients were cured, 3 improved, 7 not benefited, or made worse, while 25 died. Engel- mann found a larger proportion of failures, and 121 cases, collected by Dr. Munde, furnished 28 deaths ; but, as with ovariotomy, individual ojierators have been much more successful. Battey believes that, in skilled hands, the mortality should not be more than two or three per cent. Tait's Operation ; Salpingectomy___Tait has extended Hegar's and Battey's operation by removing the diseased Fallopian tubes (in cases of suppurative salpingitis, etc.) as well as the ovaries. His results from this operation have been extremely brilliant, 413 cases in his second list of 1000 abdominal sections having given but 12 deaths. Oophorraphy—Under this name Dr. Inilach describes an operation for painful prolapsus of the ovaries, which consists in fastening the mis- placed organs by sutures to the infundibulo-pelvic ligaments near the pelvic brim. He reports 14 cases successfully treated in this manner. Double Ovariotomy was first performed by Dr. J. L. Atlee, of Lan- caster, Pa., in 1843, and has since been very frequently repeated. The operation is attended with but little greater difficulty and risk than that of removing a single ovary, but has the necessary disadvantage of rendering the patient sterile. Extirpation of both Ovaries and of the Uterus has been not unfrequently* performed, but with very unfavorable results (see Chapter XLVII.). In the light of past experience the operation cannot, in my judgment, be recommended, unless under very exceptional circumstances. Cesarean Section, etc. The Cassarean section may be performed with the hope of saving the child alone (in case of sudden death occurring to a woman far advanced in pregnancy), or with the hope of saving both mother and child, in cases of extreme deformity of the pelvis, etc. The operation consists in opening the abdominal cavity in the median line (as in ovariotomy), incising the womb, rupturing the membranes, and extracting with the least possible delay both child and jilacenta. Bleeding is then to be arrested, the peri- toneal cavity* cleansed by sponging, and the uterine wound and that of the abdominal jiarietes separately* closed with sutures. Sanger advises that a strip of muscular tissue should be cut away on either side of the uterine wound, so as to allow the peritoneum to be turned inwards, thus bringing two serous surfaces into contact, and facilitating adhesion. According to Leopold and Harris, however, this is unnecessary, the approximation of the peritoneal surfaces being readily effected, without resection, by the use of Gely's suture. Harris advises the application of tw*o rows of su- tures, one dceji and one superficial. Either silver wire or silk may be used, and the uterine cavity* should be drained by a tube carried through the vagina. When performed during the first few hours of labor, the statistics of the operation are much more satisfactory than might be anti- cipated, 195 cases of the improved or " conservative" Cesarean section (as it is called to distinguish it from Porro's procedure), having furnished during the last seven years, according to Dr. Harris, who has kindly suji- plied me with the figures, no less than 147 recoveries. Porro's modifica- tion of the Caesarean section involves the extirpation of the uterus itself. Of 265 cases operated on by this method, and collected by Harris, 121 have proved fatal, so that its results are less favorable than those of the " conservative" operation. The Caesarean section has occasionally been 948 DISEASES OF THE ABDOMINAL ORGANS. repeated on the same patient, in successive pregnancies, from two to seven times. Laparotomy for rupture of the pregnantuterus is often spoken of as a variety- of Caesarean section, but is, according to Harris, much less seri- ous than the old form of that operation. The steps of the procedure are the same, except that the incision of the womb is not required. Laparotomy mav be called for in cases of extra-uterine pregnancy. The abdominal cavity having been opened, the sac containingthe feet us is care- fully incised, and the foetus removed. The jilacenta should, as a rule, be left in situ, the peritoneal cavity being carefully closed, while the opening in the abdominal sac is stitched to the lower part of the abdominal wound. The placenta is ultimately discharged jiiece-meal, when the sac, which must be frequently washed out by syringing, gradually becomes ob- literated. Laparo-elytrotomy, or opening the vagina through the abdominal wall, above Poupart's ligament (an operation devised by Ritgen, Physick, and Baudelocque), is recommended by Thomas and Skene, as a substitute for Caesarean section. Fourteen cases, collected by Harris, resulted in seven recoveries and seven deaths. Operations on the Kidneys. Nephrotomy for Renal Calculus; Nephro-lithotomy.—Cal- culous concretions have been not unfrequently extracted from the kidney or ureter, in cases in which the existence of an abscess or urinary fistula has served as an indication for the proceeding,1 but the first formal neph- rotomy for the removal of renal calculus appears to have been performed by an Italian surgeon, named Marchetti, in the latter part of the seven- teenth century. Several concretions were extracted, and the patient re- covered with a renal fistula. The revival of this operation is owing to its advocacy by Mr. Thomas Smith, who recommends a longitudinal incision along the outer border of the erector sjiinae muscle, extending downwards four inches from the lower margin of the last rib. The incision is cau- tiously deejiened until the finger can be placed upon the hilus of the kid- ney*, when, if thought proper, this organ can belaid open. This operation does not involve the peritoneal cavity, so that there is little risk of' perito- nitis, while urinary infiltration is prevented by the depending position of the wound. The objections to the procedure are the difficulties of deciding (1) whether renal calculus exists at all, (2) which kidney is affected, and (3) whether the calculus be not so adherent as to render its extraction im- possible. The operation appears to have been performed in 105 cases, 10 times without finding any stone, and 24 times with a fatal result, while the issue in 4 cases has not been ascertained, leaving only 67 successes. The mortality of the operation is thus nearly 25 per cent., and the failures, apart from the deaths, have formed over 10 per cent, of determined cases. This operation should not, therefore, be lightly undertaken, but in cases in which the symptoms are definite and urgent, may be looked upon as a valuable procedure. It should be added that, even when no stone has been found, great relief has been sometimes afforded by the exploration. 1 As in the case of the late Mr. Startin, a well-known English surgeon, and in cases recently recorded by Petersen, Ingalls, Hatch, and M. H. Richardson. Mr. H. Morris limits the term nephro-lithotomy to cases in which an otherwise healthy kidney is opened for the removal of a stone. NEPHROTOMY FOR HYDRONEPHROSIS AND PYONEPHROSIS. 949 Cases of Nephro-lithotomy. No. Operator. Result. No. Operator. Result. 1 Agnew, Recovered. 54 Imlach, Recovered. 2 Anderson,1 i< 55 Jacobson, i< 3 Annandale, No calculus found. 56 Id. n 4 Id. 11 57 Id. Died. 5 Baker, Died. 58 Id. a 6 Barbour, No calculus found. 59 Jones, tt 7 Bardenheuer,2 Undetermined. 60 Lange, n 8 Barker, Died. 61 Id. Recovered. 9 Beck, Recovered. 62 Lauenstein, " 10 Id. *' 63 Lente, No calculus found. 11 Belfield, it 64 Lloyd, Recovered. 12 Bergmann, 11 65 Id. " 13 Browne, Died. 66 Lucas, No calculus found. 14 Butler-Smyth, . i 67 Id. Recovered. 15 Butlin, Recovered. 68 McCosh, " 16 Callender, Died. 69 Marchetti, ti 17 Chiene, Recovered. 70 May, Died. 18 Clark, ii 71 Id. Recovered. 19 Clarke, 11 72 Id. " 20 Id. «i 73 Mayo-Robson, n 21 Couper, Died. 74 Morris, n 22 Croft, Recovered. 75 Id. a 23 Cullingworth, Died. 76 Id. it 24 Czerny, Recovered. 77 Id. Died. 25 D'Antona, " 78 Mynter, ii 26 Dawson, Died. 79 Nicholson, Recovered. 27 Duncan, < 8 Fantoni, ti 9 X Faris, << 10 y( Ferguson, ti 11 Hunter, K 12 MacDonnell, <( 13 r^ Markham, a 14 Matthias, (( No. Operator. Result. 15 O'Brien, Recovered. 16 Pietrzycki, " 17 ^ Powell, it 18 \% Purmann, it 19 Roddick, Died. 20 Sch u Hz, Recovered. 21 Trendelenburg, Died. 22 Weir, " 23 Wilson, Recovered. 24 [Ballonius,J " 25 [Clarke,] " 26 [Leuhossek,] " 27 [Rousset,] u Cases of Splenectomy for Disease. No. Operator. Result. No. Operator. Result. 1 Aonzo, Died. 42 t. Leonard, Recovered. 2 Arnison, u 43 Liebman, it 3 Bergmann, Recovered. 44 McCann, . _„«« <-*-_-- 4 Billroth, u 45 McGraw, n ^~ 5 Id. Died. 46 Id. Died. 6 Id. " 47 Martin, Recovered. 7 Blanc, k 48 Mas, tt 8 Bonora, u 49 Miner, Died. 9 Brown, 11 50 Myers, Recovered. 10 Browne, it 51 Nilsen, u 11 Bryant, " 52 Park, Died. 12 Id. It 53 Pean, Recovered. 13 Casini, Recovered. 54 Id. K 14 Ceci, a 55 Podrez, Died. 15 Chiarleoni, Died. 56 Polk, Recovered. 16 Cr£de, Recovered. 57 Quittenbaum, Died. 17 Czerny, k 58 Ribera Sans, " IS Id. it 59 Rydygfier, (< 19 Id. Died. 60 Severeanu, Recovered. 20 D'Antona, Recovered. 61 Simmons, Died. 21 Dewolf, Died. 62 Span ton, a 22 Fehleisen, Recovered. 63 Strong, n 23 Id. >< 64 Terrier, a 24 Ferrerius, tt 65 Thornton, it 25 Franzolini, <( 66 Id. Recovered. 26 Fritsch, << 67 Urbinati, Died. 27 Id. Died. 68 Id. '< 2 s Fuchs, 11 69 Von Hirsch, Recovered. 29 Geissel, " [ed. 70 Watson, Died. 30 Giovanni, Undetermin- 71 Wells, k 31 Goodell, Died. 72 Id. n 32 Hatch, a 73 Id. n 33 Haward, <« 74 Id. Recovered. 34 Kocher, Recovered. 75 Id. [ed. Undetermin- 35 Koeberle, Died. 76 Wright & Thorburn 36 Id. " 77 Younkin, Recovered. 37 Kiichler, << 78 Zaccarello, it 3s Kiister, n 79 [St. L.-Burke,] Died. 39 Lane, Langenbuch, Laurason, tt a Recovered. 80 81 82 u 40 <( 41 Recovered. H 1 OPERATIONS ON THE STOMACH AND BOWELS. 953 Acupuncture of the Spleen is recommended by Feletti as a remedy for malarial hypertrophy, and Fazio praises parenchymatous injections of quinine in the same affection. Operations on the Stomach and Bowels. Resection of the Pyloric Extremity of the Stomach (Pyloric Gastrectomy) was originally suggested by* a German physician named Merrem, and afterwards by Gussenbauer and Winiwarter, as a remedy for cancer of that organ. First put in practice by Pean, the operation apjiears to have been now performed in 119 cases, only 39 of which, or less than one-third, are said to have terminated successfully. Cases of Pyloric Gastrectomy. Operator. Cases. Deaths. Operator. Cases. Deaths. Albert and Maydl o 1 Marcy 1 1 Angerer 6 5 Maurer 1 1 Baikoff 1 1 Mayland 1 1 Bardenheuer 3 3 Mikulicz 1 Bernays 1 1 Molitor 2 1 Berns 1 1 Morris 1 1 Bigi .... 1 1 Nebinger 1 ... Billroth and Salzer . 22 11 Nicolaysen 1 1 Boiling 1 1 Pean 1 1 Buchanan 1 1 Reyher 1 1 Caselli • 1 1 Richter 1 1 Cavazzini . 1 Ruggi 1 1 Czerny 5 *2 Rydygier 5 2 Esmarch . 1 Sands 1 1 Fort .... 1 "i Schede 1 1 Golding-Bird 1 l Socin 2 1 Gussenbauer 2 2 Southam 1 1 Halm 4 2 Spear 1 1 Heinecke . 1 Stokes 1 1 Jessop 1 i Snperno 1 1 Jones 1 l Tansini 1 1 Jurie 1 l Tillmans 1 Kitajewski 1 i Torelli 1 Kocher 3 2 Vankleef 1 Kohler 1 1 Veliaminoff 1 i Kolatschewsky . 1 ... Von Bergmann 1 l Kronlein 1 1 Von Iterson 1 i Kiister 1 Weinlechner 1 i Langenbeck 1 1 Winslow . 1 i Lauenstein 9 5 Wolfier . 2 l Ledderhose Lticke McArdle 1 1 1 1 1 1 Zamboni . 1 l Total . 119 80 McEwen 1 1 Resection of the Cardiac Extremity of the Stomach appears to have been performed only once, by Dr. L. C. Lane, of California, and that case terminated fatally on the second day. Resection of the Greater Curvature of the Stomach was per- formed by Fischer in a case of carcinoma, the patient recovering from the operation and surviving five months. Resection of the Entire Stomach, the patient dying on the table, has been practised by* Conner, of Cincinnati. In spite of the measure of success which is alleged to have attended some 954 DISEASES OF THE ABDOMINAL ORGANS. of these operations, I confess that they seem to me hardly- within the pale of legitimate surgery. Bernays reports two cases of gastric carcinoma benefited by opening the stomach and scraping away the growth with a curette. Dilatation of the Pylorus__The first operation of this kind apjiears to have been jierforiued by Schede, in 1877 ; he ojiened the stomach and attemjited to dilate the jivloric orifice with a bougie, but the case terminated fatally. In 1881, Richter suggested that the constricted pylorus should be attacked through an opening in the duodenum, but does not appear to have put his suggestion to the test of experience. In 1882, Loreta, of Bologna, successfully treated a case of pyloric obstruction by digital divulsion, access to the part being gained by means of a preliminary incision into the ad- joining part of the stomach. Pyloric dilatation has now been practised in at least 34 cases, 19 of which appear to have ended in recovery and 14 in death, the result in Brichetti's case being uncertain. The mortality of ter- minated cases is thus over 42 per cent. Cases of Dilatation of the Pylorus. Operator. Cases. Deaths. Operator. Cases. Deaths. Barton 2 1 Loreta 16 6 Brichetti 1 McBurney 2 2 Bull . 1 Mazzoni . 1 Catani 1 Moliere 1 1 Frattini 1 Poggi 1 Giommi 1 1 Schede 1 1 Hagyard 1 Treves 1 2 1 2 Total . Jarini 34 14 Dilatation of the Cardiac Orifice of the Stomach or of the Lowest Portion of the (Esophagus, after preliminary gastric section, is said to have been performed seven times by Loreta, and once each by Von Bergmann, Catani, Frattini, and Billroth. The result in the last- mentioned case is uncertain, but all the rest are reported as recoveries. (See Retrograde Dilatation, jiage 844.) Double Divulsion (that is, of both cardiac and jiyloric orifices of the stomach) is said to have been performed by Loreta in four cases, at least two of which were successful. Enterostomy, an ojieration designed to provide an opening for the in- troduction of food into the small intestine, in cases of obstruction of the pylorus, was introduced by Surmay, and has since been practised by Lang- enbuch, Robertson, Southam, Golding-Bird, Gould, and Jessett, with, however, a fatal result in all seven cases Gastroenterostomy is an operation designed to establish a commu- nication between the stomach and small intestine in cases of pyloric obstruction not admitting of relief by excision. If resorted to, it should be done by Senn's method of lateral anastomosis (see page 913). It apjiears to have been performed in 02 cases, of which 33 were successful, 2 (Page and Von Hacker) were temporarily so, and 24 proved fatal, the result in°3 (Fenger, Hunter, Lange) not having been ascertained. The mortality of the operation is therefore over 40 per cent. HEPATECTOMY AND HEPATOTOMY. 955 Cases of Gastroenterostomy. Operator. Cases. Deaths. Operator. Cases. Deaths. Angerer 6 5 Morse 1 1 Barker 1 Page 1 Billroth . 9 5 Postempski 1 Conner 1 1 Ransohoff 1 1 Courvoisier 1 1 Reeves 1 1 Fenger 1 Rydygier 2 1 Fritsche 2 Schramm 1 Hahn 2 1 Senn 4 Hunter 1 Socin 1 Jessett 1 1 Tansini 1 Kocher 1 1 Von Hacker 1 Lange 1 Wolfler . 2 1 Lauenstein 9 8 2 1 Total . Liicke 62 24 Monastyrski 1 1 Ileo-colostomy, the establishment of an opening between the small and large intestine, has been employed by Lange (twice), Billroth, and Von Hacker; the last-named surgeon's case was the only one which ended favorably*. Colo-colostomy, the effecting a communication between two parts of the large intestine, has been successfully resorted to by Abbe and Meyer. Gastrostomy has already been referred to on page 843. Pancreatectomy and Pancreatotomy. Pancreatectomy, or excision of a portion of the pancreas, in cases of abdominal wound with protrusion of that organ, appears to have been successfully performed in six cases by Caldwell, Laborderie, Kleberg, Thompson, Justin, and B. Allen. Partial excision of the pancreas is also said to have been twice successfully performed by Billroth for carcinoma. Complete excision is, according to Senn, a necessarily fatal operation, death resulting either from the traumatism or from gangrene of the duode- num. Pancreatotomy, with drainage or excision of a cyst or abscess of the pancreas, has been resorted to in at least 15 cases, with 5 deaths and 10 recoveries. The successful operators have been Bozeman, Kulenkampff, Thiersch, Gussenbauer, Senn, Kiister, Kocher, Bull, Annandale, and Tre- maine; and the unsuccessful have been the younger Rokitansky, Rosen- bach, Salzer, Hagenbach, and Liicke. Hepatectomy and Hepatotomy; Hepatic Phlebotomy. Excision of a portion of the liver (partial hepatectomy) has occasionally been resorted to in cases of penetrating wound of the abdomen, and has been successfully employed by Langenbuch (in a case of painful constric- tion of the organ, caused by tight clothing), by Loreta, and bv Ruggi. Lawson Tait, Eddowes, Savage, Rokitansky, Siislin, Briddon, Thornton, Davies-Colley, and Ransohoff have successfully employed simple hepa- totomy in cases of hepatic abscess, hydatid or simjile cyst, etc., as has Thornton in a case of hepatic calculus. Zancarol opens hepatic abscesses with the tbermo-cautery, resecting a rib if necessary to get free access to the part, cleans out the cavity* with sponge and syringe, and introduces drainage tubes. Pozzi has successfully extirpated a hydatid cyst of the 956 DISEASES OF THE ABDOMINAL ORGANS. liver, and closed the wound in that viscus with sutures. Under the name of hepatic phlebotomy, Dr. Harley recommends direct withdrawal of blood from the liver by means of an asjiirating trocar and canula, an ojieration which appears to have been for many years resorted to with advantage in cases of acute hepatitis by Indian army surgeons; the same jihysician recommends, in cases of chronic congestion, puncture of the hejiatic cap- sule, an ojieration which is also familiar to Indian surgeons, and which is said to have originated with the Chinese. Operations on the Gall-Bladder. Cholecystotomy, or opening the gall-bladder for the removal of biliary calculi, is an old operation which was clearly described by Sharp, of Guy's Hospital, in the middle of the last century; has been occasionally practised since, by Bobbs and other surgeons; and has been revived, within a few years, chiefly* by the efforts of the late Dr. J. Marion Sims and of Mr. Lawson Tait, who has himself operated successfully in 52 out of 54 cases. In order to determine the presence of a gall-stone, Dr. Harley recommends an exploratory puncture with a slender trocar; but the only case in which he apjiears to have tried this procedure, proved fatal from peritonitis on the 27th day. Mr. Bryant and other surgeons have successfully removed biliary calculi by enlarging fistulse which communicated with the offending substances, but these operations cannot properly be called cholecystotomies, Cases of Cholecystotomy. ■o Operator. > o Abbe . . . . 1 Ball . . 1 Barton Bern ays . Bobbs . . 1 1 Bceckel Buchanan i Carmalt . l Courvoisier l Eddowes . l Edwards . Franks i Gardner . l Hagenbach Hirschberg l Hutchison l Jansen l Jessop Keen . . l Kocher i Konig . . Kiister i Landerer . l Lange . . Langenbuch McGill . 1 24 20 1 Mack ay . Meredith . Morison i S u © •a S a & Operator. * •9 > O as Q 13 9 B Naire .... 1 1 1 Ohage Packard . . . 1 1 i 1 Page .... Parkes 1 3 1 1 "2 3 Ransohoff 1 1 Robson . . 9 *8 1 Rosen bach . 2 2 ... Savage 2 2 Sendler . 1 1 i Sims .... Stewart . . . 1 1 1 1 Tait . . . . 54 52 "2 l ... Taylor Thorndike . . Thornton . . 2 1 6 2 6 i i Tiffany . . . Torrance 1 1 1 1 *2 Trendelenburg Vincent . 1 1 1 1 1 Von Hoffman . 1 1 ... Wetzel . . . Willett . . . 1 1 1 "i i White . . . 1 "i 4 Wright . . . 1 1 1 1 "i Crede " .' '. '. 3 3 ... l Total . . 156 125 24 7 TREATMENT OF ABDOMINAL ABSCESSES. 957 nor can that recorded by* Mr. G. Brown, in which the communication with the gall-bladder was not established at the time of the operation, but formed spontaneously afterwards. Of 156 true cholecystotomies, at least 125 have terminated successfully, and only* 24 are known to have proved fatal. Tif- fany records a case in which 15 calculi were removed from the gall-bladder by an incision through the liver which had been previously stitched to the abdominal wall. Most operators have fastened the edges of the incision into the gall-bladder, to the abdominal wound, but Bernays, following Spencer Wells, advises that the deep incision should be closed separately, and the organ returned into the abdominal cavity. This procedure he calls ideal cholecystotomy. Cholecystectomy, or excision of the gall-bladder, was first recom- mended by Langenbuch, and has been performed in 28 cases which are said to have given 24 recoveries and only 4 deaths. Cases of Cholecystectomy. Operator. 1 Cases. Recov-ered. Died. Operator. Cases. Recov-ered. Died. Abbe ..... 1 2 1 1 1 12 1 1 2 "i 1 10 1 i *2 Thiem .... Thiriar .... Thornton . . . Vincent .... Crede .... Total . . . 1 4 1 1 2 1 4 1 2 Courvoisier . Kohl . . . 1 Kronlein . Langenbuch Oh age 28 24 4 Cholecysto-enterostomy.—Winiwarter and Gaston, in cases of obstruction of the biliary duct, advise that a fistulous opening should be established between the gall-bladder and some portion of the bowel. In Winiwarter's case (which was successful) the ascending colon was thus utilized, but he recommends that the duodenum should be employed in future. Other operations are recorded by Kappeler and Socin. The lat- ter's patient rapidly recovered, gaining nine pounds in weight in the course of six weeks. Cholelithotrity, or crushing biliary calculi through the walls of the exposed gall-bladder or duct, instead of removing them by an incision, has been successfully practised by Tait in two instances, and may be a valu- able resource in certain cases. Treatment of Abdominal Abscesses. The surgeon is occasionally called upon to evacuate collections of pus which have been formed in connection with the liver, gall-bladder, spleen, kidney, intestinal canal, or ovary, or in the deep layers of areolar tissue found in the neighborhood of the broad ligament. Hepatic Abscess is not unfrequently met with in tropical regions. The pus may occasionally find a vent into a neighboring portion of intes- tine, or may perforate the diaphragm and enter the lung, or finally may point externally. In the latter case surgical interference may be required, the treatment consisting in puncturing the abscess with an aspirator or a small trocar and canula, the latter being provided with a stopcock, as in the operation for paracentesis thoracis. Sistach, however, employs a large trocar, and washes out the cavity of the abscess with injections of dilute tincture of iodine, while Kiister has successfully employed an incision with 958 DISEASES OF THE ABDOMINAL ORGANS. antisejitie jirecautions. The puncture should not be made until the signs of external pointing show that adhesions have been formed between the visceral and parietal layers of peritoneum, but, if the other symptoms be urgent, an attempt may be made to hasten this occurrence, by the use of blisters or caustics, by making a superficial incision over the jiart, or by the introduction of acupuncture needles. The same means may be resorted to in dealing with other abdominal abscesses. Dr. Isham, of Ohio, has reported a remarkable case in which an hejiatic abscess, bursting through the diaphragm, was successfully evacuated by an incision through the walls of the chest. In a similar case Kiister resected the ribs, but the jiatient died from gangrene of the lung. Lawson Tait and Tiffany have success- fully* evacuated hepatic abscesses by abdominal section, and Ransohoff has been equally fortunate by employing the thermo-cautery. Biliary Abscess.—The surgical treatment of abscess originating in the gall-bladder, is to be conducted on the same principles as that of hepatic abscess. Splenic Abscess is of rare occurrence. The treatment consists in evacuating the pus by means of a trocar and canula, as soon as adhesion has occurred between the adjacent layers of peritoneum. Free incision and drainage have been successfully emjiloyed by Harrison, Chowdhoory (an Indian surgeon), and Lauenstein—by the latter through an opening in the thoracic wall, and resection of a portion of the ninth rib. Perinephric Abscess.—Collections of pus, originating in the areo- lar and adipose tissue around the kidney, may find a vent by bursting into the kidney* itself, or into the bladder (the pus then escaping in the urine), by perforating the diaphragm and entering the thoracic cavity, or by open- ing into the vagina or bowel, or on the external surface, usually in the hypochondriac or lumbar region. This affection has been particularly studied by Trousseau, and more recently by* Gibney, J. B. Roberts, and Bowditch, of Boston, the last-named author having particularly insisted upon the importance of early surgical interference. The treatment consists in making a puncture or incision to evacuate the contents of the abscess, as soon as the existence of pus has been ascertained with reasonable cer- tainty ; the opening should as a rule be made in the lumbar region, because the kidney can be reached from behind without wounding the peritoneum ; if, however, absolute pointing of the abscess should have occurred ante- riorly, indicating the formation of adhesions between the adjacent layers of peritoneum, the opening should rather be made at the point at which fluctuation is most distinct. With regard to the comparative advantages of incision, and of puncture with a trocar and a canula, I much prefer the former ; the objection usually urged is that the use of the bistoury is more apt to be followed by hemorrhage, but then, if hemorrhage should occur, a free opening would afford greater facility for its control. The safest plan is, I think, to make a sujierficial incision, and then thrust in a grooved director in the way recommended by Hilton for the opening of deep-seated abscesses in other situations (see jiage 424). Even if the flow of pus do not immediately follow the operation, Dr. Bowditch's experience has shown that the symptoms are quickly relieved, the swelling gradually melting away, as it were, under the influence of the suppuration which sub- sequently occurs. Pyonephrosis has already been referred to in connection with the operation of nephrotomy. Fecal or Stercoraceous Abscess may originate in connection with any part of the intestinal canal, but its most common seat is the neighbor- hood of the caecum or appendix vermiformis, where it constitutes Peritg- phlitic Abscess. Fecal abscess may result from injury, or from perforation HYDATIDS, SEROUS CYSTS, ETC. 959 of the bowel occurring in the course of typhoid fever, but its most common cause is the irritation produced by* a foreign body. The treatment consists in making a free incision as soon as the jiresence of a tumor and the other symptoms, general and local, render it probable that suppuration has oc- curred. If the patient recover, it will probably be with a fecal fistula, which must be treated as directed at page 398. Hancock, W. Parker, Buck, Sands, and others, recommend that the abscess should be opened by an early incision, made behind the peritoneum, as in the operation for tying the external iliac artery. Dr. Gouley, of New York, has collected 25 cases operated on in this manner, 23 having terminated in recovery, and only 2 in death. Eddowes has successfully operated through the peri- toneum, and Weir believes that perityphlitic abscess always originates in the peritoneal cavity, and only secondarily involves the extra-peritoneal tissues. Burchard advises that, in case of perforation, the peritoneal cavity should be opened (with antiseptic precautions) and thoroughly cleansed, and the ulcerated appendix secured by stitches to the external wound. Weir and Morton remove the appendix itself by ligature and excision. Synionds has successfully* removed a concretion from the apjiendix. Ilio-Pelvic Abscess originates usually in connection with the ovary, broad ligament, or retro-peritoneal areolar tissue, the affection being, in most instances, met with as a complication of the jiuerperal state. The pus may* find its way into the rectum, uterus or vagina, bladder, or peritoneal cavity, or, if peritoneal adhesions have been formed, may point externally. When it is thought proper to open the abscess, this may be done by cau- tious incision, or by puncture with a trocar and canula, through the pos- terior wall of the vagina, the rectum, or the abdominal wall. If the latter situation be chosen, the operation should be delayed until after the estab- lishment of adhesions between the adjacent lay*ers of peritoneum. Lawson Tait, however, prefers abdominal section, with the subsequent use of a drainage tube, and reports six cases thus treated successfully. Fenillon has succeeded in two out of three cases by abdominal section, followed by suturing the abscess wall to the edges of the parietal wound. Suppuration occurring in an Ovarian Cyst (often though in- correctly* called Chronic Ovarian Abscess) has been successfully treated by Bryant, by making an incision in the median line of the abdomen, laying ojien the cyst, stitching its walls to the edges of the external wound, and subsequently washing out the cavity* daily by means of a syringe. Suppurative Peritonitis should be treated by abdominal section, followed by irrigation with hot water, or very weak antiseptic solutions, and free drainage. Greig Smith, Wylie, C. B. Penrose, and Weir, recom- mend repeated or continuous irrigation and fluid-distention of the perito- neal cavity. (See page 402.) Hydatids, Serous Cysts, etc. The surgeon is occasionally* called upon to open hydatids, which occur in the liver, and more rarely in other organs. The opening may be made either with caustic or with the trocar and canula, with the same precautions against the escape of fluid into the peritoneal cavity as in the case of hepatic abscess. Girdlestone employs an ojieration & deux temps, first fixing the cyst to the abdominal wall, and opening it subsequently. Dr. Soutbey, of St. Bartholomew's Hospital, London, has recorded a case of intra- thoracic hydatid, in which the cyst, after being tapped, was extracted through a free incision between the ribs ; the patient recovered. Israel and Genzmer have successfully removed hydatids of the liver by excising a 960 URINARY CALCULUS. portion of rib, and then cutting through the diaphragm. Fitzgerald, of Melbourne, Thornton, and Lawson Tait have, in similar cases, operated successfully by abdominal section. The use of the trocar is also sometimes resorted to in cases of serous cyst of the liver, kidney, spleen, or urachus, or in those of distention of the gall-bladder from accumulation of the biliary secretion. Pelyohin, a Russian surgeon, successfully treated a large omental cyst by laparotomy and incision. The same precautions should be adopted here as in the case of hydatids. CHAPTER XLTV. URINARY CALCULUS. In the urine are found deposits of various solid substances, which when in the form of an impalpable powder are called sediments, when granular or crystalline are spoken of as gravel, and when concreted into masses constitute calculi or stones. The constitutional conditions which precede or accompany the formation of the deposits are often called diatheses, and surgeons thus speak of the uric acid, the oxalic, and the phosphatic, diathesis. Varieties op Calculus. The most common and therefore the most important varieties of calcu- lus are those composed respectively of uric acid, oxalate of lime, and phos- phatic salts. Besides these, other varieties are occasionally met with, in which the concretion is composed of urates, cystine, xanthine, fatty matter, carbonate of lime, etc. Uric-Acid Calculus—This is very common, constituting, according to Roberts, five-sixths of all renal calculi, and of vesical calculi which have Fig. 550.—Uric-acid deposits. (Holmes.) Fig. 551.—Uric-acid calculus. (Gross.) recently descended from the kidney. When uric (or lithic) acid is de- posited as gravel, it occurs in the form of little crystalline masses or flattened concretions of a yellowish or reddish-brown color. The uric-acid calculus is ordinarily of moderate size, of a flattened oval form, and of a fawn color ; 0XALATE-0F-LIME CALCULUS. 961 on section, it is often found to be composed of concentric laminse. Its weight rarely exceeds an ounce. The surface of the stone is usually smooth and somewhat mammillated, but occasionally rough and manifestly crystalline. The best test for uric acid is the development of a bright violet or purple hue (murexid), on apjilying the vapor of ammonia to the residue left by treating the suspected substance with nitric acid and heat. The urine of patients with uric-acid calculus is acid, and frequently high- colored; it often deposits uric-acid crystals and amorphous urates. This form of stone is met with among free livers, especially those of a gouty habit, and among strumous, over-fed children. Urates—The urates of potassium, sodium, and ammonium are not infrequently dejiosited in the form of an amorphous sediment in urine after it has been voided, constituting the common lateritious deposit which is met with in febrile affections, or which may occur from mere con- centration of the urinary secretion ; but calculi composed of urates are very rare. They are almost exclusively observed in young children, and as renal concretions; though it is probable that urates occasionally form the nucleus of a vesical stone. The exact chemical composition of these calculi is a matter of some doubt, most authorities regarding them as con- cretions of urate of ammonium, though Roberts, of Manchester, appears to regard them as consisting of urate of sodium. Urate calculi are soft, and never large ; they may be recognized by their solubility in hot water. Urate of ammonium is often deposited in connection with phosphates from ammoniacal urine, and thus met with in the outer layers of vesical calculi. Oxalate-of-Lime Calculus (Mulberry Calculus).—When evacuated in the form of gravel, oxalate of lime occurs as minute seed-like concretions, of a smooth and rounded form, and of a grayish-brown color. The oxalate- of-lime calculus is hard, of a somewhat spherical shape, dark-brown or Fig. 552.—Oxalate-of-lime deposits. (Holmes.) Fig. 553.—Mulberry calculus. (Miller.) black (more rarely bluish-gray) in color, and tuberculated on the surface, somewhat resembling a mulberry. It rarely attains a large size. Oxalate of lime and uric acid are often deposited in alternate layers, the calculus consisting of more or less perfect concentric lamina?; the" nucleus of such a calculus is usually composed of uric acid. Oxalate of lime is soluble in nitric and hydrochloric acids, and when treated with the blowpijie leaves a residue of lime, which blues reddened litmus, and browns turmeric. The deposit of oxalate of lime appears to be due to an imperfect metamorphosis of the azotized constituents of the blood, originating sometimes in errors of diet, or in exposure to bad hygienic conditions of various kinds. The 61 962 URINARY CALCULUS. oxalate-of-lime calculus is, as shown by Carter, much commoner in India than in cooler countries. Phosphatic Calculus___Of this there are three varieties:— 1. Amorphous Phosphate of Lime (Bone Earth) is rarely met with as the sole constituent of a calculus. Stones of this variety are of a whitish, chalky, or jiale-brown color, are smooth and friable, and sometimes attain a considerable size. The phosphate-of-lime calculus may be recognized by its solubility in nitric and hydrochloric acids, and by its being totally 1 .* 1«* Fig. 554.—Phosphate of lime. (Holmes.) Fig. 555.—Triple phosphate. (Holmes.) infusible before the blowpipe. Phosphate of lime is also met with in the urine in a crystalline form (stellar phosphate), but does not under these circumstances occur as a calculus. The presence of amorphous phosphate of lime in the urine depends solely on the alkaline condition of that secretion. 2. Phosphate of Ammonium and Magnesium (Triple Phosphate).— This is more common than the phosphate of lime; the stones are of a whitish-gray color, and evidently composed of crystals. The triple phos- phate is soluble in acetic or in hydrochloric acid, and is precipitated by an excess of ammonia, in a crystalline form. It is with difficulty fusible before the blowpipe. 3. Mixed or Fusible Calculus.—This variety is formed of a mixture of the phosphate of lime and triple phosphate; it often occurs as a white mass, easily broken up, and resembling mortar; it is characterized by the great facility* with which it may be fused before the blowpipe. The mixed phosphates rarely constitute the whole of a calculus, but, on the other hand, very frequently form some of the outer layers, deposited upon uric acid or other nuclei, or upon foreign bodies. The triple phosphate and mixed phosphates are met with in alkaline and especially in ammo- niacal urine. Cystine Calculus.—This is a rare form of calculus. It is of a yellow color and has usually an oval shape, and a mammillated and slightly lustrous surface. On section it presents a radiated appear- ance, and is at first of a yellow, wax-like color, turn- ing to a pale green by long exposure to the light. Cystine is soluble in the mineral acids, and in ammonia ; when precipitated from a solution in the latter (by evaporation of the solvent), it appears in the form of characteristic six-sided crystals. Xanthine or Xanthic Oxide is a very un- Fig. 556.—Section of a cys- ,,,., i ,„ *•.. , «. , , J. ne calculus, with a nucleus Ub™\ constituent of calculous eoncretions ; it is of uric acid, and an external soluble in ammonia, but does not crystallize when coat of phosphates. (Roberts.) precipitated. RENAL CALCULUS. 963 Fatty or Saponaceous Matters (Urostealith) have been occasion- ally found in calculi; the origin and precise nature of the substances in question are not positively* known. Carbonate of Lime Calculi are very rarely met with. They are always small; are white, yellow, or ash-colored; and are smooth, hard, and sometimes lustrous. Fibrinous Calculi and Blood Calculi have been described by various writers, but can scarcely* be considered as urinary deposits. They are called by Poland pseudo-calculi. Silica is occasionally met with as a constituent of calculi, but the masses which have been supposed to be entirely* formed of this substance, have been, according to Poland, pebbles or small stones introduced from without. The same may probably be said of calculi reported to be com- posed of iron. Indigo has been found as a constituent of renal calculus by Dr. W. M. Ord. For further information with regard to the various forms of urinary deposit and urinary* calculus (of which the foregoing very brief sketch is all that the limits of this volume will allow), I would refer the student to special works on the diseases of the urinary organs, and particularly to the writings of Bird, Jones, Beale, and Roberts. Renal Calculus. Renal calculi are, in the large majority* of instances, composed of uric acid. The symptoms produced by a renal calculus consist of pain of an aching character in the lumbar region, with occasional aggravations (ne- phritic colic) in which the jiain shoots downwards towards the scrotum and inner part of the thigh, and is attended by* nausea or vomiting, and by* dysuria and increased frequency* of micturition. The urine at such times may contain blood, pus, or epithelial scales. When a calculus escapes from the kidney* into the ureter, giving rise to a fit of the stone, the symptoms are greatly aggravated. The patient is suddenly seized with intense pain, radiating down the inside of the thigh and into the spermatic cord and testicle, the latter organ being retracted. There is constant vomiting, with a feeling of great prostration, constipation, partial suppression of urine, and, if the attack continue, decided febrile disturbance. The sy*mptoms quickly subside when the calculus reaches the bladder, but if, as sometimes happens, the concretion become impacted in the ureter, dilatation of that tube will ensue, with consequent disease of the corresponding kidney. Should impaction occur on both sides, a fatal result will be inevitable. In order to facilitate the diagnosis of renal calculus catheterization of the ureters has been practised, in the male by Tuchman and Griinfeld (the latter bv the aid of the endoscope), and in the female, after a preliminary vaginal cystotomy, by Simon. Treatment of Renal Calculus__During the descent of a calculus, which may occupy* several days, the patient should be kept fully under the influence of opium—warm baths, with hot fomentations or poultices to the loins and abdomen, being also of service. In some cases, cupping over the region of the kidney may be required. The bowels should be acted on by means of enemata, and diluents may be freely* administered (if the stomach do not reject them) to encourage the flow of urine. During the intervals between the paroxysms of nephritic colic, an attempt should, in suitable cases, be made to effect the solution of the concretion by the administration of the citrate or acetate of potassium, which are easily 964 URINARY CALCULUS. taken, and which enter the urine in the form of carbonate. The cases which, according to Roberts, who has sjiecially studied this subject, admit of sol- vent treatment, are those in which the urine has an acid reaction, and in which the concretion is probably composed of uric acid. In such eases, from two to three scruples of either of the salts named may be given in three or four fluidounces of water, regularly every three hours. Ralfe advises the use of benzoate of lithium and turjientine. The ojieration of nephrotomy for the relief of renal calculus has already been referred to (p. 948). Emmet has successfully* removed a calculus from the ureter, an ojieration for which H. Morris has devised a special knife and scoop. The alkaline or solvent treatment is adapted to cases of renal calculus when the stone is already* formed. In the preventive treatment of calculus, how- ever, more may be accomplished, as pointed out by Sir Henry Thompson, by the use of saline laxatives, and particularly* of certain natural mineral waters, such as those of Friedrichshalle and Carlsbad. Yksical Calculus. A vesical calculus may, as has been seen, originate from a concretion which has descended from the kidney ; but in other cases stone is primarily formed in the bladder, by the aggregation of small granular particles, around which, as a nucleus, fresh deposits subsequently take place, or by the deposit of calculous matter around some extraneous substance, such as a bullet, jiin, straw, or broken catheter, introduced from without. Structure and Physical Characters of Vesical Calculi__ Structure.<—Calculi may* be composed throughout of the same substance, but in many instances consist of several layers or laminas of different chem- ical characters, dejiosited around a central portion or nucleus. These stones are called alternating calculi. The nucleus is usually composed of uric acid, oxalate-of-lime nuclei coming next in frequency. When the nucleus is phosphatic, the stone is not alternating, the layers subsequently dejiosited being phosphatic likewise. Whatever be the primary nature of the calculus, it may become encrusted with phosphates in consequence of ananinioniacal state of the urine, due to vesical irri- tation. Calculous matter may be deposited around a mass composed of several small concretions aggre- gated together, the stone then apjiearing on section to contain several nuclei. In addition to the var- ious constituents of vesical calculi which have al- ready been considered, Carter has shown that an animal basis is invariably present; this is never found alone, and is probably not always identical in character. It is best developed in the urate calculi, and is found to present a finely granular, striated^ or fibrillated appearance. Number.—Usually the bladder contains but a single calculus, but occasionally two or more are found in the same case, and in a few instances very large numbers of stones coexist; the most remarkable case on record is perhaps, that of Chief Justice Marshall, from w*hose bladder Dr. Physick is said, on the authority* of Dr. Randolph, to have removed by lithotomy more than one thousand calculi. The largest number of stonesthat I have myself removed from one patient is fifty-three. Sometimes several calculi become glued together by sabulous matter and inspissated mucus, forming one large stone somewhat resembling a grape-shot in miniature. Fig. 557.—Section of an al- ternating calculus. (Erich- sen.) CAUSES OF CALCULUS. 965 Shape.—The most common shape of a vesical calculus is a flattened ovoid, though mulberry calculi are often somewhat rectangular, or irregu- larly* rounded, while phosphatic stones are occasionally curiously branched or constricted. When several calculi are present, the opposing surfaces become worn by attrition, various facets being thus developed on the sides which are in contact. Size.—The size of calculi varies from that of a pin's head to that of a mass several inches in diameter. One of the largest stones known was extracted by a Belgian surgeon named Uvtterhoeven, by the supra-pubic method, the concretion in this instance being six and a half inches long and four wide, and weighing over two jiounds. Such large stones are, however, seldom seen at the present day, and one or two inches may be considered an average length of the calculi ordinarily met with in practice. Weight.—The weight of vesical calculi varies as much as their size. The lightest stones mentioned in Crosse's tables weighed three and four grains respectively*, and the heaviest, seven and eight ounces ; but even this weight has been greatly exceeded by that of stones seen by Mayo, Harmer, Cooper, Mott, Cline, Morand, MacGregor, Hodgen, and other surgeons. The average weight is from one or two drachms to an ounce. Of 104 calculi referred to in Crosse's tables, there were 340 in which the weight was under, and 3- de- layed) equally so in the case of adults. Treatment of Vesical Calculus—There are several modes of treatment employed in cases of vesical calculus, and each may be jiroperly resorted to in suitable cases. That surgeon will do more to promote both LITHOLYSIS AND LITHOTRITY. 971 the welfare of his patients and his own reputation, who, in the treatment of stone, varies his remedies in accordance with the particular circum- stances of each individual case, than he who uniformly follows one exclu- sive mode of practice. Litholysis. Litholysis, or the Solvent Treatment of Stone, is unfortunately applicable to but a very limited number of cases. In the management of renal cal- culus, as already mentioned, a trial of the plan is often proper, for there is nothing else to be done; but, in dealing with stone in the bladder, the sur- geon has no right to waste time and deprive his patients of the great ad- vantages to be derived from an early operation, by resorting to a mode of treatment which is at best slow and uncertain. There are cases, however, in which the solvent treatment may be proper. Thus, as an adjuvant to lithotrity, in the case of a uric-acid (or cystine) calculus, advantage may be sometimes gained from the administration of the citrate or acetate of potassium in the way already mentioned, so as to keep the urine mode- rately alkaline, provided thai there be no tendency to ammoniacal decom- position. If the urine be ammoniacal, the alkaline treatment is positively contra-indicated. In dealing with phosphatic calculi, injections of dilute nitric acid (Ac. nitric, dilut. (U. S. P.) f*3U, Aquae Oj) may be employed, as an adjuvant to lithotrity* (as has been done by Southam, Harrison, and Richardson), or alone, when the general condition of the patient forbids operative interference, as in the well-known case recorded by Sir Benja- min C. Brodie. A similar mode of treatment under the name of litho- clysmy, has been recently advocated by Dr. Pignoni. Injections of acetate of lead (gr. j to f|iij) and of hydrochloric acid ( ny-ij to f|j) are favorably spoken of by Sir Henry Thompson. Oxalate-of-lime calculi do not appear to be amenable to any form of solvent treatment. Lithotrity. Lithotrity, or the operation of Crushing a Stone in the Bladder, is, particularly with the modifications introduced by* Prof. Bigelow, now gen- erally, and in my opinion justly, considered the best mode of treatment for any case of vesical calculus to which it is apjilicable. The first formal pro- position to treat calculus in this manner is usually attributed to Gruit- huisen, a Bavarian surgeon, who wrote in the y*ear 1813; but a claim of priority has been advanced, and upon apparently good grounds, for two Italian surgeons named Santorio and Ciucci, who flourished in the seven- teenth century. However this may be, it is to Civiale that is unquestion- ably due the credit of giving the operation a place among the recognized Fig. 563.—Weiss and Thompson's improved lithotrite. procedures of practical surgery, his first operation upon the living subject having been done in the year 1824. Since then lithotrity has been very frequently practised both in Europe and in our own country, and the in- struments employed have been brought to a high degree of perfection. Two instruments are usually required: one with the female blade fenes- trated, for crushing stones or large fragments, and one with both blades 972 URINARY CALCULUS. plain, for reducing the smaller fragments to powder ; the jilain-bladed lithotrite is often though incorrectly- called the scoop, and is now used by Thompson almost to the entire exclusion of the fenestrated instrument. The blades of the lithotrite are rather wider than the shafts1 (which should be as light and slender as may be compatible with sufficient strength), and Fin. 564.—Fergusson's lithotrite ; the male blade moved by a key. the male blade should be narrower than the female. The shaft and blades, which are united at an angle of 110°-120°, should be cut out of solid pieces of steel, as they will thus fit more accurately and be much stronger than when bent into shajie from flat plates of metal The handles of Weiss and Thoni|ison's improved lithotrite (Fig. 563), which is one of the best now before the profession, is in the form of a grooved cylinder, the force being applied by means of a screw, and the handle being furnished with a button, which by an ingenious mechanism enables the screwing to be in- stantly converted into a sliding motion, and vice versa. In Fergusson's instrument the force is apjilied by means of a rack and pinion. Amussat emjiloys a lithotrite (or lithoclast) in which a certain amount of lateral motion can be given to the male blade, thus rendering it more easy to free the instrument from calculous detritus. Prof. Bigelow employs a very powerful lithotrite with a tube or groove between the blades, for the in- jection of water without removing the instrument. Preparatory Treatment.—For a few days, at least, before submit- ting a patient to lithotrity, the surgeon should enjoin rest in a recumbent position, and should adopt suitable means to bring the digestive system into a good condition, and to combat any vesical irritation that may exist, by the use of hiji baths, anodynes, demulcents, etc. Sir H. Thompson speaks very highly* of a decoction of the triticum repens, or couch-grass, of which he directs a pint to be taken in divided doses in the course of the day. The use of an exclusive milk-diet is recommended by Dr. George Johnson and by Dr. S. Weir Mitchell, of this city. The urethra mav also be accustomed to the use of instruments by* the introduction first of elastic, and subsequently of metallic, bougies of gradually increasing sizes, and finally, of an ordinary sound with which the stone may be touched and some notion gained of its size and composition. If the introduction of in- struments produces great constitutional disturbance, the operation should be postjioned for a short time, until the irritable condition of the urethra has been overcome ; and if this cannot be done, the surgeon may be in- duced by this circumstance alone to abandon crushing and resort to litho- tomy. The urine should be examined, and if it contain much mucus or pus, the bladder may be washed out (through a flexible catheter) with simjile injections of tepid water, which may be replaced by a very weak solution of nitric acid, if there be a copious deposit of phosphates. The conditions wished for and sought to be obtained by prejiaratory treatment are, according to Thompson, (1) a fairly capacious and not very tender 1 The shaft attached to the male blade is technically called the sliding rod. LITHOTRITY. 973 urethra; (2) a bladder capable of retaining three or four ounces of urine, not very irritable, and yet with sufficient tone to be able to expel its con- tents ; and (3) fair general health. AVith these conditions and a stone of but moderate size and hardness, the operation of lithotrity offers an exceed- ingly favorable prognosis. Operation—Some difference of opinion exists as to the propriety of employing anaesthetics in lithotrity. If performed with skill and delicacy, the operation is attended w*ith little or no pain, and anaesthesia is therefore not required unless in exceptional cases. There is, moreover, a certain advantage in operating without ether, in that the surgeon can thus judge of the irritability of the bladder, and extend or abridge the duration of the "sitting" accordingly*. The above remarks apply to what must now be called the old method of crushing. If Prof. Bigelow's improvements are to be adopted, the patient must be thoroughly etherized, and kept under the effect of the anaesthetic until all calculous fragments have been removed. The operation itself may be described as occupying three stages, viz., (1) the introduction of the lithotrite, (2) the seizing, and (3) the crushing of the stone. The patient should lie on his back on a firm mattress, across the bed, or with his right side close to its edge, and the hips slightly* ele- vated ; the thighs should be slightly flexed and supported by pillows, and should be sufficiently* separated to allow the free play of the lithotrite be- tween them, the knees being for this purpose kept at least twelve inches apart. If the prostate be much enlarged, a firm cushion should be placed beneath the pelvis, so as to raise this part from four to six inches above the level of the shoulders ; the stone thus rolls backwards from its posi- tion behind the jirostate, and conies more readily within the grasp of the instrument. If the patient has passed his urine within half an hour of the time fixed for operating, three or four ounces of tepid water may be slowly injected through a flexible catheter; but this is not usually necessary, and the preliminary catheterization is itself undesirable, as prolonging the sitting. Introduction of the Lithotrite.—The surgeon, standing or sitting between the patient's thighs, or on his right side, holds the lithotrite, previously* warmed and well oiled, lightly in his right hand, in a horizontal line, and in a direction nearly parallel to the long axis of the patient's body. The left hand raises thejienis, and slowly draws the urethra upwards over the blades of the instrument, which is allowed to enter by* its own weight as it is gradually raised into a verti- cal line. The lithotrite thus reaches the bulbous portion of the urethra, and must then be held vertically for a few seconds, until the membranous portion has been traversed, when, by gently depressing the handle between the patient's thighs, the blades of the instrument slowly rise through the prostatic portion of the canal into the bladder. Sir H. Thompson advises that at this time a slight lateral rotatory movement should be given to the lithotrite, and that the surgeon should press over the pubes, so as to relax the triangular ligament of the penis. As the instrument enters the bladder, its shaft forms an angle of 20° to 30° with a horizonal plane, and when Fib. 565.—Introduction of the lithotrite. (Erichsen.) 974 URINARY CALCULUS. the introduction is completed, the urethra loses its curve and is brought into a straight line. Finding and Seizing the Stone.—There are two ways in which this may be done. Heurteloup's plan, which was followed by Brodie, and which has been usually adopted in England, was to depress the base of the bladder with the angle or convexity of the lithotrite, and then, drawing back the male blade, give the instrument a tap or jerk, so as to cause the calculus to fall within its grasp. The other method, which originated with Civiale, is adopted by Thompson, and seems to me the best. In this method the blades of the lithotrite are passed to about the centre of the bladder, the handle (which is attached to the female blade) being lightly held in the left hand, while the sliding-rod is worked with the right. If, as often happens, the stone is touched by the instrument as it enters the bladder, the blades- are slightly inclined in the opjiosite direction, the male blade gently withdrawn, and the opened blades then inclined towards the stone, which is readily caught between them when the lithotrite is closed. Under other circumstances, the instrument is made to go in search of the calculus, by opening the blades in the centre of the bladder, turning them to the right, and closing ; opening them again in the centre, turning to the left, and closing; then repeating the same movements with the handle of the lithotrite depressed, and so on until, if necessary, the whole cavity* of the bladder has been explored. During the rotation of the blades the handle of the lithotrite is held steadily with the left hand, so that the shaft, which is in contact with the urethra and neck of the bladder, shall have no motion excejit upon its own axis, while the blades are inclined in various directions by the rotatory movement imparted by the right hand, and greatly facilitated in Thompson's instrument by the cylindrical shape of the handle. The following formula is given by Thompson as expressing the different directions in which the blades of the instrument are to be made to seek for the calculus: Vertical, right and left incline, right and left horizontal, and (if the prostate be enlarged) right and left reversed incline, and reversed vertical. For the reversed exploration a short-bladed lithotrite is preferred. In the description given above, the female blade is supposed to be fixed, and the jaws of the lithotrite to be opened by drawing the male blade backwards, but it is often found convenient in practice to fix the male blade and open the instrument by projecting the female blade. Crushing the Stone.—When the calculus has been seized, the surgeon rotates the lithotrite a little, to make sure that none of the vesical mucous membrane is included in its grasp, and then fixes it by drawing up the button attached to the handle of the instrument, which changes the sliding into the screwing action ; the stone being now held firmly in the centre of the bladder, the screw is to be turned slowly until the resistance yields, which it will do gradually or suddenly, according to the consistence of the calculus. The male blade is then to be drawn out (the screwing being for this purpose reconverted into the sliding motion), when, without altering in any respect the direction of the instrument, one of the fragments may be picked up and crushed as before ; and this process may, under favorable circumstances, be repeated two or three times. The instrument is then accurately closed and slowly drawn out by reversing the steps by which it was introduced. Unless the patient is etherized, it is better not to attempt too much at the first sitting, and Thompson's rule is that the litho- trite should not remain in the bladder more than two minutes. In the first sitting it is sufficient to crush the stone (which, if the calculus be large, is best done with the fenestrated lithotrite), the pulverization of RAPID LITHOTRITY WITH EVACUATION. 975 Fig. 566.—Position of the lithotrite in crushing the stone. (Liston.) fragments being left for subsequent occasions. The sittings, if all go well, may be repeated at intervals of from three to six day*s. Rapid Lithotrity with Evacuation (Litholapaxy)__The operation above described is the old-fashioned lithotrity, as perfected by Fig. 567.—Handle of Bigelow's lithotrite. Civiale, Fergusson, and Thompson. Prof. Bigelow, of Boston, has, how- ever, advised that the whole operation should be completed at one sitting, which he does not hesitate to prolong to three or four hours. He has devised special instruments for crushing the stone and evacuating the fragments, and has published a number of cases in which his operation, which he calls litholapaxy, has been successfully jierformed. Successful operations by this method have since been reported by Van Buren and Keyes, Thompson, Coulson, Stokes, of Dublin, Hingston, of Montreal, and many other surgeons, and from my personal ex- perience I can confirm the high estimate which has been placed upon it by all who have employed it. If this method is to be used, however, the operation should be a thorough Fig. 56S.—Blades of Bigelow's lithotrite. 976 URINARY CALCULUS. one, and no recognizable fragments should be left in the bladder. To abandon a patient with the ojieration only half done, is to exjiose him to very great danger, and I know of two cases in which death followed such a course. Dr. Andrews, of Chicago, suggests that, instead of using general anaesthesia, the bladder might be kejit insensible during the ojieration by- injecting carbolic-acid water or hydrochlorate of cocaine. After-treatment.—For at least twenty-four or thirty-six hours after each of the earlier sittings of simple lithotrity, the patient should lie in bed, and particularly avoid jiassing water except in the recumbent posture, so as to prevent angular fragments from falling upon the neck of the bladder or becoming impacted in the urethra. He should be warmly wrajijied up, and a hot napkin or poultice may be applied over the pubes and perineum, an opium and belladonna sujipository being at the same time introduced into the rectum. The sharp corners of the fragments are soon worn off by* the contact of the urine, and after two or three sittings a con- siderable quantity of debris will be passed whenever the patient makes Fio 570.—Bigelow's evacuator. The evacua- ting catheter is joined to the instrument by means of an India-rubber tube. water, or may be withdrawn in the grasp of the plain-bladed lithotrite. The final exploration, by which it is designed to detect and pulverize the last fragment, is best made with a small, short-bladed lithotrite, which is successively directed to all parts of the bladder, and particularly to the jiouch behind the prostate. As a test of the complete removal of the calculus, W. J. Coulson advises that the patient should take a drive over a rou«-h Fig. 569.—Clover's evacuating ap- paratus. ACCIDENTS AND COMPLICATIONS OP LITHOTRITY. 977 road, when, if any fragment remain, its presence will be revealed by the irritation produced by the jolting. Mr. Napier employs for the final explo- ration, an " indicator" tipjied with blackened lead, and Dr. S. C. Duncan a nickel-plated sound coated with lamp-black and collodion ; contact with calcareous matter, in either case, scrapes off the coating, and restores the natural color of the instrument. Washing out the Bladder.—In ordinary cases it is, I have no doubt, best to remove all fragments while the patient is still in a state of anaes- thesia, and for this purpose the surgeon may repeatedly wash out the bladder with tepid water applied with one of the ingenious instruments devised for the purpose by Mr. Clover, Prof. Dittel, and Prof. Bigelow. Clover's apparatus (Fig. 569) consists of an elastic bottle, with a glass reservoir, and evacuating tubes of different sizes and shapes ; the bottle is filled with tepid water, which is slowly injected into the bladder, bringing with it as it returns the detritus, which is detained in the reservoir. Dr. Gouley, of New York, has suggested that the bottle of Clover's apparatus may be con- veniently replaced by an aspirator. Prof. Dittel, of Vienna, has proposed an ingenious application of the siphon principle to the evacuation of detritus after lithotrity, and his instrument appears to me better than that of Clover ; the evacuating catheter is connected with a long, flexible siphon tube which reaches to a vessel placed on the floor, while an arrangement of valves permits water to be thrown into the bladder, the outward current depending upon the force of at- mospheric pressure ; the advantages of this method are that the bladder can be more completely emptied than by the other plan, while there is comparatively little risk of inflicting injury upon the vesical mucous membrane. The evacuating apparatus of Prof. Bigelow, which I have repeatedly employed with entire satisfaction, is represented in Figs. 570, 571. Accidents and Complications of Lithotrity.—If the lithotrite be properly employed, there can be no danger of lacerating the urethra or injuring the mucous lining of the bladder ; it has happened that the instru- ment has broken in attempting to crush a hard calculus, and should such an unfortunate event occur, there would be no alternative to cutting into the neck of the bladder and extracting the foreign body. To prevent the pos- sibility of such an accident, every lithotrite should be tested before it is used, by crushing with it a lump of sandstone about the size of an English walnut! One of the most annoying complications which can be met with after the ojieration of simple lithotrity, is the impaction of a fragment of calcu- lus in the urethra—an accident which is usually traceable to the restless- ness of the patient, and particularly to the neglect to keep the recumbent posture when urinating. Apart from the pain and local irritation pro- duced by the impacted fragment (which may cause cystitis, or abscess in the neighborhood of the urethra, leading perhaps to urinary extravasation), there is often great constitutional disturbance, with repeated rigors and possibly the development of a pyaemic condition. The course to be pur- sued in the event of impaction occurring, varies according to the point at which the fragment has been arrested : should this be in front of the mem- 62 Fig. 571.— Bigelow's catheters for ev; ting fragments after litholapaxy. 078 URINARY CALCULUS. branous portion of the urethra, the offending body should be extracted through the external meatus with delicate urethral forcejis, such as Matbieu's (Fig. 572), with a curette, or with Civiale's scoop; while if Fio. 572.—Urethral forceps. lodged in the prostatic or membranous portion, it should be pushed back into the bladder with a full-sized bougie or a stream of water directed through a catheter with an open end, or, if these means fail, should be re- moved through an incision in the median line of the perineum ; under these circumstances, it might be well to convert the operation into what has been named by* Dolbeau, perineal lithotrity, reducing the remaining fragments to a sufficient size to enable them to be extracted through the wound. Other complications of lithotrity (which, however, are not peculiar to this operation, but may* follow the use of a simple bougie or catheter) are urethral fever, hasmaturia, and inflammation of the bladder, prostate, or testis; these will be considered hereafter. Retention of urine is another complication which not unfrequently occurs, particularly in old persons, and which, on account of the insidious manner in which it is developed, should be carefully watched for ; here, as in other cases, the true condition is masked by* apparent incontinence ; the treatment consists in using the cathe- ter at regular intervals, until the natural tone of the bladder is restored. Statistics of Lithotrity__The statistical results of lithotrity, in the hands of any operator, will necessarily vary very much according to the good or bad judgment which he exercises in the selection of his cases, and as justly remarked by Sir Henry Thompson, unless the surgeon can arrive at an accurate diagnosis of the nature and size of the stone (and, I may add, of the condition of the urinary organs of his patient), it is probably- safer to avoid lithotrity entirely, and uniformly resort to lithotomy. But if an accurate diagnosis can be made, the risk to life, in suitable cases, is, I think, certainly* less (in the case of an adult) if the stone be crushed than if it be removed by cutting: to establish this, it will be sufficient to refer to the experience of those surgeons who have practised the operation most frequently, and who may therefore be supposed to have brought it to its highest state of perfection. Omitting Civiale's cases (the record of which is considered inaccurate by many of those best qualified to form an opinion on the subject), the experience in lithotrity upon male adults of Brodie, Fergusson, Keith, Thompson, and Cadge, may be summed up in the following table:— Brodie Fergusson . Keith (of Aberdeen) Thompson1 . Cadge . 115 cases, 9 deaths, or 7.83 per cent. 109 " 12 " 11 « 116 " 7 " 6.03 " 756 " 45 " 5.95 " 86 " 8 " 9.30 " Aggregate . . . 1182 " 81 " 6.85 " 1 Thompson's results, since he has employed Bigelow's method, are still more favorable, 279 consecutive cases in elderly men having given only 10 deaths, or 3.58 per cent. CONTRA-INDICATIONS TO LITHOTRITY. 979 These results, it will be seen, are very satisfactory; they cannot, of course, be in any* way compared with the results of lithotomy__and still less with those of lithotomy since the introduction of the crushing method • for lithotrity is now confessedly chosen for the most favorable, and lithot- omy for the least favorable, cases. An approximate judgment as to the actual benefits derived from the introduction of lithotrity, may, however, be arrived at by comparing the mortality in all cases of stone submitted to operation by those who practise both methods, with that of cases in the hands of surgeons who employ lithotomy only : from such a compari- son it appears that the death-rate, in cases of adult males, is reduced over six per cent, by the adoption of the former course:— 1426 cases operated on by both methods, by Fergusson, Keith, Thompson, and Cadge, gave 197 deaths, or 13.81 per cent. 799 cases operated on by lithotomy exclusively, collected by Thompson, gave 161 deaths, or 20.15 per cent. It is thus seen that a considerable gain is derived by resorting to lithot- rity in suitable cases; and it is surely, therefore, the surgeon's duty to employ the crushing rather than the cutting method, whenever the former is not positively contra-indicated. Circumstances -which forbid a Resort to Lithotrity__These have regard to the age of the patient, the nature and size of the stone, the condition of the urinary organs, and the state of the patient's general health. 1. Age.—In the first place, lithotrity is contra-indicated in the treatment of children below the age of puberty: the grounds for this assertion are that (1) the urethra is too small at this age to permit the free play of an instru- ment of sufficient strength; (2) the bladder is placed so high__in the abdomen rather than in the pelvis—as to render the use of the lithotrite difficult and not very safe ; (3) children do not bear with impunity the fre- quent repetition of operations required in the procedure of simple lithotrity, while the size of Bigelow's evacuators is such as to render their employ- ment in children quite impracticable ; and (4) lithotomy is such a suc- cessful procedure in early life as to render it difficult for any other mode of treatment to compete with it. I know of no extended statistics of lithotrity in children, but Guersant reports 40 cases (5 of them, however, in girls), with 7 deaths, or a mortality of 17^ per cent. Several cases, moreover, required subsequent lithotomy. His lithotomies number 100, with 14 deaths, and his total number of cases, treated by both methods, 140, with 21 deaths, or a mortality of 15 percent. Thus, even in his own hands, lithotrity (in children) has been less successful than lithotomy, while the results of the latter operation, when indiscriminately applied to all cases under puberty, have been still more favorable, 1028 cases collected by Thompson giving but 68 deaths, or a mortality of less than 7 per cent. Comparing these figures with those given in the preceding pages, we find that indiscriminate lithotomy, in children, is as safe as lithotrity, in selected cases, in adults; and that, on the other hand, lithotrity, in selected cases in children, is not much less dangerous than indiscriminate lithotomy in adults. Hence, the inference seems to me inevitable, that an age below puberty is a positive contra-indication to lithotrity. 2. Nature and Size of the Stone.—Xo absolute rule can be laid down upon these points, but it may be said, in general terms, that in the case of hard calculi (as of oxalate of lime), one inch is the maximum diameter which admits of crushing, and for lithotrity to be properly applied to a mulberry calculus of this size, all the other circumstances of the case should 980 URINARY CALCULUS. be favorable; in the case of uric-acid, and particularly of jihnsphatie cal- culi, this limit may be somewhat exceeded, but even in dealing with such stones, if more than an inch and a half in diameter, lithotomy will usually be a safer operation than lithotrity*. Two inches would be the maximum, even if the calculus were phosphatic and the bladder healthy—a combi- nation of circumstances which is not very* likely* to occur. The existence of multiple calculi is in itself no contra-indication to lithotrity ; on the contrary, if, as then usually hapjiens, the calculi be small, the operation of crushing may be considered as having been partially accomplished by nature ; if, however, the stones be numerous and large, lithotomy would undoubtedly be a safer procedure. If the calculus be adherent or encysted, lithotrity* is, of course, out of the question. 3. Condition of the Urinary Organs.—Several circumstances require consideration under this head. (1) Stricture of the Urethra is almost always a contra-indication to lithotrity, though Sir Henry Thompson has shown that the crushing ope- ration may occasionally be successfully resorted to in these cases, the stric- ture being of course submitted to dilatation as a preliminary measure ; in the large majority* of instances, however, and certainly in tbe hands of the majority of operators, lithotomy* either by the lateral or median method, according to the size of the stone, would be a preferable procedure in cases of this kind. (2) Enlargement of the Prostate is not in itself a contra-indication to lithotrity, though it renders the operation more difficult, and requires the use of Bigelow's apparatus or some similar contrivance to aid in the evacuation of detritus ; if, however, the enlargement be complicated with an irritable Condition of the bladder, lithotomy* should be preferred, par- ticularly if the calculus be of considerable size. (3) Atony or Paralysis of the Bladder is usually thought to contra- indicate lithotrity, but does not, in the judgment of Sir H. Thompson, whose opinion upon this point is entitled to great respect. If, however, the stone be large, in a case of atony of the bladder, the crushing opera- tion should probably not be performed. (I) A Sacculated Condition of the Bladder, if it could be detected be- forehand, would ordinarily contra-indicate lithotrity, on account of the probability* of fragments becoming lodged in the sacculi, where they would produce irritation, and might elude the efforts of the surgeon to find and dispose of them. It is probable, however, that by using Dittel's or Bige- low's apparatus, much of this difficulty might be avoided. (5) Cystitis, if present in an aggravated degree, is, in my judgment, a positive bar to the performance of lithotrity. If the urine be loaded with mucus, or, still worse, with pus, and the introduction of the sound be pro- ductive of great pain and irritation, lithotomy will certainly be the better operation. If, however, the stone be small and friable, an attempt may be made to lessen the irritability of the bladder by keeping the patient in bed and daily injecting tepid water, as advised by Brodie, when, if this plan succeeds, lithotrity may perhaps be safely resorted to. When cystitis occurs during treatment by simple lithotrity, the patient should be "ether- ized, the fragments of stone freely crushed, and the debris evacuated bv means of Bigelow's apparatus. (6) Malignant Disease of the Bladder would certainly diminish the chances of successful lithotrity, but would still more positively contra-indi- cate lithotomy ; if the stone in such a case were friable and of moderate size it would, I think, be justifiable to crush it, merely as a palliative measure! (7) Organic Disease of the Kidney, as evidenced by the presence of LITHOTOMY. 981 albumen and tube-casts in the urine, is usually considered to contra-indicate the performance of lithotrity. It undoubtedly renders the prognosis of the case very gloomy, and it is even a question whether any operation should be jierformed under these circumstances. If in any case of this kind it be determined to attempt the removal of the stone, and the surgeon has to choose between lithotrity* and lithotomy, his decision should, I think, be chiefly* guided by the character of the calculus; if this be such that the bladder can probably be cleared in one sitting, the crushiug ojieration should be preferred ; but under opposite circumstances, lithotomy would be the safer procedure. (8) A Tendency to the Development of Urethral Fever is, I think, a positive contra-indication to lithotrity; if the surgeon finds that a rigor, with subsequent febrile disturbance, follows every introduction of an instru- ment into the bladder (and this can be tested by the preliminary use of bougies), all idea of crushing the calculus had better be abandoned, and lithotomy resorted to instead. If lithotrity be persisted in under these cir- cumstances, the operation will not improbably be followed by deep-seated suppuration, jiy*amiia, and perhaps death. 4. General Condition of the Patient.—If the health of the patient be feeble, and his strength failing, without there being any special disease of the urinary* organs, lithotrity is unquestionably preferable to lithotomy, and should be performed if the size of the stone jiermits. This condition is not unfrequently met with in old people, whose constitutional powers seem to have deteriorated, without any particular lesion being present to account for the change. If, on the other hand, the patient be of a nervous, anxious, and irritable disposition, unless it be pretty sure that all the frag- ments can be evacuated at one sitting, lithotomy* may be preferable as ridding the patient at once of the source of his discomfort. Lithotomy. Lithotomy, or the operation of Cutting into the Bladder to Extract a Stone, is the remaining resource in all cases (among patients of the male sex) not admitting of lithotrity* ; it is, therefore, the mode of treatment to be adopted in all cases below the age of puberty, and in a certain projior- tion, variously* estimated by authors at from one-half to one-sixth, of the remainder; hence every surgeon who sees a fair proportion of both youth- ful and adult patients, will have to cut at least twice for each time that he crushes once. It is not my intention to give an account of the history of lithotomy, for which I would refer the student to the works of John Bell, but to describe the principal operative procedures which are in use at the present day, beginning with the ordinary lateral method, which is essentially that intro- duced by Cheselden, and considering subsequently the median, bilateral, and other forms of operation, and the circumstances by which, in my judg- ment, each is specially indicated. Preparatory Treatment.—It is seldom, if ever, that there is any necessity* for an immediate resort to lithotomy*; but, on the contrary, there is usually ample time for the surgeon to satisfy himself, by careful and repeated sounding, and by chemical and microscopical examination of the urine, as to the nature, size, and relations of the calculus, the condition of the urinary organs, and any other points which it may be necessary to investigate, in order to form a correct judgment as to the state of his patient. An imjiortant question, which occasionally* arises in practice, is whether the surgeon should ojierate in every case, provided that the patient desire it— 982 URINARY CALCULUS. giving him the "ghost of a chance," as it is sometimes called—or whether the operation should be declined whenever the surgeon's exjierience and judgment lead him to believe that operative interference can be productive of no benefit, The latter course is, I think, the one to be jiursued; the case is very different from that of amputation for injury, or herniotomy, or colotomy for imperforate rectum, or even tracheotomy for croup. In those cases the patient is in imminent danger, and the operation, even if it do not avert, will at least not hasten death; but in lithotomy, as in ovariotomy, in the excision of tumors from the parotid region, and in other ojierations for diseases not attended with immediate risk, if the surgeon's interference do not cure, it will certainly kill; hence, in any case of vesical calculus, if, after careful examination and deliberate reflection, the surgeon conies to the conclusion that the patient will, in all human probability, not survive the ojieration, that operation should, in my judgment, be positively declined. Fortunately this contingency is of rare occurrence, and it is almost always possible (unless the case be complicated by far advanced renal disease) to bring the patient into a fit state for operation, by enforcing rest for a week or ten days previously, and by adopting means to bring the digestive functions into a good state, and to lessen or relieve any existing irritation of the urinary organs (see page 972). A full dose of castor oil should be given on the previous day, and a simple enema a short time before the operation, so that the awkward accident of the patient's defecating over the surgeon's hand may be avoided, and that the rectum, being empty, may be less exposed to the risk of being wounded. It is well also, in the case of an adult, to have the perineum shaved before the patient is brought under the influence of the anaesthetic. Lateral Lithotomy. For the performance of lateral lithotomy a firm operating table is re- quired, of rather less than the ordinary height, so that when the surgeon kneels or sits before it his breast shall be about on a level with the patient's buttocks. Four assistants are required—one to hold the staff, one to give the anaesthetic, and two to fix the patient's limbs, one on either side. Many ojierators prefer to have a fifth assistant to hand the instruments, but if the surgeon adopt the kneeling posture (which I think the best), the instruments may be conveniently placed within his own reach, on a tray upon the floor. Instruments—The instruments required are a staff, a simple straight bistoury or scalpel, of a size proportioned to the age of the patient, a probe- Fiu. 573.—Lithotomy-staff, with groove on the back. pointed knife, two or three pairs of forceps, a scoop, and a lar«-e Ion"-. nozzled syringe. It is well, in addition, to have within reach&a blunt gorget, a searcher, and a lithotomy-tube. The staff should be boldly curved, and of as large a size as the urethra will admit. It should have a deep and smoothly-finished groove on the LATERAL LITHOTOMY. 983 left side, or (which I prefer) in the middle line of its convexity, beginning two or three inches above the commencement of the curve, and terminating abruptly* in a right angle about a quarter of an inch from the extremity of the instrument. In using the common staff, the groove of which becomes gradually* shallower, till it ends on the surface, there is great risk of the knife slipping off and wounding the posterior wall of the bladder. The handle of the staff should be broad and roughened, so as to give the assis- tant who holds it a firm grasp of the instrument. The particular form of the knives used in lithotomy may vary with the fancy of the operator. Almost every distinguished lithotomist has devised some special form of instrument, which bears his name, but, for my own part, I do not know of any* which is better than the common straight bis- toury*, which is found in every " minor operating-case." The probe-pointed knife is useful in case it is found necessary to enlarge the incision after the withdrawal of the staff. The forceps should be of various sizes and shapes, some straight and some curved. It is better, I think, to have the blades fenestrated, which Fio. 574.—Open-bladed lithotomy-forceps. gives more room and diminishes the weight of the instrument, and the blades may be lined with linen (as advised by Liston), thus allowing extraction to be effected with- ing Of the Calculus. Fio. 575.—Lithotomy-scoop. The scoop, well curved and of a moderate size, should be firmly* fixed in a roughened handle, to prevent its slipping. The syringe should have a capacity* of at least half a pint, and may be made of gutta-percha or of metal. The blunt gorget, which is often combined with the scoop, should be probe-jiointed, and is used to guide the introduction of the forceps when the perineum is too deep for the finger to reach the bladder. The searcher is merely a sound of slight curve, while the tube, which is introduced through the wound in case of hemorrhage, may be made either of silver, Fio. 576.—Tube for plugging the wound in lithotomy. or of gum-elastic, and should be rounded at the end, with large laterally- placed eyes, and rings at the outer extremity to admit the tapes by which it is held in place. Operation.—The operation is thus performed: The patient being thoroughly etherized (with his rectum empty, and his perineum shaved), 984 URINARY CALCULUS. the surgeon usually injects a few ounces of tejiid water into the bladder (though this is not absolutely necessary), and then introduces the staff, with which, used as a sound, he should recognize the presence of the stone. If this cannot be done, the staff is withdrawn and an ordinary sound in- troduced, when, if the stone still cannot be found, the ojieration must be postponed. This is a well-established rule of surgery, and should be in- flexibly* adhered to; for (1) the stone, if small, may have been sponta- neously* evacuated upon some occasion of the patient's jiassing water ; (2) it may have become caught in some pouch or sac of the bladder, from which it cannot be dislodged ; or (3) the instrument may not have entered the bladder at all, but may have gone through some false passage into the recto-vesical sjiace ; under any of which circumstances the operation, if persisted in, could but result in injury to the jiatient and the utter discom- fiture of the operator. It is safer, indeed, unless the surgeon's skill should enable him to be sure that the staff is actually in the bladder, not to jiro- ceed with the ojieration unless the stone can be touched with this instru- ment, as well as with the sound. The staff having been introduced, the patient is brought to the foot of the table, with his buttocks projecting over the end, and is secured in the "lithotomy jiosition" by fast- ening together his hands and feet with bandages, or with leather straps provided for the purpose. Assistants then take charge of the limbs on either side, and expose the perineum by* drawing the thighs out- wards and backwards. The surgeon now fixes the staff in the way in which he wishes it to be held, and intrusts it to an assistant, who, standing on the patient's left side, holds it firmly in his right hand, while with the left he draws aside the jiatient's scrotum. It is this assistant's duty to keep the staff exactly as the opera- tor has fixed it, until he is directed to withdraw it from the bladder. There are two ways in which the staff may be fixed. Liston's plan, which I think much the best, was to hook the staff firmly under the pubic arch, and draw it almost vertically upwards, and exactly in the median line, thus obtaining a point d'appui which insures the steadiness of the instrument, and widening the space be- tween the urethra and the rectum. Many surgeons, however believe that the operation is rendered easier by turning the staff a little to the left and by making its convexity bulge into the perineum. The surgeon now, casting a glance to see that all his instruments are in readiness, sits, or, which I much prefer, kneels on his right knee before the jiatient, and introduces a finger into the rectum, so as to insure the contraction of this tube, and, at the same time, fix in his mind the relative positions of the staff, prostate, rectum, and tuber ischii Holding the knife lightly but firmly as a pen between the fore and middle finders and thumb of the right hand, he now begins his incision a little to the left of the raphe and (according to the size of the perineum) from an inch to Fin, 577.—Position of patient and line of incision in lateral lithotomy. (Ebichsen.) LATERAL LITHOTOMY. 985 an inch and a half in front of the anus, and cuts obliquely downwards and outwards to a point below and between the anus and "tuberosity of the ischium, but rather nearer the latter than the former. This incision should divide the skin and superficial fascia and fat, and should be rather deeper below than above ; the left forefinger is next placed in the wound so as to press down the rectum and feel for the staff, which is soon reached by Fio. 57S.—Deep incisions in lithotomy. (Fergusson.) making a few light touches with the edge of the knife, dividing the trans- verse space between the accelerator urinae and erector penis muscles. The finger-nail is pressed into the groove of the staff at as low a point as can be felt, and upon the nail the point of the knife is introduced, so as to open the membranous part of the urethra; the surgeon then drops the handle of his knife a little, so as to fix it firmly beneath the knuckle of the index finger, and turning the blade half sideways (lateralizing the knife) and slightly depressing its handle, pushes it steadily onwards along the groove of the staff (which it must never leave), following it constantly with the left forefinger to protect the rectum, until the cessation of resistance and the escape of urine show that the bladder has been reached; the knife is then cautiously withdrawn, still lateralized, and kept closely to the staff, so as not to enlarge the incision.1 The surgeon now lays down his knife, and placing his left forefinger above the staff, insinuates it by a twisting movement into the bladder, between the concavity of the staff and the roof of the urethra; by observing this pre- caution, there is no danger of the surgeon pushing the neck of the bladder before him, and thrusting his finger into the recto-vesical space. The stone is usually felt lying at the end of the staff. If the perineum be very deep and the prostate much enlarged, the surgeon's finger may not be long enough to reach the bladder, and then the blunt gorget must be substi- tuted, being introduced by cautiously pushing it along the groove of the staff. The finger having entered the bladder, the surgeon directs his assistant to withdraw the staff, and then, while selecting the forceps which he is going to use, dilates the incision of the prostate by pressing his finger in different directions; the forceps are next introduced closed, along and above the palmar surface of the finger, which is slightly withdrawn as 1 Furneaux Jordan introduces a knife with a concealed blade, and, having re- moved the staff, incises the prostate and neck of the bladder in an anterior direction. 986 URINARY CALCULUS. the forceps enter; the forceps having touched the stone, are ojiened, one blade being depressed against the wall of the bladder, when the calculus will commonly fall into the grasji of the instrument; the left forefinger is now placed upon the stone, rectifying its position, if necessary, so as to make its long axis correspond to the line of the wound, and extraction is then effected, in the direction of the axis of the jielvis, with a slow, swaying, to-and-fro movement, such as obstetricians employ in applying the forcejis to the foetal head. In some cases it is more convenient to lay aside the forceps, and effect extraction with the scoop employed as a vec'tis; should, unfortunately, the stone be broken in extraction, the scoop must likewise be used to remove the fragments. After the calculus has been extracted, the surgeon again introduces his finger (or the searcher, if the jieri- neum be deep and the bladder saccu- lated), and makes a careful exploration Fin. 579.—Position of fineer and scoop in ex- , . •/. . ■ • , i . _ * f to ascertain if there is another stone tracting stone. (Erichsen.) . . . . remaining, such being cautiously dealt with in the same manner as the first. When the calculous matter has been removed, the surgeon, as a matter of precaution, washes out the bladder through the wound with a syringeful of tepid water, and then, having seen that there is no hemorrhage, has the patient untied and placed in bed. After-treatment.—This is sufficiently simple. The bed must be pro- tected with India-rubber cloth covered with a folded sheet or blanket, to absorb the urine (which of course flows through the wound), the sheet being frequently changed, so as to keeji the patient dry and comfortable. For a day or two the urine escapes entirely by the wound, then probably for a few hours by the urethra (owing to the swelling of the deep part of the incision), and then again partly by the wound in gradually decreasing quantities as the healing process continues. No dressing should be applied as long as any water escapes through the perineum, but after this the inci- sion may be treated as a superficial wound in any other situation. Opium may be administered in the form of suppository, to relieve pain and insure sleep, the diet and general treatment of the patient being adapted to his constitutional condition. Variations.—The operation of lateral lithotomy, as above described, is varied in different ways by many surgeons; thus as regards the staff, many, as already mentioned, have the groove on the left side, and project the instrument into the perineum; Aston Key employed a straight staff, and Buchanan, of Glasgow, uses one which is not curved but rectangular; the latter instrument has been further modified by Hutchinson, by making the staff hollow and adding a stojicock, so that it can be used as a catheter. Still more complicated forms of apparatus have been devised by Earle, X. R. Smith, Corbett, Wood, and Avery*, designed to render it impossible for the surgeon to miss the groove or the staff in making his incision. Instead of using the same knife for the deep as for the sujierficial part of the wound, some surgeons employ a probe-pointed or beaked knife after opening the urethra, while others prefer the cutting gorget (Fig. 580), and still others the lithotome cache (Fig. 581); excellent operations have been done with each of these instruments, and I have no wish to decry their usefulness in the hands of those who feel that the procedure is thereby rendered easier or safer; but for my own part I am quite satisfied with the simple bistoury, and think it an advantage not to have to change the instrument during the operation. DIFFICULTIES IN LATERAL LITHOTOMY. 987 In common with most surgical writers of the present day*, I have advised a very limited incision of the prostate and neck of the, bladder, the wound to be subsequently dilated with the finger —and I certainly* believe this to be the best mode of practice; other surgeons, however, as Teevan, recommend a free division of the prostate, and believe that by this course they increase the proba- bility* of a successful result. I have not advised the introduction of the lithotomy- tube in cases uncomplicated by hemor- rhage, but many* surgeons employ it in every* instance, partly to prevent the accumulation of clots in the wound, and partly* with the idea that its use dimin- ishes the risk of urinary* infiltration ; I do not think it necessary* in ordinary cases, but there is no particular objec- tion to its emjiloyment. and, if the sur- geon cannot see his patient at short intervals after the operation, its use may be jirojier as a measure of jirecaution. Difficulties in the Operation.— The most difficult part of the operation, in the case of children, is to reach the bladder, the extraction of the stone being then usually effected without any trouble. If tlie rule which has been given, to pass the finger between the upper surface of the staff and the roof of the urethra, be followed, there will be little risk of miss- ing the bladder. If, however, the finger be thrust in from below, it may readily tear across the membranous portion of the urethra, and, jiushing back the neck of the bladder before it, enter the recto- vesical space. If such an accident should happen, and should be noticed before the staff is withdrawn, the surgeon may retrace his stejis, and, fixing the knife firmly in the groove of the instrument, notch the neck of the bladder, and cautiously introduce his finger into the organ ; if the staff has been already withdrawn, it should be reintroduced, if possible, when the surgeon may* proceed as before; but if this cannot be done, the operation should be abandoned and the wound allowed to heal. This course, though mortifying to the surgeon's pride, is infinitely* preferable to endangering the life of the patient by attempting to reach tbe bladder without a guide. In the adult, the bladder is usually* reached without trouble, but there may be considerable difficulty in seizing and extracting the stone. This is commonly* due either to the position or to the size of the calculus. (1) Difficulty in Extraction from the Position of the Stone.—The stone may be lodged at the inferior fundus of the bladder, behind an enlarged prostate; extraction is to be effected by using forceps with a decided curve, and by* pushing up the bladder with the finger in the rectum. If the stone, K k Fio. 580.—Physick's cutting gorget. Fig. 581.—Frere Coine's lithotome cachi. 988 URINARY CALCULUS. on the other hand, is at the superior fundus, above the pubis, it may be brought into reach, as advised by Aston Key, by compressing the wall of the abdomen. If the stone be caught between the folds of the vesical mucous membrane, or between the enlarged fasciculi of the bladder, an attempt may be made to dislodge it by patient manipulation with the finger and scoop, or perhaps by directing upon the calculus a stream of tepid water; it is sometimes recommended to expand the walls of the bladder by opening very large forceps within it, in the hope that the stone may then drop out from its hiding-place, but the plan is not free from danger, and there is reason to believe that rupture of the bladder has been thus produced. Spasm of the bladder—a kind of hour-glass contraction of the organ-—is said to occur sometimes, preventing the seizure of the stone; all that could be done in such a case would be to wait patiently until the spasm should disajipear, jiostponing, if necessary, the completion of the operation until another day. If the calculus be adherent or encysted, its removal will be attended with great difficulty; if merely adherent, the stone may* jierhaps be coaxed away from its bed with the scooji—with all gentle- ness, however, lest the bladder itself be torn. If the calculus be encysted, it will probably be necessary to abandon the operation, though an attempt might in some instances be made to enlarge the orifice of the cyst (as was done by Brodie), with a probe-pointed knife, and then enucleate the stone, as it were, with the scoop. Deformity of the pelvis from rickets may prove an obstacle to extraction, as in cases observed by Erichsen, Thomp- son, and others. (2) Difficulty arising from the Size of the Stone.—If the short diame- ter of the calculus exceed an inch and a half in length, extraction will always be difficult, and if it exceed two inches, almost impossible without dangerous bruising of the prostate. Under these circumstances the sur- geon must either (1) gain more room by incising the right side of the prostate, (2) reduce the size of the stone by crushing it within the bladder, or (3) resort to the recto-vesical, or to the supra-pubic operation. Incision of the right side of the prostate was the plan recommended by Liston, and is readily* accomplished with the probe-pointed knife, guided by the finger. Crushing the stone within the bladder1 is attended with some risk, on account of the contracted state of the organ, unless the calculus be soft, when it may be readily* broken up with strong forcejis. This plan was adopted by Prof. Nathan Smith, of New Haven, who, according to his son, Prof. N. R. Smith, of Baltimore, " was always desirous of accomplish- ing that which many operators have deprecated, the fracture of the stone by the forceps." After crushing, the fragments must be carefully removed, and the bladder repeatedly washed out with a stream of tepid water. If the incision of the right side of the prostate does not give sufficient room, and the stone cannot be crushed without endangering the integrity of the bladder, the only remaining course is to perform either the recto-vesical or the high operation—the former benis? probably the preferable procedure. Dangers, Complications, and Accidents of the Operation__ These may arise during or after the ojieration. Thus, in making the in- cision, if the knife be entered too far forwards, or penetrate too deeply at the ujijier part of the wound, the artery of the bulb, or the vessels of the corpus cavernosum, may be cut, giving rise to troublesome hemorrhage; ' Dr. Dyer of Hartsville, Tenn., has recorded a most remarkable case in which a surgeon split a stone in the bladder by repeated blows with a chisel and mallet • the patient recovered! Large calculi have been broken up after lithotomy by drilling by Civiale (who invented an instrument for the purpose), Miss Anna E. Broomall' of this city, and others. COMPLICATIONS OF LATERAL LITHOTOMY. 989 If, on the other hand, the incision be placed too low, there is some risk of wounding the rectum, of cutting through the entire breadth of the prostate and neck of the bladder, thus allowing infiltration of urine behind the pel- vic fascia, or even of ojiening the bladder entirely behind the prostate, an accident which would in all probability be fatal. Again, if the knife be too much lateralized, in making the deep incision, the pudic artery maybe wounded ; while, if not sufficiently lateralized, the rectum will be en- dangered. Finally, if the knife be not kept closely to the staff, in the deep incision, the posterior wall of the bladder may be injured, and it has, according to Miller, even happened (with the cutting gorget) " that by a more heroic thrust the bladder has been completely perforated, the intes- tines have protruded, and after death the liver has been found wounded." Dangers may arise during the extraction of the stone from a portion of mucous membrane being caught in the grasp of the forceps, from the sur- geon pulling too much upwards—not in the direction of the axis of the pelvis—and thus attempting to force the stone through the narrowest part of the jielvic outlet, or from the extraction being effected with such rapidity as to bruise and tear instead of dilating the prostate. It occasionally hapjiens that the extraction of a stone is impeded by a portion of an en- larged prostate—a lobule, as it were, resembling an adenoid tumor—be- coming entangled in the triangular space between the blades of the instru- ment and the calculus. The usual practice, under these circumstances, is gently to push back the protruding body, but Sir William Fergusson gave the high sanction of his name in commendation of a bolder course, no less than the enucleation of these semi-detached prostatic masses—a plan which he declared to be perfectly safe, while possessing the manifest advantage of enabling the surgeon to relieve the prostatic affection at the same time that he removed the stone. This practice has since been adopted by other surgeons, including Cadge, Keith (of Aberdeen), Williams, Harrison, and myself. Among the rarer accidents occasionally met with after lithotomy are (1) the discovery, after a few days, that a second stone or calculous frag- ments, which at first escaped detection, remain in the bladder—to be re- medied by dilating the wound and extracting, or by lithotrity ; (2) the persistence of a perineal fistula—the treatment of which condition will be described hereafter ; (3) sexual impotence, or sterility, usually attributed to wound of the seminal duct, but, according to Thompson, really due to sloughing or inflammatory action—probably incurable ; (4) incontinence of urine—to be treated as when arising from other causes; and (5) no stone, being discoverable when the forceps are introduced—a most mortify- ing occurrence, which may result from an error of diagnosis, no calculus having existed, from the stone being encysted or lodged in a pouch of the bladder, where it cannot be found, from its having escaped from the wound with the first gush of urine, or, finally, from the surgeon having missed the bladder and cut into the recto-vesical space. If the stone cannot be found, all that can be done is to abandon the operation for the time, and this should be done before the patient is exhausted by the repeated but fruitless introduction of instruments into the bladder. If the symptoms of calculus persist after the wound has healed, a careful examination with the sound should be again instituted, when, if the stone be unmistakably pre- sent, the operation may be repeated. It has occasionally* happened that a second lithotomy has enabled the surgeon to extract a calculus which com- pletely eluded discovery at the time of the first operation. Treatment of Complications. 1. Hemorrhage.—The superficial and transverse perineal arteries, one or both, are always divided in lateral 990 URINARY CALCULUS. lithotomy, but rarely give trouble, though, if large, they may require liga- tures. The artery of the bulb or the internal pudic may be wounded, even in the hands of the most skilful operator, on account of an abnormal dis- tribution of these vessels, and, from a similar cause, the dorsal artery of the penis or the inferior hemorrhoidal may be likewise exjiosed to injury. The application of ligatures to the deep arteries of the perineum is some- times attended with great difficulty, or may even be impossible. Under such circumstances the surgeon may rely upon pressure, kept up by the fingers of assistants for several hours, or may pass a tenaculum beneath the bleeding vessel and tie the instrument in the wound, as was success- fully done by Physick, in 1704, and as has since been recommended by Thompson, and by Keith, of Aberdeen, the latter surgeon having devised for the purpose a tenaculum from which the handle can be detached at will. Another plan, also suggested by Physick, is to pass, with suitable forceps, a curved needle armed with a ligature beneath the vessel, and then, disengaging the forceps, draw out the needle and secure the vessel with a knot. When the bleeding artery* is far back, at the side of the prostate or by the neck of the bladder, " I know," says John Bell, '' of no way of securing it but by laying hold of it with the old artery forceps and letting them remain for the night." The same purpose may be accomjilished by using the " artery comjiressor" with movable handle, devised by Prof. Gross, or by catching the vessel with a Pean's forceps or a Nunoeley's clip, armed with a ligature to facilitate its withdrawal. Venous hemorrhage sometimes occurs very insidiously, the blood flow- ing backwards into the bladder, where it may become coagulated, instead of escaping externally. When the bleeding is from a superficial vein, this should be unhesitatingly tied, but if the hemorrhage proceed from the prostatic plexus, it will be better to introduce the lithotomy-tube sur- rounded with a piece of muslin arranged as a "petticoat" or "shirt" (canule a chemise), into which strips of lint can be stuffed so as to firmly plug the entire wound, or, as recommended by Crequy, Guyon, and Buck- stone Browne, with an India-rubber bag which can be distended with air after it is placed in jiosition. Cold irrigations and the application of ice- bags to the perineum and hypogastrium may also be of service, or cold and pressure may be combined by using the tube and India-rubber bag and filling the latter with iced water. Hemorrhage, though seldom the immediate cause of death after litho- tomy, is always to be dreaded, as it certainly' predisposes the jiatient to the occurrence of diffuse inflammation of the areolar tissue around the wound. Secondary hemorrhage is a comparatively rare complication of lithotomy. It is to be treated by the application of ligatures, if the source of hemor- rhage can be discovered, but if not, by the use of styptics and pressure, or by the actual cautery. 2. Wound of the Rectum is an annoying, but usually not a very serious, accident. If the wound be of small extent and low down, it will "probably heal spontaneously, but, under other circumstances, may lead to the forma- tion of a recto-vesical fistula, which must be remedied in the way described at page 922. 3. Diffuse Inflammation of the Areolar Tissue surrounding the Neck of the Bladder and the Rectum may arise from infiltration of urine, or from bruising of the part in the attempt to extract a large stone. Urinary infiltration, which is probably* not as often met with as was formerly sup- posed, arises from too free division of the prostate in the deep incision. It has been suggested that the occurrence of this accident might be prevented RESULTS OF LATERAL LITHOTOMY. 991 by the use of the lithotomy-tube, but as the urine always flows out along- side of the tube as well as through it, it is evident that nothing could be gained in this way. The second condition which gives rise to diffuse areo- lar inflammation, bruising of the parts around the neck of the bladder, is due to rough manipulation and the endeavor to bring a large stone through an opening which is too small for the purpose. The remedy* is not to hastily enlarge the incision, for this exposes to the risk of urinary infiltra- tion, but to effect gradual dilatation by means of the finger and by the lever- like action of the forceps, notching, if necessary, the opposite side of the prostate, crushing the stone, or even resorting to the recto-vesical section (see page 988). The occurrence of diffuse inflammation of the areolar tissue is certainly predisposed to by the existence of renal disease, and by exces- sive loss of blood at the time of the operation. The treatment consists in the administration of nutritious food, with stimulants and tonics, and in making free incisions to allow the escape of jient-up fluids. Brodie in one case saved his patient by freely dividing all the tissues between the perineal wound and the rectum. 4. Other Complications may arise, such as sloughing of the wound, inflammation of the bladder or kidneys, peritonitis, erysipelas, pyaemia, or tetanus, the treatment of which affections is to be conducted on the principles which guide the surgeon in their management when they occur under other circumstances. Results of Lateral Lithotomy.—The results of lithotomy are unquestionably more influenced by the age and general condition of the patient, the size of the stone, etc., than by the greater or less degree of skill with which the operation is executed; manual dexterity is, however, by no means to be despised, and lithotomy* is justly declared by Sir Henry Thompson to be a " grand operation," and " one of the best practical tests of a good surgeon." The statistics of lithotomy* have been investigated by numerous authors, and the general mortality*—for all ages and conditions—appears to be about one in seven or eight; Rosenthal's collection of 7628 cases shows a death- rate of 12.08 per cent. Of 28 cases of the lateral operation in my own hands, only* 2 have proved fatal, and only one of these as the result of surgical interference. The effect of age in influencing the result of lithotomy is very marked; 377 operations on patients between 6 and 11 years old gave, according to Thompson, but 16 deaths, a mortality of but little over 4 per cent., while, on the other hand, 233 ojierations on patients between 59 and 70 gave 63 deaths, a mortality of over 27 per cent. In neither category were the cases in any way selected. That the size and weight of the stone influence the result of the operation is seen from Crosse's tables, which show that the mortality of cases in which the stone weighed less than half an ounce was 8-g- per cent., and of those in which it weighed more than half an ounce, 19^ per cent. But nothing influences sodecidedly the results of lithotomy as the condition of the urinary organs: " it.is," says Brodie, " organic disease of the urinary organs, the kidneys, or bladder, or parts connected with them, that is to be especially ajiprehended, as increasing, tenfold, the hazard of the operation. Of persons in whom the calculus is not of a large size, on whom the operation is performed, I will not say very well, but not very unskilfully, and who are free from all organic dis- ease, there are very few who do not recover ; while of those in whom organic disease exists, there are few who do not die." For the statistical results of lateral lithotomy, as compared with litho- trity, see page 979. 992 URINARY CALCULUS. Bilateral Lithotomy. This ojieration was introduced in its jiresentform by Dupuytren, in 1824, and has been, in this country, particularly illustrated by the late Prof. Kve and Prof. Briggs, of Nashville, and by Prof. Hughes, of Keokuk. The first-named surgeon is said to have performed it in 92 cases, with only 8 deaths. The instruments required are a staff, grooved in the median line, a scalpel, a double lithotome cache (Fig. 582), modified by Dupuytren from Fia. 532—Dupuytren's lithotome cachi, opened. the single lithotome of Frere Come (Fig. 581), which is still used by French surgeons in the lateral ojieration, forceps, scoops, etc. The first incision is made in a curve around the rectum, the extremity on each side reaching to a point midway between the anus and tuber ischii, or a little nearer the latter, and the middle of the incision passing from a half to three-quarters of an inch in front of the anus; the wound is then deepened until the Fio. 583—Bilateral lithotomy. membranous portion of the urethra is exposed, when this is opened suffi- ciently to admit the beak of the lithotome, which is introduced, closed along the groove of the staff into the bladder. The instrument'having touched the stone, is turned with its concavity* downwards, when the staff is withdrawn; the surgeon now exjiands the blades of the lithotome to an extent previously determined, and regulated by means of a screw and divides both lobes of the prostate from within outwards by drawing the instrument out with the handle well depressed and exactly in the median line of the patient's body. The finger is then passed into the bladder^ and upon this the forceps are introduced, extraction being completed as in the lateral operation. The theoretical advantages of this operation are, that the wound beinc MEDIAN LITHOTOMY. 993 placed low, there is little or no risk of hemorrhage, the arteries of the bulb and the transverse and superficial perineal arteries being all above the line of incision, and that the prostate is equally divided upon both sides, thus giving a free opening into the bladder; in practice, however, the bilateral is not found to be any more successful than the lateral method, which is, I think, an easier operation. Gross has collected 514 cases of bilateral lithotomy, with 41 fatal results, a mortality of about 1 in 12^. Instead of pushing in the lithotome along the groove of the staff, some operators take the latter instrument in their own hands as soon as the beak of the lithotome is lodged in its groove, and, by depressing the handle with a quick rocking motion, bring both instruments together into the bladder; this manoeuvre I have seen skilfully executed by the late Prof. Joseph Pancoast, of this city. Pre-Rectal Lithotomy. This, which is a modification of the ordinary bilateral method, was intro- duced by Nelaton, and consists in making a careful dissection in front of the rectum, so as to open the urethra at the apex of the prostate, without coming in contact with the bulb ; the remaining steps of the operation are the same as in Dupuytren's method. Medio-Bilateral Lithotomy. This operation was introduced by Civiale, in 1829, and was adopted in several instances by Sir Henry Thompson, who has, however, since aban- doned it in favor of the lateral and supra-pubic methods. The staff being firmly held by an assistant, an incision about an inch and a half long is made in the median line of the perineum, terminating a little in front of the anus, and cautiously deepened so as to open the membranous portion of the urethra without wounding the bulb; a straight double lithotome is then lodged in the groove of the staff and pushed on into the bladder, dividing both lobes of the prostate as it is withdrawn, just as in Dupuy- tren's method. Sir Wm. Fergusson has imitated this plan, as regards the external wound at least, by making a perineal incision in the form of an inverted \. Civiale's seems to me on the whole better than Dupuytren's operation, but neither presents any particular advantage over the lateral method; either may, however, be properly resorted to in cases in which the stone is large, and in which hemorrhage is to be for any reason specially dreaded. Prof. Briggs, of Nashville, has successfully employed the medio-bilateral method in nine cases. Median Lithotomy. This is an old operation, formerly known as the " Marian" (from Marianus Sanctus Barolitanus, a surgeon of the sixteenth century), but revived with improvements by Manzoni, De Borsa, and Rizzioli, and per- fected by Allarton, whose name it now generally* bears. A staff grooved in the median line is firmly held against the pubis by an assistant, when the surgeon introduces his left forefinger with the palmar surface upwards into the rectum, placing its tip upon the apex of the prostate; a straight bistoury, double-edged at the point, is then entered with its jirincipal cut- ting edge upwards, in the median line of the perineum, half an inch in front of the anus, and pushed steadily onwards until it penetrates the mem- 63 994 URINARY CALCULUS. branous jiortion of the urethra and lodges in the groove of the staff; the apex of the prostate is now notched by pushing the knife a few lines towards the bladder, and the urethra then slightly divided and the external wound enlarged to about an inch and a half, by cutting upwards as the knife is withdrawn. A ball-pointed probe is next passed into the bladder, along the groove of the staff, which is then removed—the surgeon's finger following the probe and dilating the prostatic incision in its course ; the forceps are then introduced, and the stone extracted as in other operations. In order to assist the dilatation of the prostate, Allarton has suggested the use of fluid pressure applied by* means of an Arnott's dilator, and Teale, Dolbeau, and others have devised metallic instruments for the same pur- pose; as pointed out, however, by both Erichsen and Thompson, instru- mental is much less safe than digital dilatation. Allarton's operation has been variously modified by other surgeons, as by Thompson, who exposes the staff by cutting from before backwards, and by Erichsen, who employs a rectangular staff, passes a beaked director along the groove after making the incision (to open the way for the finger), and effects digital dilatation before withdrawing the staff, as in the lateral operation. The advantage of the median over the lateral operation is the diminished risk of hemorrhage (though, according to Thomjison and Cadge, the gain in this resjiect has been greatly exaggerated), and of urinary infiltration. Its disadvantage is the limited amount of space which it affords for the extraction of the stone. Hence its application should, it seems to me, be practically limited to those cases among adults in which, though the stone is small, lithotrity is inadmissible, and hemorrhage particularly to be feared. It is decidedly contra-indicated by* the presence of a large stone, and by hypertrophy of the prostate, which interferes with the manipulation of the forceps through the small opening afforded by the median incision. There is, however, another class of cases, in which the median operation often answers a very good purjiose, and that is when it becomes necessary to cut into the bladder to remove a foreign body (see p. 416). Allarton has collected 139 cases of the median operation, with 13 deaths, or a little over 9 per cent.; his tables are, however, according to Poland, not very accurate, many known cases of death after the median operation being unrecorded, and section of the prostate having been required in two of the author's own cases which are rejiorted as successful. The statistics of the Norfolk and Norwich Hospital, as collected by Mr. Cadge, give a much less favorable picture, 90 cases, at all ages, having given 16 deaths, a mortality of nearly 18 per cent. Of five cases in my own hands, only one has proved fatal, and that from causes unconnected with the operation. Dolbeau has introduced a modification of the median method, which he calls perineal lithotrity, and which consists in opening the membranous portion of the urethra, dilating the neck of the bladder, crushing the stone, and removing the fragments through the jierineal wound, all at one opera- tion. The principal advocate of Dolbeau's method in this country is Dr. Gouley*, of New York. Medio-Lateral Lithotomy. This operation, which was introduced by Buchanan, of Glasgow, in 1847 has already been referred to as a modification of the ordinary lateral method! It is performed with a rectangular staff grooved upon the left side, which is fixed so that the angle corresponds to the apex of the prostate, and well pressed down so as to be readily felt from the perineum. The operator, RECTO-VESICAL LITHOTOMY. 995 keeping his left forefinger in the rectum, " enters a long straight bistoury opposite the angle of the staff, and therefore immediately in front of the anus: he holds it in his right hand, with the palm upwards; the blade horizontal and its edge directed to the left; and he pushes it straight into and along the groove as far as to the stop at its extremity. He thus enters the bladder at once, taking care to keep the blade parallel with the horizontal or grooved portion of the staff throughout the whole of the thrust. Next he withdraws the bistoury slowly, but, as he does so, cuts outwards and downwards a distance rather more than equal to another breadth of the blade [a quarter of an inch], and then directly downwards to the same extent, describing, in this manner, a curved line equal to about one-fourth of a circle round the upper and left side of the rectum." This operation makes an external wound of about an inch and a quarter in length, and has, according to Thompson (from whose description the pre- ceding account is taken), been performed over 60 times, with results corres- ponding very* closely to those obtained by Allarton's method. The name medio-lateral is also given by H. Lee to a somewhat similar operation devised by himself. These are the principal operations by which it is sought to remove a stone from the bladder by incisions through the perineum, and from which the surgeon has to choose in ordinary cases. Each method has certain merits and demerits, and each may be properly adopted in particular cir- cumstances. As, however, the success of lithotomy depends, to a con- siderable extent, upon the readiness and skill with which the operation is performed, and as to acquire equal facility in each of these methods would require a wider experience in stone cases than falls to the lot of most sur- geons, I would strongly advise the general practitioner to familiarize himself with one procedure (and the ordinary lateral* method I consider decidedly the easiest and safest in the large majority of instances), and,. having acquired sufficient skill in its performance, to be content. It is doubtless desirable for the professed lithotomist, who counts his cases by scores or even by hundreds, to try every new plan that is suggested, and to publish his experience with it for the benefit of the whole profession ; but there is no reason why the general practitioner, who, perhaps, sees but half a dozen cases in the whole of his career, should feel obliged to operate by three or four different methods. It will, on the contrary, I believe, be much better for his patients for him to be able to do one operation well, than a large number with doubt and hesitation. Recto-Yesical Lithotomy. This operation, which was devised by Sanson, aims to extract the stone by an incision through the rectum. A staff is held in the ordinary manner, and into the groove the surgeon thrusts the point of his knife (guided by the left forefinger) through the prostate, from the rectal surface, cutting then upwards and outwards through the sphincter ani and perineum. The finger-nail is then placed in the groove at the membranous portion of the urethra, and the bladder is opened by an incision from before backwards, joining the original wound. Extraction is effected as in other operations. Maisonneuve has modified this procedure by making an incision through the rectum above the sphincter, which is not divided, the section of the prostate being completed with a double lithotome. Chassaignac has per- formed recto-vesical lithotomy with the ecraseur. This operation, in addition to the risk of diffuse cellulitis and peritonitis by which it is attended, exposes the patient to the possibility of the forma- 996 URINARY CALCULUS. tion of a recto-vesical fistula; to meet this contingency, Prof. Bauer, who is the most prominent advocate of the method in this country, adjusts the edges of the wound with metallic sutures, with the view of securing pri- mary union, and a similar plan has been followed by Dr. Noyes. Kbnig has collected 83 cases of this operation, which gave 56 cures, 11 recoveries with fistula, and 16 deaths. The operation is, in my judgment only to be recommended in cases of very* large stone, in which extraction by the lateral incision has been found impracticable (see p. 988). Supra-Pubic Lithotomy. The High, Operation. This operation, which appears to have originated with Pierre Franco, in the latter part of the sixteenth century, and w*hich was first performed in this country by the late Prof. Wm. Gibson, is designed, as its name implies, to effect the extraction of a vesical calculus through an incision above the pubis, where the bladder is not covered by peritoneum. It may be per- formed as follows : The parts having been shaved, and the rectum emptied by means of an enema, the patient is etherized, lying on his back with the pelvis elevated, so that the abdominal viscera may not press upon the bladder; this organ is then fully injected (but not over-distended) with tepid water, and a well-curved sound or solid catheter introduced, so that by depressing its handle between the patient's thighs, the beak of the instru- ment may become prominent in the supra-pubic region. Petersen, Gos- selin, Bois, and Fehleisen advise that the bladder should be pushed upwards by introducing an India-rubber bag (air-pessary) into the rectum, and in- flating it, or by otherwise distending this organ. While this plan greatly facilitates the operation, it is not entirely free from risk; Nicaise records a case in which the rectum was ruptured by over-distention, and in other cases the bladder itself has suffered in the same way. An incision about three inches long is now made, exactly in the median line1 and reaching at its lowest point to the upper margin of the pubic symphysis: the wound is cautiously deepened until the linea alba is reached, when this is opened at the lowest part of the incision, and divided upwards with a probe-pointed knife for a distance of an inch and a half or two inches, taking great care not to wound the peritoneum, by gently pushing it out of the way of the knife. The surgeon now carefully cuts down upon the extremity of the sound, which is made to project in the wound, and thus opens the bladder —the incision into this organ, which should be held forwards with tenacula, being then enlarged by cutting downwards towards its neck (and therefore below the symphysis) with a probe-pointed knife. One or two fingers are next introduced so as to ascertain the position of the stone, which is ex- tracted with forceps in a line corresponding to the oblique direction of the wound. Langenbuch advises that the operation should be done antisepti- cally in two stages, which should have an interval of five or more days between them. Civiale devised several special instruments for use in this operation, the most important being the sonde a dard, a catheter with a stylet which could be protruded from the concave surface of the instrument, designed to make the opening into the bladder from within outwards. The after-treatment is very simple; the patient should be kept in bed i Bardenheuer, Trendelenburg, and Helferich prefer a transverse incision imme- diately above the symphysis pubis, dividing the attachments of the pyramidalis and rectus abdominis muscles. RECURRENT CALCULUS. 997 with the limbs drawn up so as to relax the abdominal muscles, the wound being allowed to heal by granulation under simple dressing. Bruns, of Tubingen, and Tiling, of St. Petersburg, recommend the introduction of sutures, in hope of obtaining primary union. A flexible catheter may be introduced through the urethra and allowed to remain, so as to jirevent urinary accumulation, but should be removed if it produce any vesical irritation. Diffuse areolar inflammation may follow the operation, and is usually attributed to the occurrence of urinary infiltration; it is probable, however, that, as in the case of the lateral method, bruising of the edges of the wound in extracting a large calculus is at least equally efficient in giving rise to this complication. The high operation has been recommended by some of its advocates as a method of universal application, but is generally, and, in my opinion, projierly reserved for cases in which the calculus is of unusual size—more, for instance, than two or two and a half inches in its lesser diameter—or in which the lateral or other perineal methods are contra-indicated by the ex- istence of pelvic deformity*. The mortality after this operation is variously estimated by Belmas, Humphry, Gross, MacCormac, Rosenthal, and Dulles, at from 22 to 30 per cent.1 Of 56 terminated American cases, col- lected by the last-named writer, 40 terminated successfully and 16 proved fatal, thus giving a death-rate of 2 in 7. It is to be remembered, however, that the supra-pubic, unlike the median, operation is habitually reserved for unfavorable cases. Recurrent Calculus. The recurrence of vesical calculus after an operation for its removal, may be due to the persistence of the causes which gave rise to the existence of the first stone, or to the imperfect removal of the stone, a fragment having been allowed to remain in the bladder. The descent of a renal calculus is comparatively seldom a cause of recurrent stone, which is more frequently due to the continued deposit of phosphatic matter in the bladder, as the result of cystitis with an ammoniacal state of the urine. Fragments may be left in the bladder after either lithotomy or lithotrity, but are more likely to form the nuclei of fresh calculous formations after the latter than after the former operation, because in this the wound affords a free means of exit, by which any portions of stone that may be chipped off are readily* washed out by the flow of urine. In the early days of lithotrity, recurrence was, indeed, a frequent event, and was not unreasonably considered a grave ob- jection to that operation ; it is satisfactory, therefore, to know that with larger experience, and with the aid of the improved forms of instrument now in use, the probability of a relapse has been considerably diminished ;a moreover, as pointed out by Brodie, patients are willing to submit to a repetition of lithotrity, when they would refuse a second cutting operation. The treatment of recurrent calculus consists in removing the stone by either lithotrity* or lithotomy*, the choice of operation being made in accordance with the principles already laid down. If it be decided to cut a patient a second time, the incision may be made in the line of the cicatrix left by the first operation. 1 Dennis, however, estimates the mortality of cases operated on since 1879, as only 9 per cent. Assendelft reports 102 cases with only 2 deaths, and Thompson 23 cases with 3 deaths. 2 Of 36 cases submitted to lithotrity by Civiale, in the year 1860, no less than 10 were cases of recurrent calculus, while of 204 cases operated on by Thompson, during six years ending in 1870, only nineteen were cases of recurrence. 998 URINARY CALCULUS. Urethral Calculus. Urethral calculi usually* consist of renal or small vesical concretions, which, being too large for spontaneous evacuation, have become imjiacted in the urethral canal ; but calculous matter may* occasionally* be primarily deposited in the urethra, in cases of urinary obstruction from organic stric- ture, etc. The symptoms of urethral calculus are difficult or painful micturi- tion, and in some instances complete retention of urine, followed, perhajis, by ulceration and urinary extravasation ; the stone can usually be felt through the strictures of the penis, perineum, or rectum, and can generally be touched with a sound introduced into the urethra. The treatment con- sists in effecting removal, either by gentle manipulation with the finger and thumb, pushing the stone towards the meatus, by the use of narrow forcejis,1 etc., as in the case of foreign bodies or of fragments impacted after lithotrity, or by cutting into the urethra and extracting the stone through the incision. Before resorting to the last mode of treatment, the calculus should, if pos- sible, be pushed back into the perineal portion of the canal, as urethrotomy in the scrotal portion is attended with risk of urinary* infiltration, and in the penile portion with danger of the formation of a fistula. The opera- tion may be facilitated by introducing a full-sized staff as far as the jiosition of the calculus, the incision being made directly upon the point of the instru- ment. In some instances it may, perhaps, be thought better to push the calculus back into the bladder, and then dispose of it by lithotrity. In all cases of urethral calculus, a careful exploration of the bladder should be made, to ascertain if vesical concretions be likewise present; if any be found, they may*, if of suitable size, be crushed; or, if the urethra have already been opened in the perineum, the incision may be readily extended so as to convert the operation into a median or into a lateral lithotomy. Prostatic Calculus. Calculous concretions are sometimes found in the prostate gland, result- ing from the deposit of phosphatic matter upon the inspissated secretion of the part; they may be conveniently referred to in this place, though not strictly belonging to the category of urinary calculi. Prostatic calculi usually consist of about eighty-five parts of phosphate of lime, with fifteen parts of animal matter, and a trace of carbonate of lime; hence they may- be readily distinguished from the vesical calculi which occasionally lodge near and become imbedded in the prostate. Prostatic calculi rarely attain a large size, have a rather smooth surface—often presenting numerous facets—and are usually of a light brown or gray color ; they may exist in considerable numbers, occupying the various cells and ducts of the gland, or several may become aggregated into a single mass, through the gradual disajipearance by absorption of intervening intercellular substance. The symptoms are a sensation of weight and distention in the perineum, often attended by a flow of mucus, and sometimes by retention of urine- the calculus can usually be detected by exploration with a sound, aided by digital examination through the rectum. The treatment consists in extrac- tion by the urethra, with long and delicate forceps—this is rarely practi- cable—or through a perineal incision, as in the operation of median litho- tomy. If the concretions are small and very numerous, it may, perhaps be better not to resort to operative interference, but to employ palliative measures only, to relieve the irritation of the part. 1 Dr. Will, of Aberdeen, recommends a wire loop ; the same plan was succi employed many years ago in this country by Dr. Conaut. TREATMENT OF VESICAL CALCULUS IN WOMEN. 999 Treatment op Yesical Calculus in Women. The operations for the removal of stones from the female bladder are lithectasy, lithotrity, and lithotomy. Lithectasy,1 or Dilatation of the Urethra and Neck of the Bladder, is much the best mode of treatment for all stones of a moderate size. The dilatation may be effected slowly, by the introduction of sponge tents of gradually increasing sizes; or, which is much preferable, rapidly by means of a two- or three-bladed dilator,2 or simple dressing forceps, introduced closed, and then opened so as to dilate the part upon withdrawal. The stone is extracted with ordi- nary lithotomy forceps or with the scoop, as may be found most convenient. The operation should be performed with the aid of anaesthesia. Bryant, who has ably investigated the litera- ture of the subject, finds that, in children, calculi one inch in diameter, and, in adults, calculi two inches in diameter, can be safely* removed by rapid urethral dilatation, without any resulting incontinence of urine. Lithotrity is adapted for cases in which the stone is too large to be removed by lithectasy, and yet in which the urinary organs are in healthy condition. The operation may be performed with a short-bladed lithotrite, or with strong forceps; it is not necessary (as it is in the male) to reduce tbe calculus to powder, but is sufficient to break it into fragments—these being then immediately extracted with lithotomy forceps through the urethra, which is rapidly dilated for the purpose. The patient should be in a state of anaesthesia, so that the whole operation may be completed at one sitting ; injections of tepid water are required to insure the removal of detritus. Lithotomy.—This may be performed in several ways. 1. Urethral Lithotomy is often combined with lithectasy ; the operation consists in introducing a probe-pointed bistoury into the urethra, and incising the mucous membrane with or without the submucous tissue, directly upwards as practised by Brodie, directly downwards as suggested by Chelius, downwards and outwards on both sides as done by Liston, or, in fact, in any direction that suits the surgeon's fancy. The operation is very apt to be followed by incontinence of urine, and appears to me in every way inferior to the method by simple rapid dilatation. 1 This name was applied by Dr. Willis to an operation which he proposed for stone in the male, and which consisted in opening the perineal urethra and dilating the neck of the bladder ; a procedure which has been supplanted by the median opera- tion as modified by Allarton. 2 An ingenious dilator and speculum combined has been devised by Dr. A. W. Stein, of New York. Fia. 584—Urethral dilator. 1000 URINARY CALCULUS. 2. Vaginal Lithotomy has been particularly commended by Marion Sims, Aveling, Emmet, and Collins Warren, and is probably the best mode of treatment for cases in which the calculus is large, and in which crushing is inadmissible, but seems to me, under ordinary circumstances, decidedly inferior to lithectasy and lithotrity. The operation may be thus performed: A straight staff is introduced into the bladder and held by an assistant, so Fig. 585.—Female staff. as to depress the vesico-vaginal septum, the point of the instrument being fixed by* the surgeon's left forefinger introduced into the vagina. A sharp bistoury is then thrust through the septum to the groove of the staff, just behind the urethra, and the incision carried backwards for the space of about an inch and a half, taking care not to infringe upon the peritoneum ; the stone is extracted with forceps, and the edges of the wound are immedi- ately brought together with sutures, the case being, in fact, treated as one of vesico-vaginal fistula. Simon, of Heidelberg, recommends vaginal cysto- tomy as a jircliminary to catheterization of the ureters in cases of sus- pected impaction of a renal calculus, etc. 3. The High Operation may be required in cases in which the calculus is too large to admit of vaginal lithotomy. The operative procedure is the same as in the male sex, but requires even more care not to wound the peritoneum. The late Prof. Parker is said to have practised supra-pubic lithotomy in the female on three occasions, and in each instance with a suc- cessful result. 4. Buchanan, of Glasgow, has practised the lateral operation, cutting through the left nympha upon a grooved staff introduced into the urethra. Walshrnan has collected four cases of this operation in children, all of which terminated favorably. Extra-pelvic Yesical Calculus. Calculus is occasionally developed in the protruded bladder, in cases of hernia of that organ, or cystocele. Prof. Gross has collected eight cases of this description. The treatment consists in cutting down upon the hernia (which has no peritoneal investment), and extracting the calculus—a ca- theter being kept in the bladder during the healing of the wound to pre- vent urinary* infiltration. A calculus has been extracted by a Polish sur- geon from a child's scrotum, whither it had made its way by ulceration of the walls of the bladder. Dr. Yosburgh has removed a calculus from the umbilical region, apparently from a patent urachus, as has Henriette, of Brussels ; and other cases of urachal calculus have been recorded by T. Paget and Amussat. MALFORMATIONS AND MALPOSITIONS OF THE BLADDER. 1001 CHAPTER XLV. DISEASES OF THE BLADDER AND PROSTATE. In no department of surgery is it more necessary for the practitioner to be a good physician than in that which relates to diseases of the urinary organs. So immediately connected with each other are these organs, both anatomically and physiologically, that it is impossible to treat satisfactorily even those affections which are usually considered purely surgical, as, for instance, stone in the bladder, hypertrophy* of the prostate, or stricture of the urethra, without an accurate knowledge of the whole subject of urinary pathology, and more particularly a practical acquaintance with the methods of examining the urine, both chemically and by the aid of the microscope. It is the more necessary to make this statement because the limits of this volume will only admit a description of those diseases of the urinary organs which the surgeon is habitually called upon to treat; and I must therefore refer the student, for information on the other topics mentioned, to works on the Practice of Medicine, and to treatises specially devoted to the subject of Urinary Disorders. Malformations and Malpositions of the Bladder. In some cases the bladder has been totally absent, the ureters opening directly into the urethra, or into the rectum or vagina, while in other in- stances two or more bladders are said to have coexisted in the same sub- ject, though, as justly remarked by Thompson, it is probable that in most of these cases the condition has not been congenital, but rather one of extreme sacculation, the result of disease. Another explanation, suggested by Demandre, who has himself observed a case of so-called " super- numerary bladder," is that the abnormal pouch may be simply a dilated urachus. Extroversion or Exstrophy of the Bladder is by far the most common congenital defect of this viscus, and is met with sufficiently often to make its treatment a subject of considerable importance. This deformity, which is much commoner in the male than in the female sex, and which appears to be due to an arrest of development during fcetal life, consists in an absence of the anterior wall of the bladder, with a corresponding de- ficiency of the lower part of the abdominal parietes, and usually of the pubic symphysis. The penis in the male is epispadic and shortened, and the clitoris, in the female, is split into two portions corresponding to the nymphae, the anterior commissure of the vulva being wanting, and the bladder and urethra thus opening between the labia and' directly into or immediately above the vagina ; the uterus is commonly well formed, and in one of my cases the vaginal orifice was normally closed with a hymen. The anus is" placed in front of its usual position, and, in the male, the scrotum not unfrequently contains a hernia on one or both sides. The recti abdominis muscles are separated at their lower part, passing obliquely outwards to their insertions into the pubic bones, and in many, but by no means in all, cases the separation is continued upwards almost to their 1002 DISEASES OF THE BLADDER AND PROSTATE. costal attachments, in which case there is no umbilicus, the interval be- tween the recti being filled with a fibrous tissue analogous to the linea alba.1 The appearances in a case of exstrophy of the bladder are quite character- istic. The posterior wall of the bladder (covered, of course, with mucous membrane) is pushed forward by the abdominal viscera which are behind it, and forms a prominent but reducible tumor in the situation of the pubes. The mucous surface, which is red, papillated, and vascular, is continuous at its periphery with the abdominal walls, the line of junction having a thin cicatricial appearance. At the lower part of the projecting vesical surface, the ureters can be seen, giving exit to the urine by* drops, or some- times in a stream. The exposed mucous membrane, which is constantly irritated by* the contact of the patient's garments, becomes inflamed, and bleeds when touched, while the groins, thighs, and buttocks are excoriated from urine flowing over them. In addition to the physical distress thus occasioned, the patient has the annoyance of knowing that he is deformed in a part which few are so philosophical as to consider of no importance in their own persons, and is besides rendered, by the continual dribbling of urine, an object of disgust to himself as well as to others. Otherwise the deformity does not particu- larly interfere with the general health, and is by no means incomjintible with a long life; though, in a remarkable case related by Dr. J. A. Master- son, of Waterloo, Wisconsin, the extroverted posterior wall of the bladder formed the sac of a hernia, which, by pressure on the ureters, led to dila- tation of those organs, and ultimately to renal disease, which proved fatal. In the female the reproductive function is not impaired, and instances are on record in which women with extroverted bladders have borne children ; but in the male sex the accompanying deformity of the genital organs is so great as to render procreation impossible. Treatment.—Until within a few years, this malformation was thought to be beyond the reach of surgical aid, and the utmost that was attempted for patients thus affected, was to supply a mechanical apparatus to shield and protect the exjiosed bladder from injury, and to convey the urine into a suitable receptacle; but the apparatus was necessarily cumbrous and irk- some, and fulfilled its design in, at best, a very unsatisfactory manner. Within a few years, endeavors have been made to remedy, or at least to alleviate, by operative interference, the condition of patients afflicted with exstrophy of the bladder, and in many instances with very gratifying suc- cess. The operations which have been devised for the purpose may be divided into two categories, viz., 1, those which aim to divert the course of the renal secretion into another channel, and, 2, those the object of which is merely to cover in the exposed bladder by a plastic operation, and thus render possible the adaptation of a convenient receptacle for the urine. To the first category* belong the operations of Simon, Holmes, T. Smith, Son- nenburg, and Levis, of this city, and to the second the jilastic procedures of Richard, Pancoast, Ayres, Holmes, Wood, Bigelow, and others. 1. Mr. Simon, of St. Thomas's Hospital, in the case of a boy of 13, established, by an ingenious procedure, fistulous communications between the ureters and rectum, with the hope that, the flow of urine being diverted 1 Prof. Cheever, of Boston, has reported a successful operation in a case which as described, seems to have been one of congenital, fistula rather than of extroversion of the bladder. The penis and urethra were normal, and the posterior wall of the bladder protruded through an opening in the abdominal parietes, half an inch wide, and an inch above the pubis. A somewhat similar case has also been successfully operated on by Prof. Bigelow. Dr. T. More Madden, of Dublin, reports a case of congenital fistula of the right ureter. EXTROVERSION OF THE BLADDER. 1003 the exposed mucous surface of the bladder would assume the character of skin. The operation was, from the first, only partially successful, and the patient died about a year afterwards from disease of the ureters and kid- neys, which apparently was set up by the irritation caused by the opera- tion itself. In other cases in which similar procedures were undertaken, by Lloyd and Athol Johnson, the patients died within a few* days from acute peritonitis; but somewhat more successful efforts in the same direc- tion have been recently made by Sydney Jones. Uraemic poisoning proved fatal in a case in which T. Smith turned the ureters into the colon. Dr. Levis, of this city, in two cases established a communication between the bladder and perineum, and then covered in the former organ by a plastic operation, which, however, terminated fatally in each instance. Holmes bas suggested a plan of effecting the desired object, by applying in the bladder and rectum the two branches of a pair of screw-forceps (with a plate broad enough to extend from one ureter to the other), which, act- ing like Dupuytren's enterotome, should establish the necessary communi- cation between the organs without risk of perforating the peritoneal cavity. Sonnenburg in one case attached the ureters to the dorsal groove of the penis, and then dissected away the bladder, and in two other cases simply dissected away the bladder, leaving the ureters in situ—operations of which I confess that I do not see the advantage, as they would necessarily permit the urine still to dribble constantly as before. Sonnenburg's first opera- tion has been successfully repeated by Niehans. 2. Plastic Operations, varying more or less in their details, have been employed for the relief of extroverted bladder, and in many instances with very gratifying results. (1) Richard, modifying Nelaton's operation for epispadia, operated, in 1853, by dissecting a broad flap from below the umbilicus, turning it with its skin surface towards the bladder, and covering it in with a bridge of skin taken from the front of the scrotum. This operation, though most ingeniously planned, unfortunately induced peritonitis, which proved fatal. Le Fort has recently modified Richard's operation by taking the covering flap from the enlarged prepuce instead of from the scrotum. (2) To the late Prof. Joseph Pancoast, of this city, belongs the honor of having, in 1858, performed the first successful plastic operation for ex- strophy of the bladder. His method consisted in taking flaps from the groins, inverting them over the protruded organ, and attaching them together in the median line, thus leaving a broad granulating surface which slowly cicatrized. The patient recovered from the operation, but died some months afterwards from another affection. (3) In the same year Dr. Ayres, of Brooklyn, N. Y., operated on a woman (who had previously given birth to a child) by turning down an umbilical flap—as had been done by Richard—covering it in by simply dissecting up the skin of the abdominal walls on either side, and bringing together the tissues thus loosened in the median line. The operation was perfectly successful. (4) Mr. Holmes, who has operated in a number of cases, emjiloys two flaps, one from the groin, which is inverted, with its cutaneous surface towards the bladder, and the other taken from the opposite side of the scrotum and slid over to cover in the first. This plan was also followed by J. Wood, in some of his earlier cases. (5) The late Dr. Maury, of this city, in three cases adopted Roux's method, taking a saddle-shaped flap, attached at both ends, from the scro- tum, and inverting it bridge-like over the bladder—leaving the raw surface of the flap to heal by granulation and cicatrization. In one case the ope- 1001 DISEASES OF THE BLADDER AND PROSTATE. ration failed, but in the other two furnished a good result, and in each of these Dr. Maury succeeded (as did Pancoast) in effecting the cure of a hernia by the contraction which accompanied the healing jirocess. (6) Thiersch, of Leipsic, and Sir W. MacCormac emjiloy lateral flaps which are allowed to remain attached at both ends for several weeks, until they become thick and vascular, and are then laid across the bladder, with their granulating surfaces towards the mucous membrane. (7) Mr. Barker, of Melbourne, has successfully ojierated in a young girl, by simply dissecting up the integument on either side of tin' bladder, uniting the flaps thus formed with deep and superficial sutures, and reliev- ing tension by means of lateral incisions. (8) Prof. H. J. Bigelow, of Boston, instead of endeavoring to restore the cavity of the bladder, simply* dissects off the mucous membrane as low as the level of the ureters, and covers the raw surface with flaps taken from the groins. A similar operation has also been practised by Foulis, of Glasgow. Fios. 586, 587, 588.—Plastic operation for extroversion of the bladder. (From a patient in the Chil- dren's Hospital.) (9) Prof. Wood, of King's College, London, has ojierated in a large number of cases, and has latterly employed a method which is now usually known by his name, and to which I have resorted in five cases, from one EXTROVERSION OF THE BLADDER. 1005 of which the annexed illustrations are taken. Three flaps are used, one taken from the umbilical region and inverted over the bladder, as in Rich- ard's and Ayres's methods, and the others, one from each groin, united in the median line over the first, which they cover in. The great advantage of the inverted umbilical flap is that it effectually prevents the escape of urine in an upward direction, while the groin flaps cover in the raw sur- face of the other without undue tension, and, having broad bases, are in no danger of sloughing. In the case of a male subject, a roof may be formed for the urethra, at a subsequent operation, by inverting flaps from the newly-formed covering of the bladder, and from the sides of the penis, adjusting over them a bridge-like flap from the scrotum, as in Nekton's and Richard's procedures. In three of the five cases in which I have ope- rated, the result was quite satisfactory, but in one, though a first operation was successful, a second terminated fatally, from shock, in a little over twelve hours, and a second case likewise terminated fatally in the course of the fourth week. Cases of Plastic Operation for Extroversion of the Bladder. £■ 1 1 .2 Operator. o> > o ? 3 Operator. g > 0 a? 3 00 '3 03 * a> '3 OI o « t. ft 0 « h 0 Agnew 5 3 1 1 Maury . . . 4 3 1 Annandale 1 1 • •• Mears • •• 1 Ashhurst 5 3 "2 Michel 1 Ayres . 1 1 ..• Monmonier 1 1 Barker 1 1 Pancoast 1 Barrow 1 1 Parker1 . 1 Bigelow 2 2 Porter1 1 Billroth . 2 2 Read . 1 Brigham . 1 1 Richard i Durham . 1 "i Richelot "i ... Forbes 1 1 Robson 1 Goodman 1 i Ruggi 2 Hodges 1 "i Shrady 1 Holmes 6 3 "2 i Sloan 1 Johnston . 1 1 Smith 3 Jones . . 1 1 Thiersch 20 16 4 King . . 1 1 Vogt . ... 1 Kiister 2 1 "i White 1 Langenbuch 3 3 Wilkins "i Le Fort . 1 1 Wood1 16 13 "2 i Levis . 2 "2 Wyman 1 1 Liicke 2 '*2 3 3 MacCormac 1 1 1 1 Aggregate . . Maisonneuve 110 82 6 22 Marsh .... 1 1 By this operation the patient is placed in a very comfortable condition; incontinence of urine, to a certain extent, necessarily continues, requiring the patient usually to wear a "railway urinal," or some similar con- trivance, but the bladder is effectually protected from irritation, and exco- riation is readily prevented. The principal points requiring attention in the after-treatment, are to prevent tension on the flap and encourage the contraction of the granulating surfaces by the position of the patient, who 1 Mr. Parker, Dr. Porter, and Mr. Wood have operated on other cases, the results of which I do not know. 1006 DISEASES OF THE BLADDER AND PROSTATE. should be placed in an almost sitting posture, with the knees flexed over pillows. In an adult, trouble may be caused by the growth of the puden- dal hairs, if the reversed flaps embrace any portion of skin naturally thus covered, and it will then be necessary, from time to time, to practise avul- sion with suitable forceps, until the inverted surface shall have lost its cutaneous character and become assimilated in nature to mucous membrane. Injections of dilute acetic or nitric acid may* also be required, to relieve vesical catarrh and prevent the dejiosit of phosphates. The statistics of these plastic operations are quite as favorable as could be exjiected, 110 ter- minated cases, to which I have references, having given 82 recoveries, (i failures, and but 22 deaths, exactly* 20 per cent. Trendelenburg and Ma- kins advise division of the sacro-iliac synchondroses, so as to approximate the pubic bones, as a preliminary* measure. Passavant endeavors to effect the same object by gradual compression. Malpositions.—Under this head may be included two affections, one of which, Hernia of the bladder, or Cystocele, has already been referred to, the other being Inversion of the bladder, which is extremely rare, and which is almost exclusively met with in female children. Inversion of the Bladder, a rare affection of which I have seen but one example, consists in a protrusion or invagination of the bladder through the urethra, where it appears in the form of a red, vascular tumor ; this, in one of the few cases of the affection on record,1 was mistaken for a new grow*th, and preparations had actually been made to remove it by ligation, when the discovery of the orifice of a ureter fortunately prevented the consummation of the operation. The protruding organ is readily reduced by manual pressure, but is apt to redescend when the pressure isremoved, when incontinence of urine necessarily remains. To remedy this, Dr. John Lowe, of Lynn, made repeated applications of the actual cautery to the urethra, keeping the bladder in place by means of a catheter with a bulbous extremity; he thus induced sufficient contraction to jirevent any protrusion whatever, and to diminish, though not entirely to remove, the incontinence. The same object might, in some cases, be accomplished by means of a plastic operation. The administration of nux vomica was of service in a case recorded by Dr. Yance, while Dr. Langworthy derived advantage from the use of gallic acid applied as a suppository to the urethra. Recumbency alone effected a cure in a case under the care of W. L. Richardson. Dr. CaiHe* has reported a remarkable case of inversion of the ureter, which protruded through the urethra. Cystitis. Cystitis, or Inflammation of the Bladder, may be acute or chronic, and in the latter case may or may not be accompanied with vesical catarrh. Acute Cystitis.—The seat of inflammation is the mucous lining of the bladder, especially the part around the neck of the organ. In some cases, however, the submucous and muscular coats are also involved, and the inflammation may even spread to the adjacent layer of peritoneum. The vesical mucous membrane is found after death to be injected or deeply congested, and sometimes, if the inflammation have been long continued of a slate-colored or chocolate hue. Occasionally, shreds or patches of" lymph are formed, and in rare instances a complete cast of the interior of the organ has thus been produced. Ulceration and gangrene may be met with in the worst cases. 1 Mr. Croft, in 1871, could find but three cases on record besides that observed by himself; the reporters of these were respectively Dr. Murphy, Mr. Crosse and Dr Lowe. CHRONIC cystitis. 1007 Causes.—Acute cystitis may result from various forms of injury, from the irritation produced by a calculus or foreign body, from the action of certain medicines, such as cantharides or some of the mineral poisons, from the use of irritating injections, from acidity of the urinary secretion, from the extension of inflammation from neighboring parts (esjiecially from the urethra, as in cases of gonorrhoea), from an exacerbation of chronic cystitis, from exjiosure to cold, from gout, etc. Symptoms.—There is pain over and behind the pubis, and in the sacral region, perineum, and thighs, attended in bad cases with tenderness on pressure, and increased by rectal exploration and by the use of the catheter. The desire to urinate is almost constant and irresistible, the act of mictu- rition itself being intensely painful and often accompanied with great tenesmus. In mild cases, such as ordinarily follow gonorrhoea, and in which the inflammation is usually limited to the neck of the bladder, the urine is cloudy and contains a certain quantity of mucus and pus, but in severe cases it is tinged with blood, and soon becomes decidedly purulent, containing also shreds of partially organized lymph or false membrane. In these cases there is also a great deal of constitutional disturbance (which is almost entirely absent in the milder forms of the affection), the patient soon falling into a ty*phoid condition, often attended with delirium ; death may* ensue, usually in the course of the second week. In the milder cases resolution occurs—when recovery may be complete—though, in many instances, the inflammation subsides into a chronic state. Treatment.—The patient must be kept in bed. A few leeches may be applied to the hypogastrium or perineum, and followed by hot poultices or fomentations. The bowels must be kept in a soluble condition, and pain and vesical irritation relieved by the use of hyoscyamusand opium, given by the mouth, or in the form of suppository. Enemata of atropia are re- commended by Dr. Seniple, of Yirginia. Hot hip-baths may be adminis- tered during the acute stage, and the patient should drink moderately of flaxseed-tea, or other demulcent, medicated with a small quantity of citrate of potassium. When the inflammation begins to subside, buchu or copaiba may be cautiously administered. The diet should in ordinary cases be mild and unirritating ; but if typhoid sy*mptoms appear, free stimulation must be resorted to. If retention of urine occur, catheterization with a flexible instrument must be cautiously practised, and if symptoms of nephritis be manifested, wet or dry cups should be applied over the kidneys, and fol- lowed by mustard poultices or turpentine stupes. Chronic Cystitis may result from the same causes as those which produce the acute form of the affection (which indeed it often succeeds), from atony or paralysis of the bladder, or from any obstruction to the free evacuation of its contents—both of these conditions causing accumulation and partial decomposition of the urine, which then becomes very irritating to the vesical mucous membrane—or from tumors or other structural dis- eases of the bladder itself or of neighboring organs, as the rectum, uterus, or vagina. 1. Simple Chronic Cystitis, which is the form of the affection unattended with vesical catarrh, is the pathological condition which is present in most of the cases commonly called " irritability of the bladder"— a term which is not very well chosen, as it refers to a mere symptom. Microscopic examination of the urine, in cases of simple chronic cystitis, will always detect the presence of pus, and this, with increased frequency of micturition, and slight augmentation of the amount of vesical mucus, are the evidences by which the surgeon may recognize the existence of the disease. The treatment is the same as for the mildest cases of acute 1008 DISEASES OF THE BLADDER AND PROSTATE. cystitis, the inflammation in many instances subsiding under the influence of rest. 2. Chronic Cystitis with Vesical Catarrh is characterized by the deposition from the urine of a rojiy, tenacious, muco-purulent sub- stance, usually of a grayish-white color, and of alkaline reaction. This is often mixed with phosjihates, the urine itself being ammoniacal and ex- tremely offensive. The bladder becomes thickened, roughened, and some- times sacculated ; ulceration occasionally occurs; and the case mav termi- nate fatally by the patient falling into a tyjihoid or ursemic condition, to which Roser gives the name of ammonaemia. This form of cystitis is particularly apt to supervene in cases of vesical paralysis from injury of the spine (see p. 348). In the treatment of this condition, topical remedies are of the highest importance: urinary accumulation should be prevented by the cautious use of the catheter, or as suggested by McGuire, of Virginia, by the employment of a delicate flexible tube, which may be left in situ; and great benefit may sometimes be derived from washing out the bladder, by in- jecting at first warm water merely, and subsequently, if this be well borne, mild astringent or sedative lotions; the best, according to Thompson, are those containing acetate of lead (gr. ss to f^iv), ni- trate of silver (gr. ss to f^iv),1 dilute nitric acid (n^x to f Jiv), car- bolic acid (ntij to f^iv), or borax (Sodii boratis gr. viij-xxx, glvcer- inae f3ij, aquae f^iv). In order to prevent ammoniacal decomposition of the urine, Dubreuil recommends injections of a weak solution of silicate of sodium (gr. iij-iv to f§j); Clemens, of Frankfort, and Purdon, of Belfast, frequent injec- tions of healthy urine ; Erichsen and Nunn injections of quinia (gr. j—f3j); and Jefsner injections of creolin (0.5 per cent.). Salicylic acid and permanganate of potassium are favorably spoken of by Schiiller, and nitrite of amyl by Dittel. Yesical injections are most conveniently administered with an India-rubber bottle with a nozzle, and an ordinary elastic catheter ; not more than three or four fluidounces should be used on each occasion, the injected liquid being kejit in the bladder for a few minutes, and then allowed to flow off. When the patient himself applies the injection, Keyes recommends an ordinary fountain syringe provided with a two-way stopcock, the injected liquid thus entering the bladder by simple hydrostatic pressure (Fig. 589). A somewhat similar arrangement is employed by Zeissl, McGuire (of Richmond, Ya.), and Bertholle, who dispense with the catheter altogether, simply introducing the pipe of the instrument into the mouth of the urethra. Harrison, of Liverpool has Fltt. 589.—Keyes's apparatus for washing out the bladder. 1 T. G. Richardson employs a much stronger solution, viz., gr. xx-xxx to f zj. STRUCTURAL DISEASES OF THE BLADDER. 1009 devised an ingenious instrument for introducing medicated pessaries into the bladder. Counter-irritation to the supra-pubic region is often of service, and pain may be relieved by the use of anodyne suppositories. A belladonna plas- ter over the pubes may be used for the same purpose. Hot hip-baths will often be found useful. A large number of internal remedies have been employed in this affec- tion, and, it must be confessed, often in rather an empirical manner, those which seem to succeed best in some cases, failing utterly in others. Those which are probably most deserving of mention are buchu, uva ursi, pareira, matico, chimaphila, triticum repens, senega, copaiba, and cubebs. Dr. Gar- nett recommends a decoction of the broom-corn seed or Sorghum vulgare. Alkalies, especially the liquor potassae, in combination with the extract of hyoscyamus, may be tried if there be much vesical irritation, but must be watched, lest they increase the tendency to phosphatic deposit. Chlorate of potassium is recommended by Edlefsen, and has proved quite satisfac- tory in many cases in which I have employed it. The mineral acids may be useful on account of their tonic properties. When the urine is ammo- niacal, benzoic acid is highly recommended by Gosselin. Skene employs a combination of benzoic acid, biborate of sodium, and infusion of buchu ; I often direct 5 grains of the acid, with 8 or 10 of the borax, made up with lemon syrup, and water. Little reports several cases in which great benefit was derived from the administration of saccharin. Wyman, Comstock, and Delamere speak favorably of fabiana (pichi). An exclusive milk diet is advised by Dr. George Johnson, of London, and Dr. Weir Mitchell, of this city. It is scarely necessary to add that if the condition of the bladder depend upon any removable cause, such as vesical calculus or urethral stricture, this must be attended to before the cystitis can be cured. In the case of a female, dilatation of the urethra may be employed, as recom- mended by Papin, Howe, Teale, Duncan, Heath, Hewetson, and Madden,1 and in either sex recourse may be had, as a last resort,2 to cystotomy, the bladder in the case of a male being ojiened from the perineum, as in litho- tomy, and in the case of a female from the vagina; the operation, which is said to have been first performed by Bouchardat, in 1803, was strongly recommended by Guthrie, and has been advantageously employed in the male by numerous surgeons, including Syme, Fergusson, Willard Parker, Bickersteth, Parona, Bryant, Holmes, Teevan, Post, Hamilton, of Liver- pool, Powell, of Chicago, and Battey, of Georgia, and in the female by Emmet, Sims, Bozeman, Simon, Hegar, C. C. Lee, and others Horovitz has collected 58 cases of cystotomy for cystitis in the male, the results being known in 57 ; 30 patients were cured by the operation, 7 relieved, and 4 not benefited, while 16 died—15 of these, however, from advanced disease of the kidneys. Structural Diseases of the Bladder. Sacculated Bladder—Obstruction to the flow of urine, as from en- larged prostate or stricture, leads to hypertrophy of the muscular wall of the bladder, and gives its inner surface a roughened and fasciculated appearance. As a result of the violent contractions of the organ in the 1 Madden supplements urethral dilatation by the application of the glycerin of car- bolic acid to the vesical mucous membrane, and in some cases by scraping the latter with a dull wire curette. 2 Prof. Agnew suggests that the ureters might be separated from the bladder, and made to empty on the surface, in the groin or loin. 64 1010 DISEASES OF THE BLADDER AND PROSTATE. effort to expel its contents, the vesical mucous membrane and submucous tissue protrude between the interlacing bundles of muscular fibre, and form sacs or pouches, sometimes of very* large size, in which the urine accumulates and undergoes decomposition, giving rise to cystitis, and often leading to the formation of jihosphatic calculi. The treatment should be directed to preventing accumulation, which may* most conveniently be done by the use of an elastic catheter, aided by the sijihon arrangement of Prof. Dittel (see p. 077). Tumors of the Bladder.—Yarious forms of morbid growth are met with in the bladder—as the fibrous, fibro-cellular, and fibro-mu scuta r, con- stituting the polypoid tumors met with in this organ ; the papillary or villous, closely resembling in structure the chorion, very vascular, and sometimes, though by* no means always, of a cancerous nature (see pages 524 and 538 ; the encephaloid, the scirrhous (usually secondary to scirrhus of the rectum), and the epitheliomatous. Dermoid cysts have also been found to communicate with, if not to originate in, the vesical cavity. Any of these tumors may becomeincrusted with phosphatic matter, and thus sim- ulate calculus: but the diaguosis can usually lie made by careful sounding; Fenwick, Cushing, Newell, and Otis have successfully em- jiloyed the electric cystoscope for diagnostic purposes. He- morrhage attends both the villous and the malignant growths—in cases of the for- mer kind being of the charac- ter of capillary oozing, and in those of the latter occurring less constantly, but in consid- erable quantities at a time. The treatment, in the large majority of instances, must be merely palliative, consist- ing chiefly in the free admin- istration of anodynes, with stimulants, if necessary. As- tringent injections may be tried in the cases of villous Fio. 590.—Polypoid vesical tumors. (Civiale.) tumor, but should notlie re- peated if they produce vesical irritation. Polypoid, and even sessile, growths may be removed from the female bladder by the ligature, ecraseur, or scoop, the urethra being dilated for thejiurpose; or, as has been done by Norton and Kaltenbach, through a vaginal incision. W. F. Atlee has successfully removed a fungous growth by dilating the urethra and scraping away the neojilasm with his nail. It may occasionally be possible to remove a vesical polypus in the male by avulsion with a lithotrite, as was done in one instance by Civiale• with Bigelow's evacuator, as has been clone by Hurry Fenwick- or with slender forcejis, as effected by Antal. Humphry has successfully'removed a fibroma by lateral cystotomy, and Billroth a fibro muscular tumor (myoma) by incisiou above the pubis, as in the high operation for stone, while other successful supra-pubic operations have been recorded by various surgeons including Geza, Lange, Weir, F. S. Watson, and Buckston Browne' Yolkmann's patient, a man aged 54, died on the fourth day. Kocher Da- vies-Colley, Lund, Whitehead, Ransohoff, Duplay, H. Morris, J. M Bar- FISSURE OF THE NECK OF THE BLADDER. 1011 ton, and other surgeons have successfully removed villous and papillary tumors from the bladder by opening the organ from the perineum and scraping away the morbid growth with a sharp scoop, and an unsuccess- ful operation for villous tumor, by the sujira-pubic method, has been re- corded by Marcacci. Sir H. Thompson has several times succeeded in remov- ing vesical tumors through a jierineal opening into the urethra, followed by dilatation, without incision, of the neck of the bladder, and equal success has attended the same operation in the hands of Rauschenbusch and others. Stein has collected 98 cases of operation for vesical tumor (principally in men), with 53 recoveries and 39 deaths, the result in 6 not having been ascertained. Sir H. Thompson reports 38 cases operated on by himself by one or other method, with 5 permanent cures and only 8 deaths, decided though only temporary benefit having been afforded in the remainder. Partial excision of the bladder, for tumor, in the hands of Sonnenburg, ter- minated fatally some months after the operation ; Antal's case ended in recovery; and in one operated on by Wallace, of Liverpool, the patient was doing well on the seventh day. Helferich recommends, as a jireliniinary to supra-pubic section, the excision of the upper portion of the symphysis, so as to afford readier access to the bladder, while Zuckerkandl exposes the base of the organ by* a transverse perineal incision, separating the prostate which is turned backwards with the rectum. Tubercle of the Bladder is a rare affection, and is probably never met with except in connection with tuberculosis of other organs. The symptoms, as pointed out by T. Smith, closely resemble those of calculus, while the treatment, as far as the bladder is concerned, must be merely palliative; Smith particularly* recommends the confection of black pepper (Ward's paste), to relieve the haematuria which often accompanies the affection. Bar at the Neck of the Bladder.—This name was given by Guthrie to a rare form of obstruction situated at the neck of the bladder, and entirely distinct from the common hypertrophy of the middle lobe of the prostate. There are two forms of bar—one consisting in a ridge-like elevation of the mucous and submucous tissues, due to enlargement of the lateral lobes of the prostate, the median lobe being unaffected—and the other a similar fold or ridge, which Guthrie attributed to disease of an "elastic structure" (which he described as existing at the neck of the bladder), and which occurs without there being any apparent cause for its formation. The treatment in most cases must be palliative merely, though, if the condition could be accurately diagnosticated during life, it might perhaps be occasionally proper to divide the bar with a catheter carrying a concealed blade, as recommeuded by Guthrie and Mercier, the latter of whom has also devised an instrument for excising a portion of the offend- ing bar; Mercier's operation has been successfully employed in this country by Dr. Gouley, of New York. Fissure of the Neck of the Bladder is a condition described by Spiegelberg and Reginald Harrison as analogous to fissure of the anus. It is attended with pain and hemorrhage at each act of micturition, and seems sometimes to result from the improper use of instruments, or the use of unduly large instruments for the cure of stricture. The treatment con- sists in dilatation and cauterization with nitrate of silver, or, which I think preferable, division of the vesical neck through a perineal opening, an ope- ration which I have performed under these circumstances with entire suc- cess. 1012 DISEASES OF THE BLADDER AND PROSTATE. HEMATURIA. The existence of blood in the urine may be a symptom of various affec- tions of the urinary organs,1 and it often becomes important to determine the source of the hemorrhage. 1. Bleeding from the Kidney may be due to blows on the loin, to the existence of acute Bright's disease, to the irritation produced by a renal calculus, to tuberculous deposit, etc. The blood is usually intimately mixed with the urine, but may form a clot, in which case, by floating out the coagulum in water (as suggested by Hilton), its shape may betray its origin. By using the electric cystoscope, Mr. Hurry Fenwick has ob- served blood escaping in jets from the ureter. 2. Vesical Haematuria may result from congestion of the bladder, from tuberculous disease, from the irritation caused by a calculus, from fissure of the neck, or from the presence of a villous or malignant growth. The blood often coagulates within the bladder, but, when passed in a liquid form, the urine which first flows is less tinged than that which follows. If the hemorrhage be caused by a morbid growth, the appearance in the urine of shreds of the abnormal tissue, recognizable with the microscope, may aid the diagnosis. 3. Bleeding from the Prostate may depend upon congestion, in- flammation, or tuberculous or malignant disease of that organ. The diag- nosis from vesical hemorrhage may be aided by exploration with the finger in the rectum. 4. Hemorrhage from the Urethra may depend upon congestion or inflammation of the part; upon laceration from blows on the jierineum, injuries inflicted by instruments, imjiacted calculi, etc. ; upon rupture from straining in the effort to urinate, or from violent coitus;2 upon ulceration from malignant disease, etc. The diagnosis of urethral hemorrhage may always be made by observing that, in urinating, blood precedes the flow of urine, and that this, if drawn off by the catheter, is clear. Treatment of Haematuria—This must vary with the source of the hemorrhage. If due to renal injury, calculus, etc., the patient must be kept in bed, and astringents, such as gallic acid or acetate of lead, with opium, administered. The confection of black pepper is highly spoken of by T. Smith. When of vesical or prostatic origin, cold applications are of service. It is better, as a rule, not to interfere with clots in the bladder, but to leave their disintegration to the efforts of nature. If, however, it becomes neces- sary to adopt artificial means of evacuation, a portion of the clot may be gently drawn out through a large-eyed catheter, by means of Clover's or Bigelow's lithotrity apparatus, or an ordinary stomach-pump. Dr. J. H. Ledlie, of Illinois, recommends injections of lime-water to dissolve the coagulum. For persistent vesical hamiaturia, Thompson recommends in- jections of nitrate of silver (gr. j-iv to fgiv), or of the tincture of the per- chloride of iron (f5j to f |iv). Hemorrhage from the urethra may be controlled by cold applications, or, if these fail, by introducing a full-sized catheter, and compressing the penis upon it with "strips of adhesive plaster or a bandage. Bates, of Brooklyn, has devised an ingenious apparatus for applying cold and pressure within the urethra. Intermittent or Paroxysmal Haematuria, or (as it should per- haps rather be called) Haematinuria, has been observed in several cases i Haematuria without disease of the urinary organs has been observed by Raymond in connection with the urethralgic crises of locomotor ataxia. 2 The bleeding which occasionally follows immoderate sexual intercourse without rupture is, according to Hilton, usually prostatic. RETENTION OF URINE. 1013 by Greenhow, Marley, Fuller, Gull, and other writers, the paroxysm usually following exposure to cold. The treatment consists in the ad- ministration of tonics, particularly iron and quinia. Pneumo-Uria, or Pneumaturia, a condition in which gas escapes from the urethra, is occasionally observed, and is a source of much annoy- ance to the patient. Air may be introduced into the bladder in catheter- ization, and vesical gas may likewise come from a fistulous communication with the bowel, or from decomposition of coagula. Racibbrski and Keyes think that gas may be secreted by the walls of the bladder itself, but from four cases of the kind observed by Guyon and Guiard, in all of which the patients were diabetic, the latter surgeons conclude that the gas results from fermentation of the saccharine urine. In a case recorded by Dr. C. H. Ralfe, pneumaturia and glycosuria co-existed, and disappeared simultane- ously. Paralysis and Atony of the Bladder ; Retention and Incontinence of Urine, etc. True Paralysis of the Bladder is not very often met with ; it is most commonly seen in cases of injury or organic disease of the brain or spinal cord, though it occasionally occurs as a result of functional exhaus- tion of the spinal system from sexual excesses, as a reflex phenomenon dependent upon injuries or diseases of other parts of the body, or as a temporary consequence of the use of belladonna or similar drugs. When the paralysis affects the neck of the bladder only*, the urine constantly flows away, giving rise to incontinence ; when the body of the organ alone is involved, the bladder cannot expel its contents, and the result is retention; while, if the whole organ be affected, though most of the urine may escape, the bladder remains partially distended—and incontinence and retention may thus coexist. The treatment consists in keeping the bladder empty (when this is necessary) by the cautious and gentle use of a flexible catheter, and in relieving by suitable remedies any cystitis that may occur. In some cases, galvanism and the administration of various tonics, especi- ally stry*chnia, may be of service. The latter remedy has been successfully used by injection, in doses of ^ gr., by Dr. W. E. Tarbell, of China. Atony of the Bladder, from over-distention of this organ, is, on the other hand, frequently met with. This condition may arise in the course of low fevers, if the catheter be not used—or even from voluntarily neg- lecting the calls of nature—but is most commonly due to some source of obstruction, either prostatic or urethral, which, while not giving rise to absolute retention, yet renders the bladder unable to expel its whole con- tents. A certain quantity of "residual urine" thus remains, and gradually increases in amount until the organ is completely'distended, when the neck of the bladder becomes partially dilated, and, as pointed out by Thompson, an overflow takes place, masking the real condition, and leading the patient —and sometimes his medical adviser—to consider the case one of inconti- nence rather than retention of urine.1 Retention of Urine, though merely a symptom, is one of such im- portance as to demand special consideration. When it occurs gradually (as is the case when it arises from paralysis or atony of the bladder), the vesical cavity becomes slowly distended, until it may contain several quarts 1 I once saw a patient who, supposed to have paralysis of the bladder, had been taking strychnia for one year; the introduction of a catheter effected the evacuation of nearly a quart of urine, and showed the real condition to be one of prostatic retention with overflow. 1014 DISEASES OF THE BLADDER AND PROSTATE. of urine, and forms a prominent tumor in the hy*pogastrium, reaching nearly- to the umbilicus. The patient is usually* not conscious of jiassing a smaller quantity of urine than in the normal condition, though a certain amount of difficulty* may be exjierienced in completing the act of micturi- tion—the water being expelled w ith less force than in health, and dribbling of urine continuing after the bladder has been apparently emptied, or occurring during sleep or upon making any* muscular exertion ; when the bladder has become fully distended, overflow occurs in the way already described, and simulates incontinence. The diagnosis of retention is usually made with facility ; even if there be no hypogastric tumor, there will be dulness on permission over the pubes, and the distended bladder can be felt by* placing a finger in the rectum, when, by tapjiing over the supra- pubic region, fluctuation can be distinctly recognized. If, however, the walls of the bladder be thickened and contracted, the diagnosis may* be more difficult. Retention of urine, if unrelieved, leads to cystitis, with an ammoniacal state of the contents of the bladder; it may even jirove fatal through the supervention of a typhoid or uraemic condition. Treatment.—The treatment of retention with overflow, which is the condition met with in cases of atony of the bladder, requires in the first place the systematic use of the catheter, two or three times a day, so as to evacuate the "residual urine." A long and large flexible catheter is the best, but, whatever form of instrument may* be used, care must be taken that it actually enters the bladder, and not merely the prostatic portion of the urethra, which in these cases is often dilated, and may contain a couple of ounces of urine. When the retention has lasted for a long period, it may be better not to evacuate the entire contents of the bladder at once—which would probably give rise to cystitis—but to draw off a portion at a time, and thus enable the organ gradually to return to its normal state. In cases of short duration the bladder may perfectly regain its tone, but in many instances all that can be done is to palliate the patient's condition. Thomp- son recommends the application of the cold douche to the lumbar spine and abdomen, and the injection of cold water into the bladder. The hypodermic injection of ergotine has been successfully resorted to by Langenbeck, Iversen, and other surgeons. Spasmodic Retention of Urine, or, as Sir James Paget has happily called it, stammering with the urinary organs, is a condition occasionally met with, and one which is more annoying than dangerous. A person who is liable to this form of retention should learn to use a catheter, and should constantly carry one with him, as the fear of being unable to uri- nate is often of itself sufficient to bring on an attack. Hysterical Retention of Urine is occasionally observed in women, in connection with various other phenomena which are conventionally de- nominated hysterical. The treatment consists in regulating the state of the bowels, and administering tonics and nerve stimulants, with the local use of the cold douche; the catheter may be used once, to make sure that there is no actual obstruction, but should afterwards be withheld ; rujiture of the bladder never occurs in these cases, and the patient usually passes her water without difficulty, as soon as the distention becomes painful, and she is convinced that instrumental relief will not be afforded. Incontinence of Urine.—This may occur either in children or in adults. 1. Nocturnal Incontinence in Children.—The patient may wet his bed during sleep only occasionally, or may do so once or oftener every night This infirmity may result from habit (through neglect of the nurse to take the child up at jiroper intervals), from excessive secretion of urine or some Irritability, spasm, and neuralgia of bladder. 1015 irritating quality of this fluid, from irritation transmitted from neighboring organs, as the rectum, or from the existence of slight chronic cystitis, of phimosis, of preputial adhesions, etc. According to Major and Ziem, it is sometimes caused by nasal stenosis, forcing the child to breathe through the mouth, and thus leading to imperfect aeration of the blood. The treat- ment consists (1) in removing the cause, if this can be ascertained ; (2) in improving the general health ; (3) in obtunding the excessive sensibility of the bladder; (4) in endeavoring to induce a habit of attending to the calls of nature at suitable intervals; and (5) above all, in developing a hearty wish for relief on the jiart of the patient, for without his co-ojiera- tion, as justly observed by Brodie, little can be accomjilished. The first indication is to be met by regulating the diet, attending to the digestive functions, forbidding excessive use of liquids, etc; the second, by the ad- ministration of tonics, and the emjiloyment of sea-bathing or the cold douche; and the third, by the use of belladonna given by the mouth, in the form of tincture or extract, or by the hypodermic administration of atropia, aided in obstinate cases by the application of a solution of nitrate of silver to the prostatic urethra. The patient should be aroused and made to urinate once or twice during the night, and should be induced to strive himself to get relief from his infirmity—not by threatening punishment, but by encouraging the formation of cleanly habits. Yarious remedies beside those mentioned above have been employed with more or less success, such as blisters to the sacrum, the use of an apparatus to prevent the patient lying on his back (the urine, when this position is assumed, resting on the trigone of the bladder, which is its most sensitive part), the application of collodion to the meatus, as recommended by* Corrigan, circumcision, the application of electricity, the administration of hydrate of chloral, hypodermic injections of strychnia, etc. These may be, each or all, properly tried in obstinate cases. 2. True Incontinence of Urine in the Male Adult is very* rare, the real condition in most cases so described being, as already mentioned, retention with overflow. In women, owing to the shortness of the urethra, inconti- nence of urine is more common, resulting usually from injury received during parturition. True incontinence in the male may, however, result from paralysis of the neck of the bladder—in which case the treatment appropriate to that condition must be adopted—from urethral stricture, or from a peculiar form of hy*pertrophy of the prostate, in which the enlarged third lobe projects wedge-like between the lateral lobes, keeping the neck of the bladder constantly* patulous. Under these circumstances, unless the cause can be removed, little can be done beyond the adaptation of a well-fitting urinal to keep the patient dry. Irritability, Spasm, and Neuralgia of the Bladder (Cystalgia) are often spoken of as distinct diseases, but are usually merely symptomatic of other conditions, such as cystitis, tumor or fissure of the bladder, or vesical calculus. The treatment must be addressed to the relief of the pathological condition to which the symptoms are due, when this can be ascertained. Anodynes and antispasmodics are often useful as palliatives. Lund and Teale recommend, in cases of females, rapid dilatation of the urethra, and report several instances in which this mode of treatment gave entire relief. The same ojieration has been successfully resorted to by other surgeons, and in three cases, in my own hands, afforded complete relief from the distressing symptoms which had been complained of. In the case of the male urethra, benefit may be derived from rapid dilatation with metallic sounds, or with Thompson's stricture expander, or resort niay be had to division of the vesical neck in front of the rectum, as suc- «essfully practised in two cases by Yerneuil. 1016 diseases of the bladder and prostate. Inflammatory Diseases of the Prostate. Acute Prostatitis.—Acute inflammation of the prostate usually fol- lows urethritis, especially when due to gonorrhoea, but mav also result from various forms of injury, as from the introduction of instruments or the use of strong injections, from exposure to cold and moisture, as from sitting in wet grass, from previously existing cystitis, or from vesical cal- culus. As a complication of urethritis it is apt to be excited by the use of alcoholic stimulants or by* excessive venery. The symptoms of acute pros- tatitis are pain and weight in the jierineum, with great frequency of mictu- rition, dysuria, and vesical tenesmus, the pain also being increased by the act of defecation. There is a good deal of constitutional disturbance, and the swelling is sometimes so great as to induce comjilete retention of urine. The diagnosis can be readily made by rectal exploration. The inflamma- tion may terminate in resolution, or may run on to the formation of an abscess, which usually bursts into the urethra; even if resolution occurs, however, the urine will probably* contain pus, from the coexistence of cystitis. The treatment consists in the enforcement of rest and the admin- istration of laxatives, with the application of leeches or cups to the perineum, followed by hot hip-baths and poultices. Pain may be relieved by the use of anodyne enemata. Should complete retention occur, it may be neces- sary to use the catheter. Abscess of the Prostate usually occurs as a sequel of acute prosta- titis, but may be develojied in an insidious manner from bruising of the part in the use of instruments, etc. In the latter cases, it is often the areolar tissue around the prostate which is affected, rather than the organ itself, and the affection is then called peri-prostalic abscess. Pointing usually occurs, as already* mentioned, in the direction of the urethra, but occasionally towards the rectum, or even externally in the perineum. The symptoms are those of deep-seated suppuration in general, and the diagnosis ean be made by rectal exjiloration. Retention is apt to occur when the swelling is principally on the side of the urethra, and the introduction of the catheter may then serve the double purpose of opening the abscess and evacuating the contents of the bladder. When the swelling makes its appearance in the perineum, an early and free incision is required, to relieve tension and prevent the formation of a rectal or urethral fistula. If fluctua- tion is distinctly felt in the rectum, it will be proper to make a puncture in that locality. Prostatic abscesses usually heal without much difficulty, but occasionally fall into a chronic state, persisting as suppurating cavities which form receptacles for urine. This condition is often not recognized during life, the symptoms closely resembling those of chronic cystitis. Benefit may sometimes be derived from the application of a weak solution of nitrate of silver. Chronic Prostatitis or Prostatorrhcea___This may be a sequel of acute prostatic inflammation, or may occur as a primary affection, result- ing from the urethritis which accompanies organic stricture of long stand- ing, from bruising of the perineum in equestrian exercise, from inordinate indulgence in sexual intercourse, from onanism, or from piles, habitual constipation, etc. The symptoms are pain and weight in the region of the prostate, increased during micturition or coitus; diminution in the force with which the urine is evacuated ; a slight, thin, gleety discharge, some- times in sufficient quantity to discolor the clothing ; and usually the pres- ence of a little pus in the urine, with occasionally a few drops of blood. Nocturnal seminal emissions occur in some cases. The affection is chiefly important on account of the mental distress often occasioned to patients CHRONIC HYPERTROPHY OF THE PROSTATE. 1017 who believe the gleety discharge to consist of seminal fluid. This is, perhaps, the most prominent symptom of the disease, and has suggested the name prostatorrhoea, which is employed by Prof. Gross, who has given an excellent account of the affection. The diagnosis between prostatic fluid and semen can always be made by microscopic examina- tion ; the former contains very few if any* spermatozoa, while these are, on the other hand, abundant in the latter. The treatment consists in removing any* cause that can be detected, in the administration of tonics, especially phosphoric acid and strychnia (with laxatives, if required), and in the application of blisters or other counter-irritants to the perineum. In cases accompanied by nocturnal emissions, a solution of nitrate of silver (gr. v-x to f^j), or, which is preferred by H. Lee, of the perchloride of iron (n^xv-xxx to f'3j), may be occasionally applied to the prostatic urethra, by means of a sy*ringe with a catheter-like nozzle. Winternitz applies cold by passing a stream of water of a temperature from 55° to 60° Fahr. through a double-current catheter without eyes, which he calls a psychrophor. Chronic Hypertrophy of the Prostate. This is an affection of advanced life,1 being seldom if ever met with in men less than fifty years old, though inflammatory enlargement (a totally distinct condition) may of course exist at any age at which prostatitis is possible. So often is prostatic hypertrophy seen among those past the middle period of life, that Sir Ben- jamin Brodie considered it almost a normal condition under such circumstances; but the statistical investigations of Thompson, Mes- ser. Lodge, and Dittel have shown that its actual frequency is less than has been sup- posed, appreciable enlargement existing in but about one-third of the cases examined in persons more than sixty years of age. The hypertrophy may affect only the un- striated muscular fibres and connective tissue of the prostate, or may* involve its glandular structure as well; there may* be enlargement of the whole organ, or the increase of size may be confined to its lateral lobes, or to its central portion, constituting what is com- monly called the enlarged "third lobe of the prostate." In many cases independent or semi-isolated tumors are found—principally in the lateral lobes—almost identical in structure with the prostate itself, though con- taining less glandular tissue, and that imperfectly developed ; these pro- static tumors, which have been specially studied by* Thompson, are some- times surrounded by a fibrous capsule, and may often be readily enucleated with the finger, as has been done in the operation of lithotomy (see page 989); they are in many respects analogous to the fibro-muscular growths (myomata) met with in the uterus. Physical Characters.—The weight of an hypertrophied prostate may vary from one to twelve ounces, and its size from two to four inches transversely, and from one to three inches in an antero-posterior direction. Fio. 591.—Enlargementof median lobe of prostate. (Erichsen.) 1 Dr. Mudd, of St. Louis, however, has seen a well-marked myomatous enlargement of the third lobe of the prostate in an infant of 13 months. 1018 DISEASES OF THE BLADDER AND PROSTATE. The consistence may be firmer or softer than in the normal condition, the increased firmness being usually* attributable to the jnesence of the pro- static tumors which have been referred to. Hyjiortrojihy of the prostate produces various changes in the form and direction of the prostatic portion of the urethra: this is increased in length and often rendered tortuous; it is usually* contracted laterally, and widened from before backwards, so that on making a transverse section it apjiears as a narrow chink instead of a round tube ; but in other cases, this portion of the urethra is dilated into a pouch which may hold an ounce or two of urine. When the central portion or " third lobe" of the prostate is enlarged, the urethra is commonly* bent forwards at an angle—its course being thrown also to the right or left if either lateral lobe is increased in size, and the deviation* being to the side opposite to that of the principal enlarge^ ment. The internal orifice of the urethra usually assumes a crescentic shape, the concavity of the crescent corresponding to that lobe of the pros- tate which is principally affected ; but if the whole organ be irregularly enlarged, the urethral opening is much and curiously distorted. A pro- jecting portion from the median lobe not unfrequently hangs over the orifice in a valve-like manner, closing it more or less completely when the patient attempts to urinate. An- other mode in which the urethral orifice may be occluded, is by the formation of a bar at the neck of the bladder from the elevation of the mucous and submucous tissues by enlargement of the lateral lobes (see page 1011). In the large majority of cases, hypertrophy of the prostate inter- feres with the complete evacuation of the contents of the bladder in one of the ways mentioned, leading to a thickened, roughened, and sac- culated condition of that organ, which becomes slowly distended, and falls into a state of atony at- tended with habitual overflow of urine ; under these circumstances, a very slight cause, such as ex- posure to cold, or local congestion produced by alcoholic indulgence or sexual emotion, may be sufficient to produce an attack of complete retention. On the other hand, it occasionally happens that the me- obes, keeps the urethral orifice con- stantly jiatulous, thus giving rise to true urinary incontinence (page 1015). In cases of long standing, the ureters and pelves of the kidneys'often be- come dilated, and chronic renal disease supervenes. Symptoms.—The early symptoms of enlarged prostate are diminu- tion of the force with which the contents of the bladder are expelled, the stream, though perhaps not smaller than in health, being feeble and slow and tending to drop vertically* from the meatus. The patient has to strain at the beginning of micturition, and the process requires a longer time than usual, because the bladder is in a state of partial atony • as the Fig. 592.—Section of bladder and prostate, the former hypertrophied, the latter forming pro- minent tumors within the bladder. (Thompson.) dian, projecting between the lateral TREATMENT OF ENLARGED PROSTATE. 1019 organ, morever, is never completely emptied, the desire to make water recurs with undue frequency, and the normal sense of relief is not ex- perienced from the act of urination ; the water continues to dribble after the discharge of all that can be voluntarily evacuated, and particularly at night when the control of the will is withdrawn. There is a feeling of weight and distention about the perineum, with irritation of the rectum, tenesmus, piles, or prolapsus; and ultimately the symptoms of chronic cystitis are developed, with an ammoniacal state of the urine, and perhaps the formation of phosphatic calculi. Diagnosis.—Hypertrophy* of the prostate may always be recognized by careful exploration with the catheter, aided by the finger in the rectum; in this way the surgeon can ascertain not merely* that the prostate is en- larged, but can determine approximately the degree of hypertrophy, which lobe or lobes are particularly affected, and the direction in which the urethra deviates from its normal course. The ordinary*'catheter frequently will not reach the bladder, on account of the elongation and altered direction of the prostatic urethra which have been referred to; hence the surgeon should have at hand some prostatic catheters, which are from two to four inches longer" than the ordinary instruments, and have a larger curve (Fig. 594). Rectal exjiloration will also enable the surgeon to ascertain if the distended bladder can be felt beyond the prostate—an important point in case the question of puncturing the organ for relief of retention should arise. By conjoined urethral and rectal exjiloration, the surgeon can distinguish prostatic hypertrophy from paralysis or from simple atony of the bladder, from the bar at the neck of the organ unconnected with jirostatic disease, and from chronic cystitis; the diagnosis from stricture of the urethra may be made by observing the locality of the obstruction (which in stricture is rarely more than six, and in prostatic hypertrophy at least seven, inches from the meatus), and the different characters of the stream, which in stricture is small and often forked, but is not always reduced in force, and sometimes keeps its normal parabolic curve, while in prostatic obstruction, though perhaps not diminished in size, it is always weak, and tends to drop vertically* from the meatus. The diagnosis from calculus may be made by careful exploration with a sound; but it must not be forgotten that cal- culus and prostatic disease often coexist. Acute prostatitis can be recog- nized by rectal exploration alone, through the pain which is thus excited ; while the catheter alone will show whether or not there is atony of the bladder, the flow when the obstruction is overcome being forcible and par- tially under the control of the will, when this organ is healthy, but weak and totally* uninfluenced by volition, if it be in a condition of atony. This circumstance will of itself suffice to distinguish simple atony from prostatic obstruction. Tumor of the bladder is to be diagnosticated by observing the presence of blood and of fragments of the morbid growth in the urine, and by careful instrumental exploration (see jiages 1010 and 1011). Treatment.—The most important point is to obviate the effect of ob- struction, by emptying the bladder at suitable intervals by catheterization. Twice a day—morning and evening—is usually often enough, but the fre- quency* with which the instrument is used must depend upon the degree in which obstruction is present. The patient should be taught to pass the in- strument for himself, the best form for ordinary* use being the " English" gum-elastic catheter, which should be kejit, as advised by Brodie and Thomp- son, on an over-curved stylet (Fig. 594, a), so that, when this is removed, it may pass readily into the bladder. For special cases it may be necessary to use silver instruments, some of which should have a large curve—a third of the circumference of a circle the radius of which is 2| inches—^and 1020 DISEASES OF THE BLADDER AND PROSTATE. others a short beak like a lithotrite, which form of instrument is known as the elbowed catheter (sonde coudee); flexible catheters of the same form are also useful, and are known as Mercier's (Fig. 593). In other cases it may be necessary* to use the gum instrument with the stylet, so that the curve may & Fig. 593. — Mercier's el- bowed catheter. Fia 594.—a, Gum catheter mounted on a stylet of the proper curve for use in cases of prostatic obstruction ; b, c, d, silver prostatic catheters of different curves. be altered at will, or so that the curve may be increased when the catheter reaches the point of obstruction, by partially withdrawing the stylet, in the way recommended by Hey, of Leeds. An ingenious instrument for'use in cases of retention of urine from prostatic enlargement, has been devised by Dr. Squire, of Elmira, under the name of vertebrated catheter; its con- struction can be seen from Fig. 595. Dr. Cowan, of Danville, uses a soft gum catheter containing a spiral coil of brass wire, so as to give sufficient firmness to the instrument without interfering with its elasticity and simi- lar instruments have been employed by other surgeons, including the" late Dr. S. W. Gross. Dr. Otis, and Dr. Keyes. If it should be necessary to leave a catheter in the bladder—which should, as a rule, only be done in cases of retention in which the introduction of the instrument has been attended with great difficulty—the vulcanized India-rubber catheter should be chosen, and may be introduced with or without the stylet, as may be found most convenient; if the stylet is used, it is, of course, to be withdrawn as soon as the instrument is in place. The catheter may be most conveni- TREATMENT OF ENLARGED PROSTATE. 1021 ently* secured by transfixing it with a double ligature, and making a loop on each side, through which is passed one of the middle tails of a double T bandage. Self-retaining catheters have been devised by several sur- geons, but, I confess, have always seemed to me more ingenious than practically useful. Fiq. 595.—Squire's vertebrated prostatic catheter. Beside periodically emptying the bladder by the use of the catheter, the surgeon must pay great attention to the general condition of the patient, who should live temperately, dress warmly, and take moderate walking exercise in the open air. The treatment of cystitis with vesical catarrh, a frequent complication of enlarged prostate, has already been referred to. Various drugs, particularly conium, mercury, muriate of ammonium, and iodine, have been employed in the hope of causing absorption of prostatic enlargement, and systematic compression (first proposed by Physick) has been used for the same purpose ; none of these remedies have, however, sustained the reputation which was claimed for them, and they are now generally* abandoned. Harrison, of Liverpool, advises compression (with an olivary bougie) as a means of preventing obstruction, by moulding the prostate as it grows, in such a way as to prevent occlusion of the urethra. Various operations, such as incision, excision, cauterization (the use of the galvanic cautery has been lately recommended by Bottini), avulsion, strangulation with the ligature, crushing with a lithotrite, etc., have also been suggested, but do not as a rule offer any hope of benefit commensu- rate with the risk which they entail. In exceptional cases, however, en- larged portions of the prostate may be advantageously removed, either by supra-pubic cystotomy*, as advised by McGill, Buckston Browne, Kiim- mel, Atkinson, and F. S. Watson, or through a perineal incision, a plan which I have myself pursued with benefit on several occasions. Harrison recommends that the obstructing portion of the prostate should be divided, and a large tube introduced and worn for several weeks. Prof. Gross thought highly of the occasional application of leeches to the perineum. Heine recommends the injection of tincture of iodine, and Langenbeck and Iversen that of ergotine, the injections being given through the rectum. Heine's method has been successfully employed by Dr. Melville Taylor, of Maryland, but, according to Dr. B. Howard, several cases thus treated by Dittel, of Vienna, terminated in suppuration and death. The internal administration of ergot was advised by the late Dr. W. L. Atlee, of this city, and is favorably spoken of by Dr. Satterthwaite, of New York. I often employ ergot in connection with chlorate of potassium. Sir Henry Thompson, some years ago, advised that, in cases which required the very frequent use of the catheter, an opening should be made above the pubis, and a flexible tube introduced and permanently retained in position. A similar plan has been recommended by Dittel, and by Keyes, of New York, and in one case in which I tried the operation it certainly afforded very great relief. Sir Henry has more recently suggested that the opening 1022 DISEASES OF THE BLADDER AND PROSTATE. should be made into the urethra from the perineum, and that the flexible tube should be introduced in that position. A successful operation by the first (supra-pubic) method has been recorded by Mr. Swinford IMwards. Fio. 596.—Catheterization in en Urged prostate. (Erichsen.) Treatment of Retention from Prostatic Obstruction. If comjilete retention occur, the surgeon may try the effect of a hot bath with a full dose of opium; but if this fail (as it usually will), jiersevering attempts must be made to pass a catheter. The patient should be in a recumbent position, for if erect, fatal syncope might occur from the rapid withdrawal of a large quantity* of fluid (as in the operation of tapping the abdomen), and the sur- geon should then try in succession, with all gen- tleness, however, prostatic catheters of various kinds and shapes, until, if possible, relief is af- forded, when, if thought proper, the instrument mav be fastened in the bladder. If the disten- tion has been very great, it may be jirudent to remove only a portion of the urine at a time (see page 1014). The chief points to be attended to in catheterization, in these cases, are (1) to firmly depress the extremity of the instrument between the patient's thighs, so that its beak may ride over the enlarged third lobe into the bladder, and (2) to make sure that the bladder is actually* reached, and that the catheter does not merely enter the elongated and dilated urethral pouch which often exi-ts in cases of prostatic enlargement. If catheterization cannot be accomplished, the bladder must be punc- tured in one of four ways, viz., (1) through or behind the prostate; (2) through the rectum ; (3) above the pubis; or (4) through or below the pubic symphysis. Puncture through the Prostate (Tunnelling the Prostate).—This operation was recommended by Home, Brodie, and Liston, the two former surgeons simply perforating the obstruction by pushing through it a silver catheter, while the latter employed a large and slightly curved canula car- rying a concealed blade. The surgeon first satisfies himself that the instru- ment is exactly* in the median line, and has not deviated from the urethra, and then pushes it steadily onwards while he depresses its handle, until the cessation of resistance and the flow of urine show that the bladder has been reached. A false passage is thus made through the projecting third lobe of the prostate, and in this false jiassage the instrument should be left for about forty-eight hours, when the parts wilJ usually be sufficiently consoli- dated to allow the catheter to be withdrawn and re-introduced as often as necessary* This mode of treatment is by no means free from risk, and should never be resorted to unless the surgeon can positively satisfy him- self that his instrument has not left the channel of the urethra, and that it impinges directly upon the obstructing portion of the prostate. Under other circumstances the bladder might not be reached at all, and the opera- tion would probably* be followed by the most serious consequences. Harrison, of Liverpool, recommends tapping through the prostate, from the perineum, with a trocar and canula, the latter of which is retained in position, and reports a case in which this procedure was resorted to with most gratifying results, the size of the prostate rapidly diminishing after PUNCTURE OF BLADDER THROUGH RECTUM. 1023 the operation, and a radical cure being thus ultimately effected. Howlett suggests " post-prostatic puncture" of the bladder from the perineum, a trocar being pushed up three-quarters of an inch in front of the anus, and guided by a finger in the rectum until resistance ceases. Puncture through the Rectum is not applicable to cases of very great jirostatic enlargement. If, however, the fluctuation of the distended bladder can be distinctly recognized above the prostate, by digital exjilora- tion through the rectum, this operation may be safely resorted to, as the puncture can then be made below the recto-vesical fold of peritoneum. Fio. 597.—Puncture of the bladder through the rectum, and above the pubis. (Phillips.) The patient being in the lithotomy position, the bladder is steadied and pressed downwards by an assistant placing one hand on either side of the abdomen ; the surgeon, then, having satisfied himself as to the extent and relations of the prostate, introduces upon the left forefinger, which serves as a guide, a curved trocar and canula, seven or eight inches in length, and by* depressing the handle of the instrument carries its point through the contiguous walls of the rectum and bladder, the cessation of resistance showing when the latter organ has been entered. The trocar is then care- fully withdrawn, and the canula secured in place by means of tapes fastened to a bandage around the waist. After a few days, probably, the catheter can be introduced without difficulty, when the rectal canula may be taken out, the wound usually closing without any trouble. The risk of rectal puncture, apart from wound of the peritoneum (which can scarcely occur if the operation be reserved for cases in which vesical fluctuation is dis- tinctly recognized by the finger in the rectum), are injury of the seminal vesicle, abscess of the recto-vesical septum, leading perhaps to urinary infiltration, and the formation of a recto-vesical fistula. Emphysema has 1021 DISEASES OF THE BLADDER AND PROSTATE. occasionally followed the ojieration. The statistics of rectal puncture have been investigated by Deneffe and Van Wetter, who have collected 97 cases, with 86 recoveries and 11 deaths. Puncture above the Pubis__The bladder may also be safely tapped above the pubis (in which position it is uncovered by peritoneum), by making a small incision in the median line just above the symphysis, and then introducing a straight or slightly curved trocar and canula (with the convexity upwards) in a direction downwards and backwards, so as to penetrate the bladder; the canula may* be left in for two or three days, after which a gum-elastic tube may* be substituted—the latter instrument being subsequently* renewed as often as may* be found necessary. Dr. Dieulafoy, of Paris, has suggested a modification of this operation, by which the bladder is emptied by means of the "aspirator," and nume- rous cases have now been recorded in which this operation, which does not appear to be attended with any particular risk, and which I have myself emjiloyed with satisfaction, has been successfully performed. It has the advantage over other modes of treatment, that it may be repeated as often as necessary, and therefore does not require the retention of an instrument. Deneffe and Van Wetter find that 152 cases of the ordinary supra-jiubic puncture gave 125 recoveries and 27 deaths, while 55 cases of jiuncture with the aspirator gave 52 recoveries and only 3 deaths. Puncture through the Symphysis Pubis was first suggested by Brander, of Jersey, in 1825, and has since been successfully resorted to by Leasure, of Pennsylvania, and several other surgeons. It is accomplished with a strong hydrocele-trocar and canula, by pushing the instrument through the symphysis in a direction " obliquely downwards and back- wards towards the sacrum." This mode of treatment is only applicable to cases in which the cartilage of the symjihy'sis is unossified, and does not appear to present any advantage over the supra-pubic puncture, particu- larly when the "aspirator" is employed; and the same maybe said of the sub-pubic mode of operation attributed to Voillemier. Dr. W. R. Whitehead recommends, as preferable to any form of puncture, a supra-pubic cystotomy, the bladder being opened in the median line, and the cut edges of the viscus attached by silver sutures to the edges of the external wound. Hunter McGuire establishes a fistulous track above the pubis, the external opening being situated about three inches higher than the internal, so that the patient ordinarily retains his urine, but can expel it when desired in a parabolic stream. Other Diseases of the Prostate. Atrophy of the Prostate is occasionally observed either as a con- genital or as an acquired affection. The prostate may be considered as atrophied whenever its weight (in an adult of medium size) is less than half an ounce. The affection presents no special symptoms and requires no special treatment. Carcinoma of the Prostate is usually of the encephaloid variety, though, according to Jolly, true scirrhus is occasionally found in this organ! The affection, which is one of great rarity, may occur either in early child- hood or in late adult life ; the symptoms are those of prostatic obstruction with jiain, haematuria, glandular implication, and, ultimately, general cachexia. The diagnosis is almost impossible during the early stages of the disease; and, indeed, according to Jolly, has rarefy been made during the life of the patient. The treatment must be purely palliative and instru- mental interference should be, if possible, avoided. If absolute retention EXPLORATION OF THE URETHRA. 1025 occur, puncture of the bladder may be required as a means of prolonging the life of the patient, though, of course, ultimate recovery is impossible! For further information on the subject of prostatic cancer, the reader is referred to the writings of Gross and Thompson, and especially to an elabo- rate and exhaustive memoir published by Jacques Jollv, in the Archives Generates de Medecine for 1869. Dr. H. R. Wharton has reported a remarkable case of prostatic sarcoma. Tubercle of the Prostate occurs in connection with tubercle of other organs, but presents no special indications for treatment. Cysts of the Prostate are of the kind called by German pathologists retention-cysts, resulting from obstruction of the glandular tubes of the organ by calculous concretions; they are seldom recognized during life, but in one instance, recorded by Lansdowne, the cyst attained so great a size as to cause retention of urine. In this case the cyst was punctured through the rectum, and suppuration followed, resulting in the patient's recovery. Lowdell has observed a true hydatid Cyst in this locality. Prostatic Calculi have already been referred to at page 998. CHAPTER XLVI. DISEASES OF THE URETHRA AND URINARY FISTULA. Exploration of the Urethra. This is accomplished by the aid of catheters, bougies, or sounds, and may be aided in some cases by the use of the endoscope. Catheterization of the urethra is an operation which is very frequently required, and in the performance of which every surgeon should strive to acquire such skill as to inflict the least possible amount of pain upon his patient. Catheters—These are hollow tubes, made either of metal—when they must have a curve corresponding to that of the normal urethra—or of India-rubber, or other flexible substance. There are two principal varieties of flexible catheter in the market—the English and------------------------- the French. The former____________________ ' ~Q is of a yellowish-brown color, and is provided with ■—---------P -.___________ a stylet; it can be made of _____________________ ""^ any Curve the Surgeon Flu. 598.—French flexible bougie and catheter. chooses, by moulding it in hot water and then quickly plunging it into cold water, when it becomes stiff, and will retain its curve long enough to allow its introduction in all ordinary cases. The French instrument, usually of a black color, is, on the contrary, perfectly flexible, bending with the utmost facility in every direction ; it is conical towards its extremity, and terminates in an olive- shaped point, to prevent its catching in the lacunae of the urethra. An- other form of French catheter, known as Nelaton's, is made of thin India- rubber, and is chiefly employed when it is desired to keep an instrument constantly in the bladder (sonde a demeure). A catheter should be ten or eleven inches long, and provided with one or two large, smoothly finished eyes near its vesical extremity*; the metallic instrument should be heavily plated with silver or nickel, and should have rings at its outer end "65 1026 DISEASES OF THE URETHRA AND URINARY FISTULA. to enable the surgeon to judge, by their position, of the exact situation of the beak of the instrument, when it is in use. The curve, of a catheter should correspond to that of the normal urethra ; the instrument emjiloyed by Thompson has a curve which forms a quarter of the circumference of a circle with a radius of one and five-eighths inches (three and a quarter inches in diameter). Benique's instrument, which was preferred by Rum- stead, has the same curve, but occupies a greater arc of the circle. The curve of the catheter should be continued quite up to its point. The sizes of catheters are arranged by either the English, American, or French scale —the latter being the best, as having more numbers, and therefore allow- ing more nicety of graduation. The English scale runs from one to twelve, the American from one to twenty, and the French from one to thirty, the numbers in the latter representing the circumference in millimetres.1 For purposes of exploration, or for ordinary* use, a medium-sized catheter should be chosen, as it is less likely to inflict injury than a smaller'one, and will not be caught in the lacunae of the urethra. A double-curved or S catheter is a convenient form of the instrument for office use. Hueter, of Greifswald, employs flattened catheters, which he considers easier of in- troduction than those of the ordinary form. Bougies and Sounds.*—These may be regarded as solid catheters. The bougie (originally made of wax, whence the name) is a flexible instru- ment, and there are two varieties, corresponding to the English and French catheter. Beside the ordinary conical, olive-pointed French bougie,3 the surgeon should have some of the kind which go under the name of bougies a boule, or, as Bumstead more accurately terms them, acorn-pointed bougies. These are particularly valuable for purposes of Fio. 599.—Bougies d boule. exploration, enabling the surgeon to judge of the extent of a stricture by noting the point at which resistance is felt, both upon the introduction and upon the withdrawal of the instrument. Care must be taken, how- ever, not to mistake for stricture the normal narrowing of the urethra in the region of the triangular ligament, at which point, as shown by Dr. J. Wm. White, of this city, the bulbous-pointed bougie is apt to be "arrested when it is being withdrawn. Filiform, bougies are simply bougies of a very* small size ; they may be made of whalebone, or of the same material as the ordinary French bougie or catheter, the latter being upon the whole the best. These instruments are indispensable for the treatment of ti"-ht strictures. Sounds are made of steel, pewter, or other metallic substance, and should be perfectly smooth and highly polished, or, which is better, plated with silver or nickel. Their curve should be that of a well-made metallic catheter, i Strictly speaking, the numbers of the French scale represent the diameter in thirds of a millimetre; the ratio of diameter to circumference is not precisely 1-3 but 1-3.1415926 ; the statement in the text, however, is sufficiently accurate for practical purposes. 2 Or urethral sounds, in contradistinction to the vesical sounds used for exploring the bladder. 3 To obtain an instrument intermediate in firmness between an ordinary bougie and a sound, Thompson suggests the introduction into the former of a leaden stylet which terminates about four and a half inches from the extremity of the instrument. INTRODUCTION OF THE CATHETER. 1027 and they should have a broad handle to prevent them from slijiping when in use. Their sizes are graduated by the same scale as those of catheters. Sir C. Bell employed a bulbed sound for purposes of exploration, and the late Mr. B. Wills Richardson, of Dublin, devised an ingenious instrument, the extremity of which was formed by the approximation of two half-bulbs' which were introduced closed, and could be divaricated after passing the stricture, thus clearly marking the posterior limit of the contraction as the instrument was withdrawn. Introduction of the Catheter.—The patient may be in a standing,1 sitting, or lying posture, the last being much the best under ordinary cir- cumstances. He should lie perfectly flat on his back, with the shoulders slightly elevated and the thighs somewhat flexed and separated; the drawers should be slipped down below the knees, and the shirt tucked up so as to fully expose the genital organs. If thought necessary, pain may be prevented by the injection of a few drops of a four-per-cent. solution of hydrochlorate of cocaine. The surgeon, sitting or standing on the left side of the patient, raises the penis with his left hand, and, holding the catheter or sound (previously warmed and oiled), lightly between the thumb and two fingers of the right hand, introduces its beak between the lips of the meatus, its shaft being nearly horizontal and lying in the direction of the fold of the patient's left groin. The penis being steadied and slightly drawn upwards so as to efface the folds of the urethra, the instrument is very gently pushed onwards, entering almost by its own weight, and being "swallowed," as it were, by the canal, until the beak has passed beneath the symphysis pubis. During the first two inches of its course the cathe- ter should be kept to the floor of the urethra, so as to avoid the lacuna magna, but should afterwards be made to cling to the roof of the canal, to avoid the sinus of the bulb and the openings of any false passages that may be present. When the point of the catheter has passed beneath the pubis, the shaft is to be brought into the median line and slowly elevated to a vertical position, when, by gently depressing the handle between the patient's thighs, supporting at the same time the convexity of the instru- ment by pressing on the perineum, or with the finger in the rectum, the beak will glide into the bladder. If any difficulty* be experienced, the instrument should be slightly* withdrawn, and re-advanced with its point held more closely to the roof of the canal. The points requiring special attention are, to avoid the lacuna magna, to keep the handle of the instrument down until its point is well beneath the pubis, and to combine the progressive and curving motions in a slow and gentle sweep, so that the beak of the instrument may follow the normal course of the urethra, which the surgeon must constantly bear in mind. Above all, the surgeon must avoid the use of force. If the resistance be from spasm, this will yield to very gentle pressure ; if from congestion and engorgement of the prostate, from excessive development of the uvula vesicae, or from the presence of a bar at the neck of the bladder, it may be necessary to employ a prostatic catheter ; while if from organic stricture, a smaller instrument must be used. Under no circumstances should the sur- geon attempt to overcome the obstruction by violence, for the walls of the urethra are readily lacerated, and a false passage is very* easily made; whereas, in the words of Sir Henry Thompson, " temper, patience, and a light hand will overcome almost all cases of difficulty." Instead of oiling 1 Gay advises the standing posture, and directs the patient to make-a straining effort at micturition, so as to overcome any tendency to spasm. 1028 DISEASES OF THE URETHRA AND URINARY FISTULA. the catheter, it is sometimes better to distend the urethra with oil, thrown in with an ordinary penis-syringe.1 If the patient be very fat, difficulty may* be experienced in bringing the catheter to the median line of the body without prematurely elevating its handle, and under these circumstances a manceuvre known as the " tour de maitre" should be adopted. This is, indeed, a very convenient mode of Fio. 600.—Introduction of the catheter. (Voili.bmieb.) catheterization, and I often employ it instead of the ordinary method. The surgeon stands on the right side of the patient, and introduces the catheter with its convexity upwards and its shaft lying obliquely across the patient's left thigh; as the point of the instrument reaches the bulb, the handle is swept around towards the abdomen—when the beak enters the membra- nous portion of the urethra, and is carried into the bladder by depressing the shaft between the patient's thighs in the way already described. One or other of these plans is to be adopted in using'metallic catheters or sounds, and English flexible catheters and bougies. To emplov either of the latter with satisfaction, the surgeon must have at band two"basins one of hot water and the other of cold. The instrument is moulded to the proper curve in the first, and then instantly plunged into the other by which method its curve is fixed and will remain unchanged long enough 1 Dr. Tytler, of Manchester, suggests inflation of the urethra, either with Politzer'a bag or by the successive injection of carbonate of sodium and tartaric acid. THE ENDOSCOPE. 1029 for ordinary purposes. If, however, there be much delay in the introduc- tion, the warmth of the urethra will again soften the instrument, and it will lose its curve. The English catheter should, as a rule, be used without the stylet. The object of the latter is not to aid in the introduction of the instrument, but to enable the surgeon to give it a permanent curve by keeping it on the stylet when not in use. When the catheter without the stylet is not sufficiently firm, a metallic instrument will commonly be safer and more efficient. If, however—in a case of enlarged prostate, for instance —it be necessary* to leave the catheter in the bladder, the metallic instru- ment is undesirable, and it may* then be necessary to introduce the flexible catheter with the stylet, the latter being, of course, withdrawn as soon as the catheter is in place. The French instrument is introduced by simply pushing it gently in the line of the urethra. It is impossible to guide its point, which will,- how- ever, unless in cases of great obstruction, readily* find its own way into the bladder. The French catheter is, unfortunately, a perishable form of instrument, and is with difficulty kept in order in warm climates. A great difference of opinion prevails among surgeons as to which is the best, the flexible or the metallic instrument; it is commonly said that, though a gum catheter may* be the safest in the patient's own hands, yet that, for the surgeon, an undeviating instrument is preferable ; such was formerly my own opinion, but increasing exjierience has convinced me that Sir Henry* Thompson is right in declaring that for all ordinary* cases the flexible catheter is quite as easy of introduction as, and much less danger- ous and painful to the patient than, the metallic. In dealing, however, with some very* tight strictures, a silver catheter may* undoubtedly be pre- ferable to any other, while, again, in the later stages of dilatation, use may properly be made of fine polished conical steel sounds; in fact, in this as in most other departments of surgery, the practitioner will do wisely not blindly to follow one exclusive method, but to vary his remedies according to the exigencies of each particular case. Before using any catheter, whether flexible or metallic, the surgeon should carefully* examine into the condition of the instrument; from neglect of this precaution the end may be broken off in the bladder, and form the nucleus of a calculous concretion. Posterior Catheterization is a name employed by Volkmann for a mode of treatment advocated by Yerguin, Hunter, Brainard, and Ranke, which consists in opening the bladder above the pubis, and passing a catheter through the wound and into the urethra from its vesical extremity*. The Endoscope.—This consists of a somewhat conical metallic tube, straight for the urethra, and beaked like a vesical sound for the bladder, with an eye-piece, an illuminating apparatus, and an arrangement of mir- rors by which a strong light can be thrown upon whatever touches the end of the tube: This mode of exploring the internal cavities of the body appears to have suggested itself to Borrini, in the beginning of this century, and subsequently to Segalas, Bombolzini, Fisher (of Boston), and Avery, but was first practically introduced to the notice of the profession by Desormeaux; modifications of the instrument have since been proposed by Cruise, Warwick, Wales, and others, simplifying the apparatus, and per- mitting the employment of sunlight instead of artificial illumination. Though changes of color in the urethral mucous membrane are readily recognized with the endoscope, it has not been found to add much to the information which can be acquired by careful exploration with the sound or catheter, and has proved less useful in practice than was at first antici- pated. Dr. Nietze, of Vienna, has devised an instrument which he calls a cystoscope, by means of which a platinum wire is by electricity rendered 1030 DISEASES OF THE URETHRA AND URINARY FISTULA. incandescent in the bladder, and a prism is so arranged as to reflect the appearances of the part, which the surgeon inspects through a tube or catheter. A somewhat similar contrivance, under the name of polyscope, Fio. 601.—Desormeaux's endoscope. had been previously employed by Trouve. The use of electric illumination for exploration of the bladder and urethra has been particularly advocated by Mr. Hurry Fenwick. Malformations of the Urethra. The urethra may be partially or completely occluded, or may be par- tially deficient, an abnormal opening existing on its upper or lower surface. When the opening is above, the deformity is called epispadia, and when below, hypospadia. Partial Occlusion, or Congenital Narrowing of the Urethra, occurs at or near the external meatus; the treatment consists in restoring the calibre of the part by an incision with a probe-pointed bisto-ury, recontrac- tion being prevented by the subsequent use of a bougie, or, as advised by Weber, by dissecting the skin from around the orifice, and then splitting and everting the mucous membrane, which is subsequently attached by several points of suture, as in Ricord's mode of amputating the penis. Complete Occlusion of the Urethra produces retention of urine which usually* proves fatal within a few hours of birth • if the condition should be recognized during life, the occluding membrane, which is usually but a few lines in thickness, should be divided with a sharp bistoury or punctured with a trocar and canula, the opening being maintained by the occasional passage of a bougie. Should the point of occlusion be so far back as to render it impossible to reach it from the meatus, it would I think, be the surgeon's duty to open the urethra behind the seat of obstruc- MALFORMATIONS OF THE URETHRA. 1031 Fio. 602.—Epispadia. Duplay's method. tion, if this could be done from the perineum, or to puncture the bladder by one of the operations which have already been described. Epispadia, or Deficiency in the Roof of the Urethra, maybe complete or partial. Complete epispadia is seldom met with except in connection with exstrophy of the bladder ; the latter deformity having been remedied in the way already described, the epis- padia may be relieved by a plastic operation, as has been done by J. Wood (see page 1005). Partial epis- padia is but a lesser degree of the same deformity, the abnormal opening extending from near the pubes to the end of the penis ; it may be treated in a simi- lar manner, by turning down a narrow flap from the hypogastric region, and covering it with a bridge of skin dissected from the scrotum. This operation, which originated with Nelaton in 1852, has been since repeated, both by himself, byFollin, and by J. Wood, with good results ; it is the operation after which was modelled Richard's method of treating exstrophy of the blad- der (see page 1003). Another plan (Fig. 602), successfully emjiloyed by Duplay, consists in simply denuding raw surfaces on either side of the urethral floor, and then bringing them together over a catheter with a modified quill suture. Schroder, Meericke, and other surgeons have suc- cessfully operated in cases of epispadia in women. Hypospadia, or Deficiency in the Floor of the Urethra, is a com- paratively common affection. The abnormal opening, which is usually much smaller than that of episjiadia, is commonly found at the base of the fraenum, more rarely at the point of junction of the penis and scrotum, and occasionally, it is said, in the jierineum. Complete hypospadia, associ- ated with cleft scrotum, constitutes one form of hermaphrodism, so called. When the opening is placed far back, the deformity, besides causing incon- venience in micturition, interferes with the ejaculation of semen, and thus renders the patient practically sterile ; under these circumstances the mal- formation (which is usually unimportant) may call for surgical treatment, which consists in endeavoring to restore with knife or trocar the natural passage from the meatus to the urethra above the hypospadic orifice—the latter being subsequently closed by a plastic operation such as will be de- scribed under the head of urethral fistula—or in making a new urethra by one of the ingenious operations devised by Bouisson, Moutet, Anger, and Duplay, of France ; J. Wood, of London ; and Couley, of New York. Of these, the best are, I think, Wood's and Duplay's—Wood's consisting in inverting a flap from the lower surface of the penis and scrotum,and covering it in with a saddle-shaped flap taken from the prepuce, and Duplay's in inverting flaps from the lower surface of the penis and covering them in with others taken from the sides of the organ (Fig. 603), a dorsal incision being made if necessary to relieve tension, or— which the same surgeon now pre- fers—in making grooves merely, on either side of the urethral Fig. 603.—Hypospadia. Duplay's method. 1032 DISEASES OF THE URETHRA AND URINARY FISTULA. roof, and covering this with side flaps held together over a catheter with a modified quill suture. In cases of glandular hypospadia with great con- traction of the orifice, I have employed with much advantage AVeber's operation for partial occlusion of the urethra. Duplay advises that, in both epispadia and hypospadia, the operations for the formation of the new urethra should be undertaken at an early* period, but that the last steji— the closure of the abnormal orifice—should be postponed until the |iatient has attained the age of reason. Emmet has successfully- operated in a case of deformity analogous to hyspopadia, occurring in a young woman. Prolapsus of the Urethra. This is said by Guersant to be a not unfrequent affection in female chil- dren. The prolapsus, which results from straining efforts in coughing or in defecation, or, as in a case recorded by Ingersley, in an attempt to stop laughing, forms a rose-colored tumor at the urinary meatus, apparently proceeding from the interior of the canal, but having in its centre an open- ing which admits the catheter and thus reveals the nature of the affection. If unrelieved, the prolapsus leads to vulvitis, and gives rise to a burning and smarting sensation in the act of micturition. The treatment recom- mended by Guersant is excision with curved scissors, hemorrhage being checked by* the use of the perchloride of iron or ice. Ligation followed by excision proved successful in the hands of Dr. Day, of Louisiana. The galvanic or actual cautery* is employed by Skene, and excision with Paque- lin's cautery by Herman. Chamorro records a case occurring in an adult, and at first mistaken for prolapsus of the womb. Rest in bed and the use of astringents rendered reduction possible. Streubel and Blum, and Sealy and Hudson, of New Zealand, have also observed the affection in adults, as have T. G. Thomas and Emmet, the latter of whom cured his patient by a plastic operation. Urethrocele. In this affection, which is only met with in females, the wall of the urethra becomes much thickened, and forms a pouch which projects between the labia, allowing the retention of a considerable quantity of urine, and eventually leading to cystitis and ulceration of the bladder. The treatment recommended by Bozeman, who has given a good account of the affection, consists in tapping the urethrocele at its most dependent point. Skene mentions a case cured by dilatation of the urethra and the injection of nitrate of silver. Gillette relieved his patient by denuding the anterior vaginal wall and bringing the edges of the wound together with stitches, while Lawson Tait has been equally successful in four cases by cutting away the base of the sac, dissecting out its mucous lining, and then bring- ing together the edges of the vaginal wound. Other cases have been re- corded by Foucher, Priestley, Simon, Thomas, and Dujilay, the latter of whom cured his patient by laying ojien the sac with the galvanic cautery and repeated cauterizations with nitrate of silver. Urethritis. Inflammation of the Urethra may arise from injury, from gastric or in- testinal disorder, from exposure to cold, from the contact of irritating in- jections, from an acid or ammoniacal condition of the urine (as in cases of long-standing stricture or prostatic enlargement), from onanism, from pro- longed or violent coitus, or from contact with the menstrual fluid or with SPASM OF THE URETHRA. 1033 leucorrhoeal or gonorrhoeal discharges. Whatever its origin, its course and symptoms are the same, and it requires the same treatment. This has already* been described at page 467. Spasm of the Urethra. Spasm, or, as it usually called, Spasmodic Stricture of the Urethra, rarely* occurs except as a complication in cases of permanent or organic stricture, or in those of inflammation of the urethra. I do not mean to deny the frequent existence of muscular contraction in a healthy urethra, which is indeed often felt closing around a catheter or bougie, the canal, as it were, grasping the instrument; but it is very seldom, indeed (except in the cases mentioned), that this contraction is sufficient to materially hinder the flow of urine, or to impede the entrance of a catheter. The chief causes of spasm, beside organic stricture and urethral inflam- mation, one or both of which are present in the large majority of instances, are (1) the irritation caused by the impaction of a calculus, by an acid or ammoniacal condition of the urine, or by certain substances which are eliminated by the kidneys, as the oil of turpentine, Spanish fly, and some varieties of wine or other liquor ; (2) voluntary neglect to empty* the bladder at the right time ; (3) exposure to cold; (4) immoderate indulgence in coitus ; (5) diseases of or operations on the lower bowel; and (6) dis- orders of the digestive apparatus or of the nervous system. To the latter cause is to be referred the urethral spasm, sometimes culminating in tem- porary retention, which occurs in the course of fevers, or after severe trau- matic injuries or surgical operations. Usually an attack of spasmodic retention is traceable to a combination of causes ; thus it not unfrequently happens that a patient with slight organic stricture, or slight urethral or prostatic inflammation, dining out or joining some party of pleasure, and indulging more freely than usual in the delights of the table, perhaps also neglecting to obey the call of nature at the proper time, finds at length, when an opportunity to empty the bladder is presented, that the power of micturition is gone. Slight spasm may occur at any part of the canal, but the common seat of the affection is at the membranous portion, from the action of the compressor urethras muscles. The symptoms of spasm of the urethra are the sudden occurrence of great diminution in the size of the stream, with great pain and straining in the act of urination, which is often accompanied with a feeling of weight and fulness in the perineum, and with irritation of the lips of the meatus, show- ing that with the spasm there exists a certain degree of urethral and pros- tatic inflammation. The treatment varies according as there is or is not complete retention. In the latter case, relaxation of the spasm may usually be induced by the administration of an enema of laudanum, and by placing the patient in a warm bath, a full dose of castor oil being given as soon as the bladder is relieved. Another remedy which has acquired a good deal of reputation in these cases, is the muriated tincture of iron, given in doses of ten or twenty minims every quarter of an hour. The introduction of lumps of ice into the rectum is recommended by Cazenave and Teevan. The recur- rence of spasm must be obviated by seeking for and removing the cause, and by attention to the state of the general health. When there is great acidity of the urine, alkalies may be administered, such as the bicarbonate of sodium, or the liquor potassse, in combination with tincture of hyoscya- mus and spirit of nitrous ether. If, as is usually the case, there is some 1034 DISEASES OF THE URETHRA AND URINARY FISTULA. permanent constriction of the urethra, this must be remedied by the sys- tematic use of bougies. In a case of comjilete retention of urine from spasm of the urethra, it is, I think, better to resort at once to the catheter. Apart from the patient's suffering, which is extreme, there is positive risk in allowing the bladder to remain distended ; atony of this organ, or cystitis, with all its conse- quences, may result, or rupture of the urethra, or even of the bladder itself, may follow, leading to urinary* extravasation, or even to fatal peritonitis. A rather small catheter—No."ll or 12 (French)1—should be employed ; and a gum-elastic is commonly preferable to a metallic instrument, as pro- ducing less jiain. If catheterization fail, the jiatient should be put into a hot bath, opium administered, and (if there be much inflammation) leeches applied to the perineum, when the bladder will either relieve itself, or it will be found that the instrument can be readily introduced. Severer measures, such as opening the urethra in the perineum, or puncture of the bladder, can only be required when the spasm is a mere complication of tight organic stricture, or of decided enlargement of the prostate. Brodie and Thompson have each recorded a case in which urethral spasm occurred periodically, and ultimately disappeared under the use of quinia. Congestive Stricture. The term is ordinarily, but incorrectly, applied to the temporary inter- ference with the flow of urine which is due to inflammatory swelling of the prostate and adjacent parts. It is, in fact, a condition of subacute prosta- titis, a disease which, as already mentioned, seriously impedes micturition, and occasionally produces absolute retention (p. 1016.) It is not unfre- quently observed as a complication of gonorrhoea, caused by exposure to cold, or by* imprudence of various kinds. (See p. 470.) When occurring in cases of organic stricture or enlarged prostate, spasm is often superadded. The treatment consists in the administration of laxatives, with laudanum enemata, and the hot bath. Leeches to the perineum will often be of ser- vice. If the urine be unduly acid, alkalies may be given, and strict atten- tion should be paid to the state of the patient's general health. If gonor- rhoea be present, this must be treated in the way described in previous pages, and benefit will often be derived, under these circumstances, from the occasional introduction of a bougie. The catheter may be required if absolute retention should occur. Stricture of the Urethra. Stricture of the urethra, or, as it is often called, in contradistinction to the temporary forms of obstruction last mentioned, Permanent or Organic Stricture, may result from long-continued urethritis (whether gonorrhoeal or otherwise), from mechanical injury (Traumatic Stricture), or from the contraction which attends the healing of chancroidal or other ulcers. The congenital defect which has been already described as Partial Occlusion of the Urethra, is sometimes not detected until adult life, when it may for all practical purposes, be regarded as a form of organic stricture. Age.— Traumatic Stricture may occur at any age. In one case which I saw with Dr. Lee, in a boy of 11, death ensued from urinary extravasation following the giving way of the urethra behind the seat of the stricture • and in another, in an older boy, sent me by Dr. Fussell, the lad, after 1 The numbers given in this chapter refer to the French scale, or "Charriere- filiere." STRICTURE OF THE URETHRA. 1035 external urethrotomy, had acute peritonitis, but eventually made a good recovery. The other forms of stricture, of which the gonorrhoeal is by far the most common, are rarely, if ever, met with before the age of puberty ; and, as several years usually* elapse between the occurrence of the gonor- Fig. 604.—Section of urethra, showing very narrow stricture, and dilated and reticulated membranous and prostatic portions behind it. (Thompson.) rhoea and that of the stricture to which it gives rise, the latter is most commonly observed for the first time in men from 25 to 40 years of age. Locality—The seat of stricture is, in the large majority of cases (over two-thirds), at the sub-pubic curvature of the urethra. This has been con- clusively established by the laborious and careful investigations of Sir Henry Thompson. The most common position is at the posterior or bulbous part of the spongy portion of the canal (Fig. 604), the liability of the urethra to constriction diminishing as it is traced backwards. The next most frequent seat of stricture is at, or within two and a half inches of, the meatus, and after this comes the central part of the spongy portion. Stric- ture in the posterior part of the membranous portion is quite rare, wbile in the prostatic portion it very seldom, if ever, occurs, though the contrary has been maintained by eminent authorities. Number___Usually*—in more than three-fourths of all cases—there is but one stricture, but occasionally two or three distinct constrictions are found in the same urethra, and cases are described in which there are said to have been still larger numbers. When several strictures coexist, one is almost invariably found at the sub-pubic curve. Morbid Anatomy__The tissue chiefly affected is the submucous areolar tissue, which, as the result of the inflammatory process, becomes the seat of lymph-formation, partial organization following, and gluing together the mucous and submucous tissues, and often involving the sub- stance of the corpus spongiosum. The contraction which ensues dimin- ishes the calibre of the canal, often throwing the lining membrane of the Fig. 603.—Stricture near the orifice of the urethra. (Thompson.) 1036 DISEASES OF THE URETHRA AND URINARY FISTULA. urethra into folds or ridges, and at the same time lessens the natural elas- ticity* of the jiart, and, of course, seriously impedes the exercise of its func- tions. Another form of stricture is described by some writers, as consisting in the dejiosit of a pseudo-membranous substance on the mucous membrane itself. Such a condition, if it exist at all, must be extremely rare. Classification.—Strictures are variously classified, according to—1, their anatomical character ; 2, the degree of contraction which they cause; and, 3, the syrmptoms which they present. 1. Classification according to Anatomical Character.—(1) A linear, bridle, pack-thread, or valvular stricture is one in which the obstruction is produced by a thick fold of mucous membrane perforated in the centre, or forming a crescentic septum at one side only of the canal, or jiassing across from one side to the other in the form of an isolated band or bands. These bands or fraena are, according to Erichsen, probably formed arti- ficially, by the perforation of a crescentic mucous fold with the point of a catheter. (2) An annular stricture resembles the variety* last described, except in the circumstance that the canal is obstructed for a greater extent, the ap- pearance being that which would be produced by tying a string or tape around the urethra. (3) Indurated annular stricture is the name given by Thompson to that form of constriction in which the tissues around the canal are indurated to the depth of from half a line to a line. The contraction is usually greatest at the central portion of the stricture, giving the part an hour-glass ajijiear- ance. The induration is commonly most dense at the floor of the urethra. (4) Irregular or tortuous strictures embrace all the more complicated forms of the disease. 2. Classification according to Degree of Contraction.—A very im- portant classification of strictures, as regards their treatment, is into per- meable and impermeable. In one sense of the word, every stricture is permeable ; that is to say, no stricture is so tight but that a drop or two of urine will occasionally find its way through ;l but that every stricture which allows the passage of urine is, as has been asserted, necessarily per- meable to a catheter or bougie, if used with sufficient skill and patience, I cannot admit. Doubtless one surgeon will succeed where another fails, but from all that I have seen, either in my own practice or in that of others, I am prepared to fully confirm the statement of the late Prof. Bumstead, that no surgeon of any considerable experience can honestly maintain that he has never seen an "impassable stricture." Liston and Syme, who were the great advocates of the doctrine that no stricture was impermea- ble, were both foiled in their later years in the attempt to pass an instru- ment, and even Sir Henry Thompson, who, in his clinical lectures, published in 1868, declared of the " ojieration for impermeable stricture" (perineal section), that he had never had occasion to perform it, and doubted if the necessity for it ever existed—in the third edition of the same work (1873) acknowledged that the general rule of permeability admitted of a few excep- tions, and confessed that he had thrice had occasion to perform the opera- tion in question. 3. Classification according to Symptoms.—Strictures are further classi- fied according to their symptoms, into the simple stricture, the irritable stricture, and the contractile or recurrent stricture. The significance of these terms will appear in the sequel. 1 Obliteration of the urethra may result from severe laceration of the part the urine all flowing through a fistulous opening in the perineum ; but such a condition is not properly speaking, a stricture. URETHRAL FEVER. 1037 Symptoms of Stricture—One of the earliest symptoms of stric- ture, in many cases, is the presence of a slight gleety discharge; there is, besides, pain in micturition, referred to the part of the urethra behind the stricture, and the calls to empty the bladder recur with increased frequency. The stream is diminished in size, and often altered in form, being curiously forked or divided. As a consequence of the small size of the stream, a longer time is required to empty the bladder, and the involuntary straining which attends the act often leads to great irritation of the rectum, with perhaps piles or prolapsus, and, in extreme cases, a discharge of the rectal contents whenever urination is attempted. Retention of urine may occur at any moment from spasm or congestion, or from the occlusion of the narrow passage by a pellet of mucus or a calculous concretion, but more usually the stream gradually lessens until the urine escapes in drops, the bladder slowly becoming distended, until the condition described as reten tion with overflow is established. The retained urine undergoes decom- position, becoming ammoniacal, and producing cystitis with deposrt of phosphatic matter. Hematuria is an occasional symptom of stricture, the blood being usually of urethral, but sometimes of vesical origin. Ulcera- tion of the bladder, or of the urethra behind the point of stricture, not unfrequently takes place, and, under these circumstances, rupture of the part may result from the straining efforts of the patient, leading to peri- tonitis or urinary extravasation. In other cases the ureters and pelves of the kidneys become dilated, and chronic renal disease1 supervenes. Ab- scesses often occur in the perineum, and more rarely in connection with the anterior portions of the urethra, leading to the formation of urinary fistulse. There is, usually, not much constitutional disturbance in the early stages of stricture; cases are, however, occasionally met with, in which grave nervous symptoms, with general depression, follow upon very tri- vial causes—such as the passage of a catheter, slight exposure to cold, etc. These symptoms, which are grouped together under the name of urethral fever, are chiefly, but not exclusively*, met with in cases of irritable stric- ture, so called, in which catheterization produces great and persisting pain. In the advanced stages of stricture, the constitution always suffers, the digestion being impaired, and the patient becoming emaciated and feeble. When the kidney*s are seriously affected, convulsions or coma may ensue. Urethral Fever is a not infrequent sequel of operations on the urethra, and may even occur after the simple introduction of a catheter. This affec- tion is said by Thompson to be most common among the inhabitants of warm climates. It is characterized by the occurrence of rigors (occasion- ally attended by syncope), with headache and vomiting, followed by febrile reaction. The symptoms, which sometimes return periodically, like the paroxysms of intermittent fever, may immediately follow the introduction of the catheter, but are usually delayed until after the first subsequent act of micturition, and thus appear to be due to the contact of urine with the tender, and perhaps abraded, surface of the urethra. The affection rarely causes death, though it may do so, particularly in cases complicated by the 1 The peculiar form of renal disease which is so often met with in cases of stricture and other obstructive diseases of the urinary organs as to have been called " surgical kidney," is described by Dr. Dickinson as disseminated suppuration of the kidney, a condition closely resembling the renal manifestation of general pyaemia. He proposes the name uriseptic as applicable to this form of renal suppuration, believing that it results from the absorption of ammoniacal and putrid urine. Dr. Goodhart is dis- posed to look upon the surgical kidney as, in some instances at least, an erysipelatous affection. 1038 DISEASES OF THE URETHRA AND URINARY FISTULA. existence of renal disease, possibly, as suggested by Thompson, from the sudden arrest of the function of the kidney. Urethral fever is occasionally followed by inflammation and suppuration of the joints, or of the muscular or areolar tissues, and, indeed, is in many respects analogous to gonorrhoeal rheumatism. It is, I believe, like that affection, a mild form of pyaemia. (See page 475.) It is maintained by Sedillot, Beltz, and other writers, that the occurrence of urethral fever is due to the absorption of urine, but this is at least not proved, while the facts that (1) the affection may and does occur in cases in which there is not the slightest reason to believe that any laceration of the urethra exists, and that (2), on the other hand, it does not occur in cases of urinary extravasation or infiltration (as after lithotomy), would seem to justify a contrary opinion. The treatment of urethral fever consists in the administration of nutri- tious food and stimulants, with tonics, esjiecially quinia and opium. The patient should be kept in bed, and great caution should be exercised in the employment of instruments. As a prophylactic, in patients predisposed to attacks of urethral or (as Holt calls it) stricture fever, quinia and opium may be given at regular intervals after each introduction of the catheter. Diagnosis of Stricture___This is made by exploration with a sound or catheter, and may be aided in some cases by the use of the endoscope. When the existence of stricture is suspected, the surgeon should introduce a medium-sized catheter—No. 13 or 14 of the French scale—and if, on several trials, the instrument is invariably arrested at the same point in the membranous or spongy portion of the urethra, the fact that there is a stricture may be considered as established. It is important, in this ex- ploration, to use a catheter of sufficient size, for a small one may lead to error on the one hand, by catching in a lacuna, or, on the other, by passing readily through the stricture, if this be not very tight. To ascer- tain the degree of contraction which exists, the surgeon may desire the patient to make water, when the size of the stream will afford some infor- mation upon this point. It often hajipens, however, that the patient is unable, from a nervous feeling, to urinate when asked to do so, and the surgeon must then try in succession smaller and smaller catheters, until one is found which enters the constricted part of the urethra. In seeking for the mouth of the stricture, it is well to have some regular course of proceeding; the catheter is not to be thrust blindly in various directions, but should be first carried along the roof of the urethra, and in the median line, then to either side, and finally along the floor of the canal. By means of the bougie a boule, the surgeon can ascertain, not only the position and tightness of the stricture, but its extent as well. Formerly wax bougies were employed, with the notion that, by pressing the instrument against the stricture, a mould might be obtained that would show its form and direction ; but this mode of exploration has not proved very satisfactory, and is rarely employed at the present day. Dr. Stuart Eldridge has de- scribed, under the name of the " pathfinder," an ingenious instrument for the diagnosis of stricture. Treatment of Stricture. The Constitutional Treatment of stricture should never be neglected. The diet should be regulated, and the digestive functions brought into a good condition. Cystitis, if present, should be treated in the way already described, and the general health maintained by the administration of tonics, and by attention to the hygienic state of the patient. Rest in bed for a few days is often a valuable preliminary to instrumental treatment, TREATMENT OF PERMEABLE STRICTURE. 1039 by relieving the congestion of the parts, and diminishing the tendency to spasm. H. Lee believes that many strictures are of syphilitic origin, and for such recommends the administration of mercury. The Local Treat- ment embraces the application of various methods, which may be classified under the five heads of dilatation, rupture, the use of caustics, and internal and external incision. The use of caustics in the treatment of stricture is rarely* resorted to at the present day, having been properly sujierseded by other and safer methods. The articles which have been chiefly employed are the nitrate of silver and the potassa fusa, the cauterizing agent being applied by means of an instrument resembling a catheter with a cup-like depression at its beak, or being simply fixed on the end of a wax bougie. Amussat has recently advocated a modification of this mode of treatment, consisting in the employment of the galvanic cautery applied to the con- stricted part by means of suitable electrodes. I shall consider the treatment of stricture under the heads of permeable stricture, impermeable stricture, and stricture complicated with retention of urine. I. Treatment of Permeable Stricture. This may* be conducted by means of—1, gradual dilatation ; 2, contin- uous dilatation ; 3, rapid dilatation, or rupture ; 4, internal urethrotomy ; and 5, external jierineal urethrotomy with a guide (Syme's operation). 1. Gradual Dilatation is by far the best mode of treatment in any instance in which it is applicable, and should be given a fair trial in every case of permeable stricture. Either flexible or metallic instruments may be employ*ed, the former being safer for tight strictures, and the latter more convenient for those of larger calibre. An instrument of sufficient size to enter and be fairly grasped by the stricture, should be introduced, without using such force as to cause pain or lead to hemorrhage; such an instru- ment having been carried through the stricture and passed into the bladder,1 may be allowed to remain for a few seconds, when it should be gently withdrawn.2 After a few days, it may be passed again and followed by a larger instrument, this process being continued until the urethra has, in the course of a fortnight or so, been dilated sufficiently to receive a No. 20 or 22 French catheter, which will be found, in ordinary cases, as large as the canal can comfortably accommodate.3 The dilatation must be sub- sequently maintained by the introduction of the catheter at gradually lengthening intervals. The mode in which gradual dilatation effects the cure of a stricture, is probably by inducing absorption of the imperfectly organized lymph which infiltrates the submucous tissue. This plan of treatment will be found satisfactory in the majority of cases of gonorrhoeal stricture. The great requisites for success are gentle manipulation and patience : no violence is to be used, lest a false passage be made; but the instrument is to be gently engaged in the mouth of the stricture, and held 1 Dr. F. D. Weisse employs a short sound with a ruled staff, so that it may be carried through the stricture only, and cannot enter the bladder. 2 Bardinet recommends that the instrument should be constantly moved backwards and forwards so as to effect an " internal massage" of the stricture—a mode of treat- ment which I cannot approve. 3 Dr. Otis, of New York, and some other surgeons, believe that the dilatation of the urethra should be carried to a much greater extent, and Dr. Otis has devised an in- genious urethrometer for determining what he considers the normal calibre of the tube ; I hope that I may not be considered as hopelessly wedded to conservatism, when I express the opinion that a stricture-patient who can pass a No. 21 or 22 catheter without suffering, had better rest and be thankful. 1010 DISEASES OF THE URETHRA AND URINARY FISTULA. there with the slightest pressure for a few minutes, when it will ordinarily slip through ; if not, it should be withdrawn, and a smaller one substituted. The dilatation must also be very gradual; if a No. 10 has been passed at one visit, it will be quite sufficient to get in a No. 11 or 12 at the next, and no advantage can be derived from attempting to progress more rapidly; for, by so doing, an attack of urethral fever may not improbably be in- duced, which, besides endangering the patient's life, necessitates an abandonment for the time of all treatment for the relief of the stricture. False Passages result from the employment of too much force, particularly in the use of small metallic instruments; the usual situation of false passages is at the lower part of the urethra, and to one or other side. At the moment of the instru- ment's deviating from the jirojier channel, the patient feels a sharp pain, and is usually conscious of something having given way ; the surgeon at the same time perceives that the instrument has slipped from the urethra, by the grating sensation which is produced ; and upon placing the finger in' the rectum, probably feels the instrument in close proximity to the intestinal wall; if a catheter has been used, blood is pumjied through it at every motion, and, whatever instrument has been em- ployed, rather profuse hemorrhage may follow its withdrawal. Should the surgeon be so unfortu- nate as to make a false passage, he should, if pos- sible, introduce a catheter into the bladder, by keeping its point closely to the roof of the urethra, FlG 606 _Fal8e pa88age8. leaving it in jilace for a few days, until the lacera- (Dkuitt.) tion has had time to heal. Even if this cannot be done, there is, however, not much risk of urinary extravasation occurring, doubtless on account of the false passage running in the opposite direction to that of the outflowing stream. Old false passages often give a great deal of trouble in the treatment of strictures by dilatation, the catheter tending constantly* to slip into the wrong channel. This may be obviated by using a well-curved instrument, and by keeping its point away from the orifice of the false passage, the position of which is soon ascertained ; assistance may be also derived from tilting up the beak of the instrument by pressure with the finger introduced into the rectum. 2. Continuous Dilatation__This requires the confinement of the patient to bed; it is effected by introducing a catheter, which is then secured in the bladder, and replaced in the course of a couple of clays by a larger one, and so on until sufficient dilatation has been accomplished. This is an efficient mode of treatment for cases in which catheterization gives great pain (irritable stricture), or in which the stricture manifests a tendency to recontract after ordinary dilatation (contractile or recurrent stricture). It may also be properly employed when, from the existence of false passages or other circumstances, special difficulty has been experienced in the first introduction of the instrument. In the employment of con- tinuous dilatation, flexible catheters are invariably to be preferred. Under the name of the " multiple-wedge treatment," Dr. J. S. Coleman, of Augusta, Georgia, recommends the introduction of several small bougies, side by side, as an efficient means of practising continuous dilatation. TREATMENT OF STRICTURE BY RUPTURE. 1041 3. Rapid Dilatation or Rupture—The methods which are included under these heads may properly lie classed together, as the difference in their mode of action is one of degree rather than of kind. Desault, Bu- chanan, Hutton, Maisonneuve, and Wakley endeavored to effect rapid dilatation of urethral strictures by introducing first a narrow sound or catheter as a guide, and then sliding over it tubes of gradually increasing sizes. Wakley's instrument, which is probably the best of its kind, con- sists of a small silver catheter which is first introduced into the bladder, a steel rod being then screwed into its outer extremity, so as to form an unerring guide over which the dilating tubes of gum-elastic or silver are subsequently jiassed. Fluid pressure,1 effected with a dilator constructed of silk and catgut, and capable of distention by means of a syringe, was long ago employed by Arnott, and has been more recently resorted to by Steurer, of New York, while the expanding properties of the laminaria digitata have been utilized by Beeves, Newman, and others; but, upon the whole, the best means of effecting rapid dilatation is by using instru- ments consisting of two or more blades, which can be made to diverge when in the urethra by a screw arrangement in the handle, or by introducing between them plungers, which act on the principle of the wedge. Luxmoor (in 1812),.Civiale, Leroy d'Etiolles, Perreve, Lyon, J. Pancoast, Thebaud, Voillemier, B. Wills Richardson, Schweig, and others, have devised inge- nious instruments for carrying out this object, but I shall only describe two, viz., Sir H. Thompson's instrument for "over-distending," and Mr. Holt's for "splitting" strictures. Thompson's instrument consists of two blades, which are joined at either end, and which can be separated at an intermediate point by turning a screw in the handle; an index serves to show the extent to which expan- sion has been carried, the figures corresponding to the numbers of the English catheter scale. The distending force is to be applied rather slowly, Fid. 607.—Thompson's stricture-expander. so as to overstretch rather than rupture the morbid tissues, and when the instrument is withdrawn, a full-sized gum catheter is passed, and allowed to remain twenty-four hours. Dilatation is subsequently maintained by the occasional introduction of a large sound. Holt's instrument (a modification of Perreve's), in its present improved form, consists of two blades joined at their lower extremity, and fixed in a handle containing a screw which can be set so as to limit the amount of expansion. A guiding rod (made hollow so as to serve for a catheter, and furnished with a stylet to keep it free from clots) passes between the blades, and when the instrument is introduced, a dilating tube, or plunger, of the required size, is slipped over the guide and quickly thrust down in such a way as to split or rupture the stricture; the plunger is next rotated upon the guiding rod, to insure separation of the split, when the whole instru- ment is removed, and the water drawn off with a full-sized catheter; no instrument is left in the bladder in ordinary cases, but a catheter is passed every other day for a week, and afterwards at longer intervals. The patient 1 Coze, of Strasbourg, employs fluid pressure, by bringing the weight of the column of water to bear directly upon the face of the stricture by means of an apparatus similar to the ordinary Weber's or Thudichum's douche. A similar plan is e nployed by Dr. Hadding and Dr. Golding, of New York. 66 1042 DISEASES OF THE URETHRA AND URINARY FISTULA. should go to bed after the operation, and take two grains of quinia with ten minims of laudanum every four hours until six doses have been taken. Mr. Holt believes that by this instrument the submucous tissue is split, Fio. 608.—Holt's instrument for splitting strictures. but the mucous membrane of the urethra itself uninjured ; but that such is not always the case is shown by* the fact that the operation is occasionally followed by rather free bleeding. My* own exjierience with Holt's method is limited, but, as far as it goes, is upon the whole favorable. I regard it as an excellent mode of treatment in cases of dense cartilaginous stricture of the sub-pubic region, as well as in those of the irritable and contractile varieties. It is, however, not free from risk, urethral fever and death having occasionally followed its employment. Until within a few years, the application of either of these methods was necessarily delayed until the stricture had been dilated sufficiently to admit the instrument, which could not be made of smaller size than a No. 8 or 9 French catheter; but it is now possible, by resorting to certain ingenious modern contrivances, to employ the over-distention or rupture treatment at once, for any stricture which is permeable to the smallest filiform bougie. One method, originally suggested, I believe, by the late Prof. Van Buren, and widely popularized by Dr. Gouley, of New York, consists in obliquely perforating the extremity of the instrument which is to be used, so as to make an "eve" by which it can be threaded over a delicate whalebone bougie, previously introduced ; while in the other plan, which is attri- buted by* Van Buren to Maisonneuve, and which was extensively employed by Prof. Bumstead, the surgeon makes use of an ordinary filiform gum bougie provided with a metallic cap, which can be screwed on to the extremity of whatever instrument is to be employed; the bougie being introduced, the instrument is attached to its end, and is thus readily guided through the stricture, the bougie itself jiassing. on and becoming coiled up in the bladder. 4. Internal Urethrotomy—This mode of treatment, which was employed by Allies and Physick in the last century, and by John and Charles Bell in the early part of this century, is particularly applicable to strictures in the anterior part of the urethra, but may also be used for those situated in the sub-pubic region—though for such the treatment by rup- ture is, I think, preferable. For strictures at or near the external meatus,1 a probe-pointed bistoury, guided by a small, straight staff or grooved director, will answer every purpose, but for strictures in other localities more complicated instruments are required. These, which are called urethrotomes, whatever their exact form (and a great many have been invented by different surgeons), consists essentially in a sound or catheter carrying a concealed blade, which can be made to project by means of a spring in the handle, and which is designed to cut from before backwards, from behind forwards, or in both directions. Urethrotomy from Behind Forwards, with such an instrument as Civi- ale's (Fig. 609), is, upon the whole, the safest method, but requires pre- vious dilatation of the stricture up to the calibre of a No. 8 or 9 French i For strictures at the meatus, B. Wills Richardson employs an operation devised many years ago by Colles, of Dublin, and very analogous to that more recently recom- mended by Weber in cases of congenital occlusion of the part. (See page 1030.) EXTERNAL PERINEAL URETHROTOMY. 1013 catheter ; it is particularly applicable to strictures in the penile portion of the urethra. Civiale's instrument has been ingeniously modified by S. W. Gross, and by Kinloch, of Charleston. Fig. 609 —Civiale's urethrotome. Urethrotomy from Before Backwards can only be safely performed by first introducing a guide through the stricture. Many urethrotomes of this kind are now before the profession, including those of Maisonneuve, Wood, Thompson, Trelat, F. N. Otis, Hill, Durham, Teevan, Mastin, Griberson, and Pritchett. These instruments vary* in their details, but all act by first securing the introduction of a guide, upon which is subsequently passed the blade which divides the stricture. Some combine cutting with dilatation, while others allow the surgeon, if he think proper, to enlarge the incision as the urethrotome is withdrawn. Whatever method be employed, the incision should usually*, I think, be made on the lower1 and not the upper side of the stricture ; a flexible cathe- ter should be kept in the bladder for twenty-four hours, and dilatation subsequently* maintained by the occasional jiassage of a sound. Internal urethrotomy* may be performed in the same class of cases as Holt's opera- tion ; but the latter is, I think, to be preferred for strictures behind the scrotum, the former being reserved for those situated anteriorly*. In the after-treatment of these cases, Otis employ*s dry cold applied by Petitgand's method of -'mediate irrigation" (p. 55). 5. External Perineal Urethrotomy -with a Guide, or the Ope- ration by External Division or External Incision (Syme's Method), is very* commonly confused2 with the old operation of perineal section, which is, however, only applicable to cases of impermeable stricture, whereas a prerequisite for this method (which was introduced by Prof. Syme in 1844)3 is that a staff shall be passed through the stricture into the bladder. Syme's staff varies in size from that of a No. 5 to that of a No. 12 French catheter, and is grooved at the lower third on its convex surface; at the point where the grooved portion joins the rest of the shaft, there is a distinct shoulder, which is made to rest against the face of the stricture, and thus guide the surgeon in his incisions. The operation is thus performed: the patient, being etherized, is secured in the lithotomy position, and the staff is introduced (in the case of a very tight stricture, by either of the methods described at page 1042) ;4 the surgeon then makes an incision about an inch 1 Dr. Otis, however, advises that the incision should always be made superiorly; he reports more than a thousand cases treated with his dilating urethrotome, with no deaths attributable to the operation. 2 A good deal of this confusion is, I think, owing to the fact that Prof. Syme re- ported as examples of his own operation, several cases, in which, having failed to introduce his staff, he cut into the perineum, guiding the subsequent course of the instrument by placing his finger in tlie wound. By so doing he really converted the operations into old-fashioned perineal sections, the only difference being that he cut down upon a small staff instead of a large one, and then slipped the same small staff through the stricture, instead of substituting a grooved director. 3 A similar procedure had been previously resorted to, and was described by De- sault as one variety of the " boutonniere," but to Syme is due the credit of making the operation generally known, and of indicating the circumstances under which it should be employed. * In order to avoid the entrance of the staff into a false passage, Prof. Gouley pro- ceeds as follows : The urethra being filled with olive oil, an attempt is made to intro- 1044 DISEASES OF THE URETHRA AND URINARY FISTULA. and a half in length,1 exactly in the median line of the perineum, and, feeling for the staff, introduces the knife, with its back towards the rectum, in the urethra behind the stricture, which is then divided by cutting in the groove of the instrument from behind forwards. A broad grooved director is then slipped into the bladder, and upon this, as a guide, a No. 13 or 14 catheter is introduced and secured in the usual way ; the instrument is retained for a couple of days, after which a sound must be occasion- ally passed to prevent recontraction ; the perineal wound usually heals without difficulty*. Syme subsequently. gave up the introduction of a catheter through the ure- thra, substituting a short jierineal tube, so as to afford a free outlet for the contents of the bladder, while Van Buren, Gouley, and other American surgeons have gone still further and have dispensed with the catheter alto- gether. The results of this operation are, on the whole, very satisfactory; 219 cases, collected by Thompson, show a mortality* of less than 7 per cent., which is a small death-rate in view of the nature of the cases in which it is ordinarily* jierformed. Five cases in my own hands have all terminated successfully. The ojieration by external division is particularly indicated in cases of dense and cartilaginous stricture (particularly when of traumatic origin), and of irritable or contractile stricture, when complicated by the existence of a perineal fistula. In cases, however, in which there is no fistula, Holt's ojieration is, I think, usually* preferable. Syme's method was also recommended by its distinguished author for the treatment of strictures in the anterior part of the urethra, but for such cases internal urethrotomy seems to me a better method. Fig. 610.— Syme's staff for external di- vision of urethral stricture. . II. Treatment of Impermeable Stricture. Cases are occasionally met with in which, from traumatic causes, the urethral canal is at some point totally obliterated, the urine escaping alto- gether through a fistula behind the point of injury ; beside these cases, there are others which are more properly called strictures, in which, though a few drops of urine make their way through the meatus, yet no instrument —not even a filiform bougie—can be introduced. For such cases, Boyer, and afterwards Mayor, recommended forced catheterization (a proceeding which was attended by* the gravest risks, and is now happily almost en- tirely abandoned), while Stafford proposed to cut through, the impassable stricture with a "lancetted catheter." This plan might perhaps be adopted duce a probe pointed whalebone guide, the point of which is rendered temporarily spiral by immersing: it in boiling water, twisting it around a small staff, and sud- denly cooling it. If the point of the guide becomes engaged in a lacuna, it is slightly withdrawn and carried onward with a rotatory movement. If it enters a false pas- sage, it is retained in situ with the left hand, while another is passed by its side this proceeding being repeated until the false passage is filled up, when at least one guide enters the bladder; the others are then withdrawn, and an "eyed catheter staff" threaded over that which is retained, in the way described at page 1042. 1 H. Dick suggested subcutaneous division of the stricture, the introduction of the knife being guided by the use of a staff provided with bulbs which could be felt through the tissues of the perineum ; and modifications of the subcutaneous method have been since employed by Mastin, of Mobile, by Teevan, of London, and by Dittel of Vienna. TREATMENT OF IMPERMEABLE STRICTURE. 1045 if a stricture in the anterior part of the urethra were so tight as to forbid the safer operation of internal urethrotomy. Such a case must, however, be extremely rare. The application of electricity by means of an electrode pressed against the face of the stricture has been occasionally employed with advantage, and might be tried if the patient objected to more radical measures. Dr. Leisenring, of Hamburg, recommends the formation of a supra-pubic fistula, as practised by Whitehead in cases of prostatic reten- tion (see page 1024). There remain to be described the Operation for Impermeable Stricture, Perineal Section, or, as it is more accurately* called by Prof. Gouley, Ex- ternal Perineal Urethrotomy without a Guide, and the operation recently recommended by Mr. Cock. The first is often spoken of as the boutonniere or button-hole incision ; but that name appears, from the writings of De- sault, to have been indiscriminately applied by French surgeons to any or all operations which had for their object the establishment of an opening from the perineum into the bladder, and thus would include (beside the ordinary perineal section) the "external division", of Prof. Syme, Cock's operation, in which the urethra is opened behind the stricture, and even the now obsolete procedure of puncturing the bladder through the perineum. 1. External Perineal Urethrotomy -without a Guide__The first formal operation of external uretnrotomy for the relief of stricture, unaccompanied by retention, appears to have been performed about the year 1652,l by an English surgeon, named Molins, upon a patient not too respectfully referred to by* Wiseman, who gives an account of the case, as "an old fornicator." The urethra had been opened behind the stricture, on account of retention of urine, some time previously, but this not satis- fying the patient, Mr. Molins placed him in the lithotomy position, and giving one testicle in charge to his servant and the other to Wiseman, " with his knife divided the scrotum in the middle, . . . and cutting into the urethra, slit it the whole length to the incision in perineo." This rather heroic procedure appears to have been followed by no unpleasant consequences, though it was not successful in curing the perineal fistula. The operation of perineal section was subsequently resorted to by Solingen, in Holland, and by other surgeons, chiefly, however, in cases of retention, but does not appear to have been generally recognized as a legitimate mode of treating stricture unaccompanied by that complication, until the publi- cation of papers by Arnott, .in 1823, and by Jameson, of Baltimore, in 1824, followed some years later by Mr. Guthrie's well-known work on the "Anatomy* and Diseases of the Urinary and Sexual Organs." The latter surgeon recommended that the urethra should be ojiened behind the stric- ture, which was then to be divided by cutting forwards upon the point of a catheter or sound previously* introduced, but most operators have, in all essential particulars, followed the practice of Jameson and Arnott, cutting directly upon the point of the sound, and then cautiously dissecting back- wards "in the median line. F. Jordan has modified Guthrie's procedure by opening the urethra through the rectum, and then endeavoring to pass a flexible catheter through the stricture from behind forwards, while Cal- lender, Howse, Hulke, McDougall, Duncan, and Duplay, following a sug- gestion of John Hunter's,2 have similarly attacked the stricture through an opening made into the bladder above the pubis. 1 According to Gregory, as quoted by Monod, perineal section was practised by the Italian surgeons in the latter part of the fifteenth century. 2 According to Duplay, this form of posterior catheterization, through a previously existing supra-pubic fistula, was originally suggested by Verduc, and first practised by Verguin, in 1757 ; his example was subsequently followed by Chassaignac, Sedillot, Voillemier, Giraldes, and Duplay himseif. 1046 DISEASES OF THE URETHRA AND URINARY FISTULA. External perineal urethrotomy with out a guide may be thus performed: The patient being etherized and secured in the lithotomy position, a full- sized catheter, or, which is better, a staff' grooved on its convexity, is jiassed down until its beak rests upon the face of the stricture, taking care that it does not enter a false passage. The staff is then confided to an assistant, who holds it steadily in one position, while the surgeon makes an incision from an inch and a half to two inches in length, exactly in the median line of the perineum. This incision should go through the skin and superficial fascia, and should reach to within about half an inch of the anus. The surgeon next feels for the groove of the staff and cuts into it, thus fairly opening the urethra in front of the stricture. The sides of the canal (the mucous surface of which is easily* recognized) are now held apart with tenacula, forceps, or loops of thread—one passed through each margin of the urethra, as advised by Avery*—and the part may be still further ex- posed by* turning out the end of the sound through the wound, and thus drawing the urethra forwards, as recommended by Wheelhouse, of Leeds. In most instances it will now be found possible to slip a small grooved director, or probe, or even a fine whalebone bougie, through the stricture, the mouth of which is thus brought into view ; in which case all that re- mains to be done is to slit up the contracted tissues upon the guide which has been introduced,1 pass a broad director into the bladder, and upon this a full-sized catheter, which may be left in place for about forty-eight hours.2 If the ojiening in the stricture cannot be found, the surgeon must cautiously dissect backwards, with very light touches of the knife, and keeping strictly in the median line, until the dilated portion of the urethra behind the stric- ture is laid open.3 This, of course, is the only plan which can be followed in the rare cases, already referred to, of traumatic obliteration of the urethra. The after-treatment consists in the occasional jiassage of a sound to prevent recontraction. Mastin, of Mobile, after cutting into the healthy urethra in front of the stricture, divides the latter by* a subcutaneous incision, and closes the external wound by means of hare-lip pins, so as to, if possible, obtain primary union. The operation which has been described is certainly a much more diffi- cult one than that of Prof. Syme, and appears to have been more often followed by death; yet, in view of the otherwise hopeless nature of the cases in which it is performed, it must be considered to give, upon the whole, satisfactory results. I have myself emjiloyed it in 19 cases, with 13 recoveries and 6 deaths, or 31.5 per cent., and of 35 cases collected by Bceckel, in which the operation was jierformed by French or German sur geons, 8 terminated fatally, or nearly 23 per cent. ; but in the hands of American surgeons, generally, the results, according to Prof. Gouley, have been much better. The operation, if carefully performed, is not in itself very dangerous, and in the majority of fatal cases death has resulted from previously existing disease of the bladder and kidneys. Perineal section, which has, in this country, always been a favorite mode of treat- ing obstinate strictures, is adapted to precisely the same class of cases as Syme's method, except that to justify the former operation, the stricture i Having secured the entrance of a filiform bougie, Otis passes the other end of the instrument forwards, through the anterior portion of the urethra, and then screwing on a Maisonneuve's urethrotome, completes the operation by internal section of the stricture at its upper side. 2 This is considered unnecessary by Van Buren, Gouley, and many other American surgeons. s This seems to me safer than Ruggi's plan of exposing the urethra by a transverse incision. TAPPING THE URETHRA. 1047 must have resisted all attempts to introduce an instrument. The operation is also indicated in some cases of stricture accompanied by retention, in cases of ruptured urethra in which catheterization cannot be accomplished (see page 417.), and in some cases of traumatic obliteration of the urethra— though it is a question whether it might not often be better under these circumstances to make no attempt to restore the continuity of the canal, but to simply dilate the fistulous orifice which always exists behind the point of occlusion, or to make a direct opening into the posterior part of the urethra in the way next to be described. 2. Tapping the Urethra at the Apex of the Prostate, unas- sisted by a Guide-Staff^ is the name given by Mr. Cock, of Guy's Hos- pital, to a variety* of the old " boutonniere" operation which was frequently practised by Wiseman and others for the relief of urinary retention, but which Mr. Cock recommends in cases of impassable stricture, even when not thus complicated. The operation consists in opening the urethra behind the stricture, very much in the way it was done byr Guthrie, in his mode of performing perineal section; but, whereas Guthrie insisted (and I think with reason) on the propriety of always completing the operation by dividing the stricture itself, Mr. Cock urgently advises that the stric- ture should not be touched, but that the patient should rather be allowed to recover with a perineal fistula. The following are Mr. Cock's directions for the performance of this ope- ration : The patient being in the lithotomy position, the left forefinger of the operator is placed in the rectum, with its tip to the apex of the prostate, the relations of which should be carefully ascertained. A double-edged knife is then plunged steadily but boldly into the median line of the perineum, and carried in a direction towards the tip of the left forefinger which lies in the rectum, while, at the same time, by an upward and downward move- ment, the incision is enlarged in the median line to any extent that is con- sidered desirable. The lower extremity of the wound reaches to within about half an inch of the anus. The knife is pressed steadily onwards towards the apex of the pros- tate, until its point can be felt in close proximity to the tip of the left forefinger, and is then made to pierce the ure- thra, by advancing it ob- liquely, to either the right or left. The finger is still kept in the rectum, while the knife is withdrawn, and a probe- pointed director introduced through the wound into the urethra, and passed into the bladder. The finger is then withdrawn, and the director held in the left hand, while a canula or female catheter is slid along its groove into the bladder, where it is retained for a few days. This operation, which I consider a very excellent one, and which I have repeatedly practised with the best results, in cases of urinary retention or urethral rupture, seems to me inferior to the perineal section (either by Arnott's and Jameson's, or by Guthrie's method), for cases of stricture in which the complication of retention does not exist. I have employed Fio. 611.—Tapping the urethra in the perineum. (Bryant.) 1048 DISEASES OF THE URETHRA AND URINARY FISTULA. Cock's method in 18 cases, with 11 recoveries and 7 deaths, none of these, however, attributable to the operation itself. Molliere, of Lyons, and Mayo Robson, of Leeds, recommend extirpa- tion of urethral strictures, a mode of treatment which is said to have originated with Krimer, in 1828, and which, I confess, seems to me unjus- tifiably severe. Meusel has supplemented extirpation by transjilanting a flap from the prepuce, so as to provide a roof of thin integument for the deficient portion of the urethra. III. Treatment of Stricture Complicated with Retention of Urine. When permanent narrowing of the urethra exists, a very slight cause may at any moment lead to complete retention (see page 1037). Under such circumstances, the sufferings of the patient are very great, and it be- comes necessary to adopt prompt and efficient means to evacuate the bladder. The best course to pursue is, I think, at once to etherize the patient, and when full relaxation has been obtained, to ascertain the exact locality of the stricture by the introduction of a No. 13 or 14 catheter, and then attempt to pass a small flexible or metallic instrument, trying various sizes in succession, and taking every precaution not to produce laceration of the urethra. If a catheter cannot be passed, perhaps a small bougie may be made to enter the urethra, and it will often happen that when this is with- drawn, after remaining a few minutes, a small stream of urine will follow. The same end may also be attained, in some instances, by pressing for a few minutes with a sound against the face of the stricture. Macnamara, of Dublin, believes that there is in the urethra a vermicular movement towards the bladder, and maintains that if a small catheter can be fixed in a stricture, it will in the course of an hour or so make its own way through the obstruction. If a filiform bougie can be introduced into the bladder, a catheter can readily be made to follow, in the way described at page 1042, when the urine can be drawn off, and the surgeon may* at once jiroceed to treat the stricture by either rupture or internal urethrotomy. Sir Henry Thompson has devised, for use in these cases, a probe-pointed catheter, the beak of which is as slender as the most delicate metallic probe. The instrument is doubtless an efficient one in skilful hands, but seems to me less adapted for general employment than the filiform bougie used in the way which has been described. Dr. F. N. Otis employs a probe-pointed " dilating catheter," with a " testing syringe," which by withdrawing a small quan- tity of urine show's conclusively when the instrument has reached the bladder. This catheter may be guided through a very close stricture by threading it over a filiform bougie of extra length. If, after a patient trial for half an hour or so, no instrument can be in- troduced, or if prolonged but fruitless attempts at catheterization have been already made by another surgeon, the patient may be placed in a hot bath until faintness is induced, and then put to bed, and wrapped in blankets with hot fomentations to the pubes and perineum. He should be brought thoroughly under the influence of opium, or, if this drug be for any reason contra-indicated, may take the muriated tincture of iron in the wav directed at page 1033. Under this treatment the bladder will, in the large majority of instances relieve itself in the course of a few hours, but should it not do so the patient must again be etherized, and the attempt to afford instrumental relief carefully* renewed. If the surgeon's efforts are still unsuccessful more decided measures must be adopted. No precise rule can be "-iven as RETENTION OF URINE FROM STRICTURE. 1049 to the length of time during which delay is justifiable in these cases, nor can the surgeon judge accurately of the degree of vesical distention by the size of the tumor which the bladder forms in the supra-pubic region ; for, in cases of long-standing stricture, the organ is often thickened and con- tracted, and may be dangerously distended by an amount of urine which, under other circumstances, would be insignificant. The dangers of delay are very great, and I believe exceed those entailed by a skilfully performed operation. Apart from the risk of rupture of the bladder or urethra, seri- ous injury cannot but be inflicted upon the ureters and kidneys, by the dam- ming up, even for a few hours, of the urinary secretion. The operations which may be employed for the relief of retention de- pendent upon organic stricture, are forced catheterization, perineal section, tapping the urethra behind the stricture (Cock's method), and tapping the bladder—through the rectum, above the pubis, or through the pubic symphysis. The first method (forced catheterization) is now, happily, seldom resorted to; it is very uncertain, and extremely dangerous—and should, in my judgment, be utterly banished from practice. The operative procedures employed in all the other methods mentioned have already been described, and it only remains to indicate the particular cases which call for one mode of treatment rather than for another. If swelling or other signs of inflammation in the perineum lead the surgeon to suppose that ulceration or rupture of the urethra may have already occurred, and that urinary extravasation is therefore imminent, if, indeed, it has not actually taken place, one or other of the perineal operations should be pre- ferred, and the choice between these should, I think, rest upon the origin of the stricture, whether gonorrhoeal or traumatic. For the former, Cock's operation may be resorted to, as being easier, and, under these circum- stances, quite as satisfactory as the perineal section ; for, by diverting the course of the urine for a short time, the stricture will, in all probability, become quite amenable to dilatation, or to one of the other methods used in the treatment of permeable stricture. If, however, the stricture be of traumatic origin, it is, I think, better to perform perineal section ; for this form of the disease is always very intractable, and it is, therefore, better to employ a radical remedy* at the outset. If, on the contrary, there be no reason to fear urinary extravasation, it may be thought better to employ the aspirator above the pubis, or, if this instrument be not at hand, to resort to puncture of the bladder through the rectum—which is usually, in these cases, an easy and safe operation ; after a few days, the stricture can be dealt with by either dilatation, rup- ture, internal urethrotomy, or external division, as may be thought proper. If, from the size of the prostate or the contracted state of the bladder, the rectal puncture should be considered undesirable, the next best course would be to open the urethra behind the seat of stricture ; or, if the disease were of traumatic origin, the perineal section might be preferred, for the reasons already mentioned. Ruptures of the Bladder and Urethra are among the gravest sequelae of retention of urine from organic stricture. Rupture of the Bladder (which is very rare) may give rise to peritonitis, or, if the rent be at a part uncovered by the peritoneum, to extravasation of urine within the pelvis; in either case the accident is usually, though not invariably, followed by death, three out of eight cases referred to by Gouley being reported as recoveries. Rupture of the Urethra almost invariably* occurs at the membranous part of the canal, the urine which is extravasated then making its way into the tissues of the perineum, scrotum, groin, and anterior abdominal parietes, and more rarely passing backwards into the 1050 DISEASES OF THE URETHRA AND URINARY FISTULA. tissues of the ischio-rectal fossa? and buttocks. The treatment of these accidents has already* been described at jiages 415 and 417. Stricture of the Female Urethra is a very rare affection. It may result from gonorrhoea, or from the cicatrization of a chancre or chancroid, but is more apt to be caused by the inflammation following traumatic in- juries, particularly from the use of forceps, or the pressure of the foetal head in childbirth. The seat of the stricture is usually at or very near the meatus. The treatment consists in dilatation, aided, if necessary, by a slight incision with a probe-pointed knife. In a case of stricture of the female urethra, complicated with retention, in which catheterization proved impossible, Curling resorted to puncture of the bladder through the vagina. Dr. R. Newman reports several cases cured by the use of electricity. Introduction of the Female Catheter.—The female catheter is shorter and less curved than the instrument used for the male urethra, and should be provided with rings, at its open extremity, to prevent the possibility of its slijiping into the bladder. The catheter should be introduced without any exposure of the person, and this maybe most conveniently done while the patient is in bed, with the thighs flexed and somewhat separated from each other. The surgeon stands on the patient's left side, and passing his left hand beneath the flexed limb, introduces his forefinger between the nymphae, bringing it from behind forwards until it touches the space be- tween the entrance of the vagina and the orifice of the urethra, the promi- nence of which is easily recognized by the touch; the catheter is then introduced with the right hand above the flexed limb, and, guided ujion the left forefinger, slips without difficulty into the bladder. The whole opera- tion is done under the cover of the bedclothes. In cases of malformation or obstruction, the introduction of the catheter may prove more difficult, and may even be impracticable without exposure of the part; should re- tention occur under such circumstances, no false sense of modesty should prevent the adoption of whatever course may be necessary for the patient's relief. Tumors and Fissure of the Urethra. The older writers attributed most cases of urinary obstruction to the existence of tumors of the urethra, which they called caruncles or car- nosities ; but in the light of modern pathology, true tumors of this part must be considered very rare. In many instances, what have been called tumors, are merely clusters of prominent vascular granulations, which, as in other mucous membranes, occasionally result from long-continued in- flammation. True urethral tumors are, however, occasionally met with, belonging chiefly to the papillary and fibro-cellular varieties. The papil- lary growths are jirincipally seen near the meatus, and are much less com- mon in the male than in the female sex, while the fibro-cellular or polypoid tumors are chiefly limited to the prostatic part of the male urethra. Tuber- culous and cancerous deposits, also, are occasionally seen in the urethra • but are usually secondary to similar formations in the kidney, bladder or prostate. The treatment of the vascular papillary growths which are seen near the meatus, and which alone are likely to be recognized during life, consists in excision, ligation, the application of caustics (of which the best, according to Dr. Edis, are chromic and carbolic acids), or the use of the actual or galvanic cautery. The latter is the safest remedy for the vascular tumors of the female urethra, excision being, in this locality attended with some risk of hemorrhage. If the hot iron'is used, the sur- rounding parts should be protected with a wooden spatula. Should spas- URINARY FISTULA IN THE MALE. 1051 modic contraction of the ure- thra persist after removal of the growth, forcible dilatation (as recommended by* Richet) may* be resorted to, and the same plan may be adopted, as advised by Spiegelberg, in the treatment of fissure of the fe- male urethra, a condition ana- logous to the fissure, or pain- ful ulcer, of the rectum (see pages 926, 1011). According to Skene, many of the so-called caruncles, or vascular growths, observed near the meatus of the female urethra, are really instances of an inflammatory condition of certain glands found in that part, to be treated by caustic applications, or by slitting open the ducts of the glands as in fistula in ano. Dr. R. H. Harte records two cases of papilloma of the male urethra, successfully treated by applying the actual cautery through an incision laying open the penis from its dorsal surface. After destroying the growths, the wounds were closed with hare-lip pins. Fig. 612.—Papillary tumor of the female urethra. (Boivin.) Urinary Fistula in the Male. Urethral Fistula.—Fistulous communications between the male urethra and the external surface of the body are not unfrequently met with in cases of long-standing stricture. There may be one or several external openings, and these may be situated in the perineum, scrotum, or lower surface of the penis, or even in the thighs, buttocks, or abdominal wall. The treatment must be directed in the first place to the cure of the stric- ture, for the abnormal openings cannot be exjiected to heal while any obstruction to the na- tural course of the urine remains. Simple dilatation will in many cases be sufficient, and it often happens that, when the normal cali- bre of the urethra has been restored, the fis- tula will heal of itself. If the stricture is very hard and cartilaginous, or peculiarly irritable, or if, though easily di- lated, it constantly tends to recontract, it will usually be advisable to resort at once to external division (Syme's method), which promises better results under these circumstances than Fia. 613.—Urinary fistulae in the male. (Liston 2456 1052 DISEASES OF THE URETHRA AND URINARY FISTULA. either rupture or internal urethrotomy If the stricture be imjiermeable, the perineal section must be performed as a last resort. If the fistula still persist after the cure of the stricture, special means must be adopted for its treatment. It is often recommended to retain a catheter in the bladder, in these cases, so as to prevent any urine from escaping through the fis- tula ; but the plan very* seldom succeeds, for the reason that a small quan- tity of urine invariably trickles alongside of the instrument, and thus defeats the object in view. Chiene emjiloys a catheter with an India- rubber tube attached, passing into a bottle jilaced on the floor ; a sijihon action is thus established, and the bladder is kept empty by drainage. W. Thomson effected a cure in one case by* maintaining drainage through a supra-pubic opening. It is, however, ordinarily better to teach the patient to use a gum-elastic catheter for himself, when, if he can be induced to co- operate with the surgeon by not, under any* circumstances, urinating except through the instrument, the fistula will probably heal without dif- ficulty under simple dressing. The special treatment of urethral fistulas varies according as they* are seated in the perineal, scrotal, or penile por- tions of the urethra. 1. Perineal Fistula__If of small size, a perineal fistula may be in- duced to heal by introducing a fine probe coated with nitrate of silver, or (which is probably* the most efficient means) by the apjilication of the gal- vanic cautery. If there be several external ojienings, a good plan is to connect them together with an oakum thread, introduced by means of an eyed probe ; while, if this fail, it may be necessary to lay open the smaller sinuses by incision upon a grooved director. If the fistula be a large one, its edges may be touched with strong nitric acid, so as to make a superficial slough, which, when detached, will leave healthy granulating surfaces ; or the edges may be deeply pared, and brought together with metallic sutures. Voillemier and Guyon recommend that the fistula and surrounding tissue should be cut out by means of curved incisions meeting in front and behind. 2. Scrotal Fistula, on account of the lax condition of the parts, usually requires to be freely laid open, when it will probably heal by granulation ; or the edges may* be deeply pared and the adjacent tissues dissected up, so as to form broad and thick flaps, which are then to be accurately brought together in the median line with deep and superficial sutures. 3. Penile Fistula is the most intractable form of urethral fistula, and can seldom be cured without a plastic operation. In some cases, however, success may be obtained by touching the edges with nitric acid, and hold- ing the granulating surfaces together with serre-fines, after the detachment of the slough. The contact of urine must be prevented by keeping a full- sized catheter in the bladder, or, which is usually better, by the frequent introduction of a fio. eu.-Dieffenbach-s lace-suture. flexible instrument. Dieffen- bach's lace-suture may also be applied with advantage in some cases. The edges of the fistula are first blistered with the tincture of cantharides, and the cuticle is scraped off with a scaljiel. By repeated introductions of a small curved needle, a waxed silk thread is next carried subcutaneously around, but not across, the fistula at a distance of about a quarter of an inch from its margin, when by drawing upon both ends of the thread, the opening is puckered up like'the mouth of a purse, and secured with a knot. The suture may be removed URETHROPLASTY. 1053 after three or four days. E. Noble Smith has reported a case in which a cure was effected by the application of a strong solution of nitrate of silver (3j-f3j) to the urethral as well as to the external orifice of the fistula. 4. Blind Urinary Fistula is the name given to suppurating tracks opening into the urethra, but having no external orifice. The treatment consists in laying open the sinus, and then proceeding as in the case of an ordinary urethral fistula. A similar affection is described by* Skene, of Brooklyn, as occurring in women, and as curable by dilating the canal and using- astringent injections. Urethroplasty__The simple urethroplastic operations occasionally required in cases of perineal and scrotal fistula, have just been mentioned. More complicated procedures are, however, often needed in the treatment of fistulae in the penile portion of the urethra. 1. A good plan is to freshen the edges of the fistula, and dissect up long, bridge-like flaps, which are then stitched together over a slip of India- rubber, or, which is better, a piece of thin lead ribbon (Fig. 615), so as to prevent the contact of urine. This operation is said to have originated with Dieffenbach. 2. Alliott, Segalas, Nelaton, and others have succeeded in curing penile fistulai by dissecting up the integuments around the opening and sliding them over the latter, after freshening its edges. 3. Astley Cooper operated by paring the edges of the fistula, so as to form a quadrilateral wound, which was then closed with a flap of similar form, borrowed from the scrotum. Fig. 615.—Urethroplasty ; Dieffenbach's method. (Erichsen.) Fid. 616.—Urethroplasty ; Le Gros Clark's method. (Erichsen.) 4. Le Gros Clark pares the edges of the fistula, and closes it by dissect- ing up flaps from each side and joining them in the middle line by means of the clamp or quilled suture. Somewhat similar operations are attributed to Reybard and Delorne. 5. R. F. Weir, following Langenbeck and Szymanowski, has succeeded by inverting an oval flap from one side of the fistula, and pocketing it in a groove upon the other side. Whatever plan be adojited, it may, perhaps, be thought advisable to divert the course of the urine for a few days, by puncturing the bladder through the rectum, or, better, by opening the urethra in the perineum, as 1054 DISEASES OF THE URETHRA AND URINARY FISTULA. has been done by Segalas, Ricord, and Thompson. The results of all these operations are ajit to be disappointing ; 82 cases tabulated by Czerny gave in all but 35 recoveries, and in many* of these the duration of treatment was more than a year. Urachal Fistula.—It occasionally happens that the urachus remains patulous and allows a discharge of urine from the umbilicus. This rare condition, of which I have seen but two or three examples, has been effect- ually remedied by Gueniot by the apjilication of ligatures and caustics so as to occlude the umbilical opening. Jacoby has effected a cure by the use of the actual cautery, and A. Rose, of New York, by means of a plastic operation. Worster has in the same way cured a case of urachal fistula opening between the umbilicus and pubes. The ligature and cautery com- bined proved effectual in a case sent to my clinique by Dr. Marcy, of Riverton, N. J. If the fistula be complicated by the existence of phimosis, this should be relieved first, when the urachal opening may close of itself, as in a case recorded by Charles. Vesico-reetal and Urethro-rectal Fistulae have already been considered (see page 922). Niehans records a case of vesical fistula in which a cure was effected by operation, after preliminary osteoplastic resec- tion of the anterior part of the pelvis. Urinary Fistula in the Female. Of this there are five varieties, the urethro-vaginal, the vesico-vaginal, the vesico-utero-vaginal, the uretero-vaginal, and the vesico-uterine fistula. The locality of the fistula in each case is indicated by* the name. The causes of these fistulse are direct injury, abscess, ulceration, and sloughing due to pressure, as from the child's head in labor—the latter being by far the most frequent origin of the affection. The consequences of this condi- tion are extremely annoying to the patient; incontinence of urine is almost constantly* present, leading to excoriation of the genital organs and thighs, and giving rise to an ammoniacal odor which renders the jiatient an object of loathing to herself, if not to all around her. The diagnosis can be made by* placing the patient on her elbows and knees, and exposing the part by drawing away the opposite wall of the vagina with a Sims's or Bozeman's duck-billed speculum (Fig. 617) ; if the fistula be very small it may elude detection unless the bladder be injected, which may be done with simple water, milk, or a weak infusion of madder or indigo. The consideration of the treatment of the vesico- vaginal and other varieties of urinary fistula met with in the female sex, belongs rather to the department of Gynaecology than to that of General Surgery, and I shall, therefore, content myself with indicating the princijiles upon which the various modern operations for the relief of these affections are founded, refer- ring the reader for more detailed information to the excellent works of Simpson, Sims, Brown, Emmet, Byford, Thomas, Agnew, Goodell, and other writers on these subjects. Until within a few years, these affections were generally considered incurable, and it is chiefly through the labors of American surgeons that the operative treatment of vaginal fistulas, from being the opprobrium of our art, has been made one of the most successful procedures in the whole range of surgical practice. Without wishing to make invidious distinctions, I may refer particularly to OPERATIONS FOR URINARY VAGINAL FISTULA. 1055 the early labors of Hayward, of Massachusetts, and Mettauer, of Virginia, and the brilliant results afterwards obtained by* Marion Sims, who, in 1852, as justly* remarked by Thomas, combined the essentials of success, and placed the operation at the disposal of the profession. Since this time the subject has been illustrated both at home and abroad, by Bozeman, Em- met, Schuppert, Briggs, Agnew, Simpson, Brown, Bryant, Wells, Kidd, Simon, Ulrich, Neugebauer, and many* other surgeons. If a urethro-vaginal, or vesico-vaginal fistula be very small, an attempt may be made to effect its closure by the apjilication of the actual or gal- vanic cautery*, or by touching the edges with nitric acid and holding them together with serre-fines, a plan which has been recommended in some cases by Sir Spencer Wells. The large majority of fistulae, however, re- quire an operation, which essentially consists in paring the edges of the opening, and approximating the raw surfaces (perfectly in a transverse direction) by means of sutures which are left in place until firm union has occurred. This plan is more generally applicable than any of the flap operations which have been suggested, though these may be occasionally useful in particular cases. Operations for Urinary Vaginal Fistulae.—The points which require special consideration are—1. The position of the patient; 2. The mode of exposing the fistula; 3. Paring the edges; 4. Introduction of the sutures; 5. Fastening the sutures; 6. Use of the catheter during the after-treatment; and 7. The time at which the sutures should be removed. The patient should be prepared for the operation by attending to the state of the general health, by subduing local inflammation, and by dividing any cicatricial bands that might interfere with the success of the treatment. A dose of castor oil should be administered the night before, and an enema given on the morning of the operation, while to avoid the suffering, both physical and mental, to which this would otherwise necessarily give rise, the patient should invariably be anaesthetized, unless there be some special reason to the contrary. 1. Position of the Patient.—The best is, I think, a modification of that known as the knee-elbow position, the patient being supported upon pillows, or on a well-padded double-inclined plane, with the hips elevated, the head and shoulders depressed, and the thighs widely separated and held apart by assistants ; Sims and Emmet, however, prefer a semi-prone position, the patient lying partly on the left side with the thighs flexed— the right rather more than the left—and the breast resting upon the table, while Simon adopts the supine position, with the hips and thighs much raised, and Wells recommends the ordinary lithotomy position, with the hands and feet fastened together with bandages or straps. 2. Exposure of the Fistula.—This may be done with an ordinary Sims's specu- lum, held by an assistant, or by means of Emmet's modification of that instrument, if the semi-prone position be chosen, or by a similar modification described by Wells, if the patient be placed either on her back or in the jiosition here recommended. These fio. 6i8.-Emmet's speculum. modifications of Sims's speculum consist in the adajitation of a fenestrated blade, which fits over the buttock or sacrum of the patient, and thus keeps the instrument in place without the aid of an assistant. A bright light is necessary for the operation, the best illu- 1056 DISEASES OF THE URETHRA AND URINARY FISTULA. niination being afforded by placing the operating table near a high win- dow; if this cannot be obtained, an Argand lamp and reflector may be substituted. 3. Paring the Edges__This may be done with either knives or scissors, according to the fancy of the operator ; it is convenient to have a double-edged knife, curved on the flat, and others with the blades bent at an angle with the shaft (Fig. 619). The sides of the fistula may be steadied by means of suitable forceps, or one or more hooks with long handles, while the paring is effected by transfixing the part with the knife, and cutting first in one, and, then, in the opposite direction, so that a com- plete ring is denuded. In doing this, some surgeons cut perpendicularly to the plane of the vesico-vaginal septum, while others bevel the edges by cutting in an oblique direction, so as to spare the mucous membrane of the bladder. Langenbeck again, and, more recently, Collis, of Dublin, have advised that the edges of the fistula should be split, so as to obtain a broad raw surface without cutting away any tissue whatever. Provided that a broad surface be obtained for adhesion, it probably makes little difference which particular plan is adopted. Before proceeding to the next step of the operation, all bleeding should be checked by torsion, by pressure with a piece of sjionge mounted on a handle or " sponge-holder," or by throw- ing in a stream of cold water with a syringe. 4. Introduction of the Sutures.—The material generally chosen for the suture, in this country, is, in accordance with the practice of Sims and Bozeman, silver wire; and this seems to me, upon the whole, prefer- able to the other substances used for the purpose. Simon, however, em- ploys a silken, and Ulrich, of Vienna, a hempen suture; while Wells considers, and probably with good reason, the choice of material much less important than has been commonly supposed. Wutzer emjiloyed the hare-lip pin and twisted suture, and the same jilan with various modifica- tions has been since adopted by Metzler, of Prague, Mastin, of Mobile, and Watson, of Edinburgh. The sutures, whether of silk or metal, may be conveniently introduced with short well-curved needles held by suitable forcejis. or with needles eyed near the point, and mounted in handles, like the ordinary ntevus needle. Sometimes the silk or wire may be threaded upon two needles, each of which is introduced from the vesical surface of the fistula; or an eyed needle, threaded, may be passed through one margin, and a notched needle, unthreaded, through the other__the loop of the thread then being caught in the notch and thus drawn through ; or, again, the surgeon may adopt a plan similar to that of Mr. A vervain the operation for cleft palate (see jiage 834). Dr. Joseph Bell emjiloys steel points welded to the wire, so as to leave no projecting shoulder and to require no threading. Special needles have been devised for this opera- tion by Druitt, Startin, and others, but I am not aware that they possess any superiority over the simpler implements above recommended. The passage of the needle from within outwards may be aided by steadying the part to be transfixed with a blunt hook bent at an anHe to its shaft and, when wire is used, advantage may be derived from drawing it over a notched " feeder," which prevents it from cutting through the margin of the fistula. When the edges have been bevelled or split, the sutures should OPERATIONS FOR URINARY-VAGINAL FISTULA. 1057 be passed so as not to encroach upon the vesical mucous membrane, but this may be included when the fistula has been pared perpendicularly to the septum. The sutures should be passed about half an inch from the free margin of the fistula, and should be about a sixth of an inch apart. The Fio. 620.—Operation for vesico-vaginal fistula ; sutures in position. (Simon.) fistula should, if possible, be closed in a transverse direction, so as to form a cicatrix at right angles to the long axis of the vagina. A single set of sutures may be used, or a deep and superficial set, according to the fancy of the operator. 5. Fastening the Sutures__If of silk, the sutures are to be tied in an ordinary surgeon's knot, all the knots being made on the same side of the fistula; wire sutures may be conveniently clamped with perforated shot, or twisted with the fingers, or, if the fistula be high up, with the "wire- twister" devised by Coghill (Fig. 621); or the ends on either side may be passed through a metallic plate and secured with shot (as in Sims's earlier operations) ; or Bozeman's ingenious modification, known as the "button-suture," may be substituted (Fig. 622); or the surgeon may employ one of the many shields and splints which have been devised by Simpson, Brown, Agnew and others. In the majority of cases, however, 67 7670 1058 DISEASES OF THE URETHRA AND URINARY FISTULA. the simple interrupted suture will, I think, be found more satisfactory than any other. Asa test of the accurate closure of the fistula, an attempt Fir. 621.—Coghill's wire-twister. Fig. 622.—Bozeman's button suture. may be made to pass a probe between the stitches, and the bladder may be injected with milk or colored water. 6. The Catheter.—It is by the large majority of writers thought very important to introduce a catheter—Sims's "sigmoid" instrument (Fig. 505) is the best—immediately after the operation, and to keep it in place during the after-treatment. Simon, how- ever, has discarded the catheter altogether, except in cases of retention, when he introduces the instrument at intervals of three or four hours; while Wells introduces at first a small vulcanite catheter, but removes it as soon as it causes any irritation or discomfort. In this country*, the principal advocates of the disuse of the catheter are Dr. Schupjiert, of New Orleans, and Dr. Briggs, of Nashville. If the catheter be used, great care must be taken not to let it become clogged with mucus. 7. Removal of the Sutures—This may be done while the patient is in the semi-prone position. Silk sutures should be withdrawn about the 6th or 7th day, and wire sutures from the 8th to the 14th; it is better to retain them unnecessarily than to remove them prematurely. The bowels should be locked up with opium for about two weeks, and cleanliness insured by daily syringing of the vagina. If the urine be ammoniacal, the patient should take benzoic acid and borax, and the bladder may be washed out through a double catheter. Modifications Required in Special Cases. —When the fistula is placed in the upper part of the vesico-vaginal septum, care must be taken not to implicate the ureters in the ojieration. Neglect of this precaution may lead to failure, from the ureter opening into the vagina above the cicatrix, or even to death, from occlusion of the ureter and conse- quent uraemia. For uretero-vaginal fistulas, Parvin turns the displaced distal extremity of the ureter into the bladder, and then closes the vaginal opening, while Landau recommends that an attempt should be made to pass a catheter from the bladder through the ureter, the opening in which is then to be closed over the instrument; or, if this cannot be done, that the lower part of the ureter should be slit into the bladder, so as to convert the case into one of ordi- nary vesico-vaginal fistula. In cases of vesico-utero-vaginal fistula, the anterior lip of the uterus, or possibly* the posterior lip, must be utilized in closing the opening; in the latter case, the patient is rendered sterile, and Fio. 623.—Operation for vesico-uterine fistula. (Thomas.) OPERATIONS FOR URINARY-VAGINAL FISTULA. 1059 the menses escape through the urethra. In cases of vesico-uterine fistula (Fig. 623), the anterior lip of the uterus must be slit up until the opening is exposed, when its edges may be freshened and united with sutures. For very great deficiency of the vesico-vaginal septum, the operation of transverse obliteration of the vagina (Fig. 624), as employed by Simon and Fi&. 624.—Transverse obliteration of the vagina. (Simon.) Bozeman, may be necessary; this consists in paring the anterior lip of the fistula, and attaching it to the previously denuded posterior wall of the vagina, so as to completely close the orifice of this canal; the menses sub- sequently escape through the urethra, but the patient is rendered sterile and unfitted for sexual congress. Hence, when applicable, a better plan, also suggested by Bozeman, is to endeavor to lessen the antero-posterior diameter of the fistula, by daily dragging down the neck of the uterus, with forceps, for some weeks prior to the operation, which is then per- formed as in an ordinary case of vesico-utero-vaginal fistula. When the floor of the urethra is completely destroyed, as well as the vesico-vaginal septum, it may be necessary to pare, or slit, and unite the labia, as in the operation of episiorrhaphy (see Chap. XLVIL), so as to close the vulva except at its anterior portion, where an opening must be left for the escape of the urine and menses, incontinence being prevented by the adaptation of a suitable truss. This operation, which I have my*self resorted to with advantage, may be supplemented, as suggested by Maunder, by tapping the vagina through the rectum and introducing a tube, so as to insure a free exit to the urine until the union of the raw surfaees is complete. 1060 DISEASES OF THE GENERATIVE ORGANS. CHAPTER XLVII. DISEASES OF THE GENERATIVE ORGANS. DISEASES OF THE MALE GENITALS. Malformations of the Penis and Scrotum. Congenital Adhesion.—The penis is sometimes bound down to the scrotum by a web of skin extending from the lower surface of the organ to the raphe ; the treatment consists in dividing the web, and bringing the edges of the wound together in a longitudinal direction (as successfully done by Bouisson), or, if this be impracticable on account of the shortness of the attachments, in carefully dissecting the penis from its abnormal posi- tion and raising it towards the belly, the gap in the scrotum being then filled with a flap borrowed from the groin or thigh, as suggested by Holmes. Murphy*, of Sunderland, records a case in which the penis, in an infant, was apparently buried beneath the scrotum, and was extracted by incisions and manipulation. Incurvation of the Penis (with hypospadia) is occasionally met with, and may seriously interfere with procreation: the treatment may consist (1) in division of the contracted tissues, subcutaneously, as practised by* Bouisson, or, a ciel ouvert, as preferred by Duplay; (2) in excising a wedge-shaped piece from the dorsum of the organ by transverse incisions, and bringing the sides of the wound together so as to raise the glans penis, as advised by Physick, Pancoast, and Gross ; (3) in amputating the head of the organ and enlarging the hypospadic orifice, as suggested by Holmes, or (4) in splicing the contracted part, as ingeniously suggested by Dr. Gouley, of New York. Dr. R. F. Weir, also of New York, has, in two cases in which this condition was complicated by congenital adhesion to the scrotum, successfully resorted to a modification of Bouisson's method, while Dr. E. Bradley, of the same city, has operated by making V-shaped incisions on the lower surface of the organ, which was then strapped up against the abdomen while cicatrization occurred. Fissure or Cleft of the Scrotum, occurring in connection with malformation of the penis and complete hypospadia, constitutes a variety of so-called hermaphrodism ; the cleft scrotum represents the labia majora, and the deformed penis the clitoris, and if the testes be retained within the abdomen the resemblance to the female organs is tolerably complete. These cases seldom admit of operative interference, but the surgeon may be called upon to express an opinion as to the sex of the child, and to advise as to the mode in which it shall be brought up. The diagnosis of sex can usu- ally, but by no means always, be made by simultaneous rectal and vesical exploration; if no trace of a uterus be found, and if the supposed vagina open directly into the bladder, the probability is that tlie subject belongs to the male sex. In case of doubt, it would probably be judicious as advised by Holmes, to bring the child up as a boy. TREATMENT OF PHIMOSIS. 1061 Phimosis. Phimosis may be either congenital or acquired. The condition consists in an elongation of the prepuce, with contraction of its orifice, preventing the foreskin from being drawn back so as to expose the glans penis. Congenital Phimosis—In congenital cases the contraction is most marked in the inner or mucous layer of the prepuce, which adheres more or less closely to the surface of the glans while the skin of the part is com- paratively lax. According to Bokai, adhesion of the inner layer of the prepuce to the glans penis is a normal condition during early infancy. It may give rise to many of the symptoms which are ordinarily attributed to true phimosis, but may be distinguished by the readiness with which the foreskin can be drawn back, showing that its orifice is not really con- tracted. Phimosis is often the source of great inconvenience, if not of positive disease. In childhood, it may form an impediment to the flow of urine, leading to irritation of the urethra and bladder, and giving rise to symptoms of vesical calculus, and, sometimes, to reflex nervous phe- nomena, paralysis, etc. By the strainin? which it occasions, it sometimes predisposes to hernia. In adult life i. may interfere with the discharge of semen, and thus render the patient practically sterile, while, by preventing the retraction of the prepuce, it causes an accumulation of smegma, pro- ducing great irritation of the part, and exposing the patient to repeated attacks of balano-posthitis. Phimosis, moreover, apparently renders its subject more liable to the various forms of venereal infection, and becomes a serious complication when venereal diseases are acquired. It aiso, in the opinion of Hey, Holmes, and others, predisposes to the development of malignant disease of the part. Acquired Phimosis may result from thickening of the prepuce, fol- lowing gonorrhoeal or chancroidal inflammation, or may* be dependent upon the existence of fissures or excoriations of the part. In some instances, phimosis is complicated with a condition of solid oedema of the prepuce, constituting a state of hypertrophy, which, like the analogous hypertrophy of the clitoris, seems, occasionally, to be due to constitutional syphilis. Treatment of Phimosis__In some cases it is sufficient to divide the mucous layer of the prepuce, which is, as has been mentioned, the part chiefly affected in congenital phimosis, but in many instances it will be necessary to adopt severer measures, which may be classified under the heads of incision, excision, and circumcision. 1. Division of the Mucous Layer of the Prepuce may be accomplished in several ways:— (1) Sudden dilatation or rupture of the mucous layer may be effected by introducing the blades of an ordinary pair of dressing forceps between the prepuce and glans penis, one on either side, and then quickly withdrawing the instrument with its blades widely separated ; the foreskin is then drawn back, and kept retracted for about forty-eight hours. This plan is said to have originated with Hutton, of Dublin, and has lately been highly com- mended by Cruise, of the same place, who has devised a special instrument for the operation. A three-bladed forceps is employed for the same pur- pose by French surgeons. Erichsen recommends, in cases of acquired phimosis depending upon fissures of the preputial orifice, gradual dilatation, effected by means of a two-bladed urethra dilator, such as is used in the operation of lithectasy in the female. (2) The surgeon may employ a small pair of scissors, the lower blade of which is probe-pointed, introducing this blade between the prepuce and 1062 DISEASES OF THE GENERATIVE ORGANS. glans, and thrusting the other or sharp-pointed blade between the layers of the prepuce. The contracted mucous layer can now be divided at a single stroke, the foreskin being then retracted, as in the previous method. This mode of operating apjiears to have originated with Dr. Edward Peace, of this city, formerly one of the surgeons to the Pennsy'lvania Hospital. (3) Faure's method consists in forcibly drawing backward the skin of the penis, and dividing the mucous layer of the prepuce, which is thus made tense, by a succession of notches with a pair of probe-pointed scissors. 2. Incision.—This may be done either at the upper or lower surface of the penis; probe-pointed scissors may be used, or the surgeon may in- troduce a grooved director, and upon this a sharp-pointed curved bistoury, which is then made to transfix the prepuce and cut from within outwards, scissors being employed, if necessary, to complete the division of the mucous membrane. Another plan is to dispense with the director, guard- ing the point of the bistoury with a small piece of wax until it has reached the desired point, when it is made to transfix and cut its way out as be- fore. If the incision be made below, the fraenum, if too short, may be at the same time divided. This method is attended with the disadvantage of leaving a wing-like projection of preputial tissue on either side of the penis, constituting an unseemly deformity, and if, as often happens, the prepuce subsequently becomes thickened and hypertrophied, interfering with coitus. 3. Excision—The prepuce having been divided with a bistoury along the dorsum of the penis, as in the operation by incision, the flaps on either side may be seized with forceps and cut off in an oblique direction, so as to make an oval wound ; the mucous membrane is then attached to the skin with fine silk sutures, and the part covered with a dressing of diluted glycerine. This operation gives a very good result, and is, I think, par- ticularly applicable to those cases in which the prepuce is in a state of solid oedema and hypertrophy. Other plans are to excise the frasnum, together with a V-shaPe(i portion of the prepuce, as in the operations of Taxil and Jobert (de Lamballe), or to remove with scissors a semilunar flap, as in the method of Lisfranc. 4. Circumcision is, I think, ordinarily the best mode of treatment. The prepuce should be drawn forwards, so that the portion which corres- ponds, in the ordinary con- dition, to the line of the corona glandis shall be en- tirely in front of the penis ; a pair of narrow-bladed forceps is then applied in an oblique direction (so as not to encroach too much upon the fraenum), and firmly held by an assistant while the surgeon with knife or scissors removes the part of the prepuce which is in front; when the instrument is removed, it will be found that more of the skin has been taken Fio. 625.—Circumcision. (Erichsen.) away than of the muCOUS PARAPHIMOSIS. 1063 membrane, and it is, therefore, usually necessary to slit this along the dorsum of the penis—when the corners of the flaps thus formed may be excised, and the operation completed by uniting the skin and mucous membrane with silk or lead sutures, or with serre-fines. This operation is commonly attended with some little hemorrhage, which, if sutures are used, can be conveniently checked by transfixing each of the bleeding ves- sels with one of the stitches ; under other circumstances, ligatures may be required. An ingenious modification of this ojieration is that introduced by Ricord, who has devised for the purpose a pair of fenestrated forceps through which the suture threads may be introduced before the prepuce is cut off; the forceps being removed, the mucous membrane is, if necessary, slit along the dorsum, and each thread divided in the middle, so as to form a suture on either side. Dr. Levis has invented ingenious forceps to facili- tate the cutting away of the mucous layer, without the skin, of the prepuce. No operation for phimosis should, as a rule, be performed in any case complicated with chancroid, lest the whole wound should become inocu- lated. In order to prevent the occurrence of painful erections after these operations, Dr. Otis, of New York, recommends the use of dry cold applied by means of Petitgand's method of mediate irrigation (p. 55). Paraphimosis. This is the name given to the condition in which the prepuce has been drawn up above the corona glandis and cannot be replaced. The glans soon becomes swollen and cedematous, from the constriction exercised by the pre- putial orifice, and, if relief be not afforded, ulceration or sloughing may occur. Para- phimosis is chiefly* met with in boys, but may occur at any age if the prepuce be contracted. The treatment consists in effecting reduction, which may be some- times aided by preliminary scarifications, or by* the application of the cold douche or of ice. Reduction may usually be accom- plished by the surgeon's fingers, combining traction upon the prejiuce with compres- sion of the glans, which should be well oiled and covered with a small rag, to pre- vent the fingers from slipping. The sur- geon first compresses the glans firmly for five or ten minutes with the fingers of the right hand, so as to squeeze the blood out _ ft0R „ . ,. , P , ' , , ^ • t i Fig. 626.—Reduction of paraphimosis. of the part, and then encircling the pre- (Phillips.) puce with the left hand, as shown in Fig. G26, gradually draws the part into its normal place, aiding the manoeuvre by trying to insert the right thumb-nail beneath the edge of the preputial orifice. Other plans are to compress the glans by surrounding it with a tape or strip of adhesive plaster, or by applying broad-bladed forceps; or to raise the preputial ring upon a director, while the glans is pushed up beneath the instrument. If these means fail, a small bistoury must be introduced flat-wise beneath the edge of the preputial orifice, which lies at the bottom of the groove behind the swollen glans, and then turned with its edge upwards so as to nick the constricting tissues at one or more points of their circumference ; the tension being thus relieved, reduction can be accomplished without difficulty. 1061 DISEASES OF THE GENERATIVE ORGANS. Inflammatory Affections of the Penis and Scrotum. Diffuse Inflammation of the Areolar Tissue of the Penis and Scrotum may result from erysipelas or urinary extravasation, or may occur as a sequela of certain fevers—particularly variola and scarla- tina. The parts become greatly swollen, constituting the condition often spoken of as inflammatory oedema, and gangrene is apt to ensue. The treatment consists in making free incisions, and in elevating the parts and applying warm fomentations; quinia and iron may be given in jiretty large doses, while the strength of the patient is kept up by the administra- tion of concentrated food and stimulants. Gangrene of the Penis is a serious affection which may result from either phimosis or paraphimosis, as it may, likewise, from traumatic causes, such as the introduction of the organ into a ring, the impaction of a calculus in the urethra, wounds of the cavernous bodies, etc. Gangrene of this part has also been observed as the result of phagedaenic ulceration, of phlebitis of the dorsal vein, and of urinary extravasation ; and has been seen in the course of low fevers. Usually the prepuce only is affected ; but occasionally the skin of the whole penis or even the entire organ may be implicated. When either the prepuce or the glans is threatened with gangrene, no time should be lost in slitting up the former, so as to relieve the part from tension. When gangrene has actually occurred, little can be done beyond sujiporting the strength of the patient, and facilitating the sejiaration of the sloughs as they become detached. Demarquay speaks favorably of the actual cautery as a means of preventing the spread of the disease. The affection may prove directly* fatal, through simple exhaus- tion, through the development of pyaemia, or through the occurrence of secondary hemorrhage; or may indirectly cause death, according to De- marquay, by the jiatient falling into a state of marasmus, caused by the impairment of the generative powers. In other cases, in spite of the loss of considerable portions of the penis, the procreative powers of the patient have not been at all diminished. Herpetic and Aphthous Ulcerations on the penis are chiefly interesting on account of the probability of their being mistaken for chan- croids (see p. 478). The treatment consists in the use of astringent appli- cations, such as the oxide of zinc in powder, or lotions of borax, and in attention to the state of the general health. Thrombosis of the Corpus Cavernosum__Prescott Hewett has described two cases in which, in persons of a gouty tendency, spontaneous thrombosis occurred in patches in the cavernous body of the penis. The chief interest attaching to the affection is its liability to be mistaken for syphilis or cancer, from either of which, however, it may be distinguished by its essentially chronic character, and by the fact that the inguinal glands are not involved. No treatment is required. Since the publication of Hewett's paper, similar cases have been described by Van Buren and Keyes, and by Howard Marsh. Thrombosis of the dorsal vein of the penis has been observed by Lucas. Balanitis and Posthitis have already been considered (see page 472). Structural Changes in the Penis and Scrotum. Hypertrophy of the Prepuce may result from long-continued irri- tation of the part, or may be due to a condition of Elephantiasis Arabum (see pp. 516, 554)—in which case the subcutaneous tissues of the penis are commonly affected in a similar manner, as may be also the scrotum. The hypertrophy or elephantiasis of the scrotum. 1065 treatment consists in the excision of the enlarged prepuce and of a V-shaped piece from the dorsum of the glans penis, the sides of the wounds being brought together with stitches. Hypertrophy of the Corpora Cavernosa has been observed in one case recorded by J. G. Kerr, of Canton. The affection does not appear to admit of operative treatment. Hypertrophy or Elephantiasis of the Scrotum is chiefly seen in warm climates. The disease anatomically resembles what has been de- scribed as the fibro-cellular out- growth (p. 516), and can only be removed by excision. When of moderate dimensions, the hypertro- phied scrotum can be removed with little risk ; but when, as not unfre- quently happens, the part forms a pendulous tumor weighing from 40 to 80 or even 165 pounds (as in a case mentioned by Van Buren and Keyes), the operation becomes one of a formidable nature. To diminish the loss of blood, which is always considerable, the tumor should be elevated above the rest of the body for some hours before the operation, as advised by Brett and O'Ferrall, and the neck of the tumor may be compressed with a clamp, as recom- mended by Fayrer ; with a running noose, as ingeniously suggested by Dr. Mactier; or with an Esmarch's tube, as practised by Partridge and Cayley, of Calcutta. If a hernia be present, this should be first fully- reduced. The operation may be performed by introducing a director down to the penis, which lies at the bottom of a sinus, deeply buried in the mass, and upon the director acatlin, which is made to transfix the superincumbent tissues and cut its way outwards. The penis is now carefully dissected out and held up towards the abdomen, when incisions are made on each side so as to expose the testes, which are similarly dissected out and turned up until the ojieration is completed. The tunica? vaginales, if diseased, are to be cut away, and then the whole mass separated by cutting across its base close to the perineum. Hemor- rhage is next to be suppressed, 50 or 60 ligatures being sometimes required for this purpose, and the wound is then to be dressed in the ordinary manner, healing usually taking place by granulation. The testes and penis quickly become covered, and cicatrization is usually completed in from six weeks to two months. If, in the case of a large tumor, it is found that the dissection of the testes would prolong the operation beyond from three to five minutes, Fayrer advises that the attempt to save these organs should be abandoned, and the whole mass swept away as quickly as possible. Of 28 patients operated on by Fayrer, 22 recovered and 6 died, one from shock, and the other 5 from pyaemia. The same surgeon, from an analysis of 193 cases, finds the general death-rate of the operation to be 18 per cent., but 1066 diseases of the generative organs. a recent writer, Dr. G. A. Turner, who practised as a medical missionary in the Sanioan Islands, claims to have operated 136 times with only two deaths. Dr. McLeod, on the other hand, Sir Josejih Fayrer's successor, reports 120 cases with 23 deaths. Dr. Kerr, of Canton, h;is modified this procedure by covering in the testes with flaps taken from the sides of the scrotum. Vegetations or Warts on the penis, Venereal Warts, as they are often, though incorrectly, called, have already been referred to (see page 548). Vascular Tumors, or Angeiomata, of the penis are occasionally met with, and may be treated by excision, the application of caustics, the establishment of aseton (Reeves), or even, as in a remarkable case reported by Parona, by amputation of the organ. The same surgeon has success- fully* employed injections of chloral in a case of varix of the dorsal vein of the penis. Malignant Diseases of the Penis.—The penis may be the seat of either ejiithelioma or scirrhus, the former, which is the more common affection, ordinarily beginning in the prepuce, while scirrhus usually ori- ginates in the body of the penis, in the depression behind the corona glandis. Both of these forms of dis- ease appear to be more common in the subjects of congenital phimosis than in those who are not thus affected, which is of itself a sufficient reason to induce the surgeon to re- commend circumcision in all cases of preputial contraction. Epithelioma of the penis may possibly be mistaken for exuberant vegetations or for chancre. From the former it may be distinguished by the indurated and infiltrated condition of the parts, which is characteristic of the malig- nant affection, and from the latter by the history and course of the disease, the comparatively late implication of the negative effect of antisyphilitic Fia IF- 623.—Epithelioma of the penis. (From a patient in the Episcopal Hospital.) the inguinal lymphatic glands, and treatment. Treatment.—In the case of epithelioma, if the nature of the affection be recognized before the glands have become involved, it may be possible to remove the whole mass of disease by circumcision ; but at a later period amputation of the penis is the only resource which offers a prosj>ect of benefit, and the same operation is required when the growth is of a scir- rhous character. Amputation of the Penis, if performed at an early period, before the lymphatic glands have become involved, is quite a successful proceed- ing, and often gives a long respite from the disease, if, indeed, it does not effect a permanent cure. The operation may be performed with either the wire loop and galvanic cauterv, the ecraseur, or the knife. The disad- vantage which attends the use of the ecraseur is that the contraction which ensues in healing is ajit to diminish the calibre of the urethra and thus lead todifficuity in micturition ; to avoid this, it has been recommended to introduce a flexible catheter, cut through this with the chain of the instru- ment, and leave the remnant in place during the process of cicatrization • EPITHELIOMA OF THE SCROTUM. 1067 but it is not always very easy to sever the catheter in this manner, and, unless great care be exercised, its end may escape from the surgeon's grasp and slip into the bladder. Upon the whole, the operation with the knife seems to be preferable under ordinary circumstances, though, if it be neces- sary to amputate the organ very high up, the ecraseur may answer a better purpose. Humphry, Thiersch, Cabade, C. Johnston, McGann, Gould, and Clarke have successfully removed the entire organ, connecting the divided urethra with an artificial opening in the perineum. To prevent hemorrhage, in the use of the knife, a tape may be tied tightly around the root of the penis, and an assistant should grasp the part with his fingers to jirevent the stump from being retracted beneath the pubis, or, as advised by Tyrrell, the penis may be transfixed with a large acupressure pin, behind which the tape is applied, the pin itself being left in place for several days, and until all risk of bleeding has passed by. The surgeon takes the glans, wrapped in lint, in his left hand, and draws the organ for- wards, so as to put its integument on the stretch ; he then cuts off the part to be removed with a sharp knife, either at a single stroke, or, which I think better, divides first the cavernous bodies, and then allows the organ to retract before severing the urethra, which is thus left rather longer than the rest of the penis. Bleeding is next to be checked, about five ligatures usually* being required, when the operation should be completed according to Ricord's plan, by splitting the projecting portion of the urethra at three or four points and everting its mucous membrane, which is then attached to the skin by* means of the interrupted suture. Another plan, suggested by Watson, of Edinburgh, is to make a slit in the integument of the penis, and to pass the projecting urethra through this slit, so as effectually to prevent the occurrence of contraction during the healing process. Unless the amputation be done very near the root of the organ, the procreative powers of the individual do not seem to be impaired by the operation. Non-malignant Tumors of the penis are occasionally met with, and may be removed without infringing upon the in- tegrity* of the rest of the organ. Epithelioma of the Scrotum is chiefly oli- served in chimney-sweepers,1 whence it has been called chimney-sweeper's or soot-cancer; it appears to be produced by the irritation caused by the con- tact of soot, beginning as a scaly or incrusted wart which soon ulcerates, and perhaps ultimately involv- ing the whole scrotum, the testis, and the inguinal and pelvic ly*mphatic glands. The treatment con- sists in complete excision of the growth at as early a period as possible. Under the name of "paraf- fine epithelioma," Joseph Bell describes a form of Flo.689.-BpitheiiomaofOie malignant ulceration met with in workers in this scrotum. (Curling.) article, and Ball, of Dublin, has reported cases of epithelioma occurring among persons engaged in the distillation of tar. The treatment consists in excision. Dr. Crocker has observed a condition of the scrotum analogous to " Paget's disease" of the nipple, and like that followed by the development of carcinoma. i In the only cases seen by the late J. C. Warren, of Boston, however, the patients were not chimney-sweepers. 1068 DISEASES OF THE GENERATIVE ORGANS. Malformations and Malpositions of the Testes. Complete Absence, of one or both. Testes has occasionally been observed, but a more common condition is an Arrest in the Normal Descent of the Organ, the gland remaining in the abdominal cavity or in some jiart of the inguinal canal. In other cases a testis may pass through the femoral ring, may* be found in the perineum, or, though lodged in the scrotum, may be inverted, so that the epididymis is placed in front of the body of the organ. Retained testes are liable to become inflamed, and are peculiarly predis- posed to structural degeneration. It would appear, also, from the re- searches of Godard and Curling, that a retained testis either secretes no fluid, or that its secretion is destitute of sjiermatozoa; hence a monorchid, or person with one undescended testis, depends for his procreative power upon the single gland which has reached the scrotum, w'hile a cryptorchid, or person with both testes retained, though capable of coition, is necessarily sterile. Treatment.—The treatment of maljiositions of the testis is in most cases limited to palliative measures. If the gland be still within the abdomen at the end of the first year of life, Curling advises the application of a truss to insure its permanent retention. When the testis is above the external ring, it requires no treatment, unless it becomes inflamed, or is the seat of structural degeneration. When at or just outside of the external ring, the gland is liable to slip backwards and forwards, and causes a good deal of pain when pinched in the inguinal canal. Under such circumstances, a truss should be used, the pad being applied, if possible, between the testis and ring; if this cannot be done, the gland may be pushed into the canal and held there with a truss provided with a suitable obturator, as advised by Curling, or a truss with a concave or ring pad to receive the gland may be employed, as recommended by J. Wood. Annandale has successfully transjilanted a misjdaced testis from the perineum to the scrotum ; but a similar operation in the hands of J. E. Adams terminated fatally from peritonitis. Transplantation of a testis from the groin to the scrotum has been successfully resorted to by J. Wood. If a testicle which is retained in the inguinal canal becomes inflamed, the affection may at first sight be mistaken for strangulated hernia, but may commonly be distinguished in the way described at page 892. The treatment consists in the application of leeches, followed by ice or hot fomentations, as most agreeable to the patient, with the internal adminis- tration of laxatives and saline diaphoretics. If the gland be subject to repeated attacks of inflammation, the question of excision may properly be considered; the operation is usually successful, 42 cases collected by Monod and Terrillon having given 35 recoveries and but 1 deaths__only one of these, moreover, having been due to jieritonitis. Excision is always re- quired in case of structural degeneration of a.retained testicle, and may also be practised when the organ is situated in the perineum, in which position it is constantly exposed to injury. Inversion of the Testicle is chiefly interesting when accompanied with hydrocele, the fluid then being found behind the organ, instead of in front of it, as is usually the case. H. Lee has recorded a curious instance of Temporary Disappearance of the Testicle, the organ having slipped up through the inguinal ring, which was dilated by the presence of a hernia. The patient was directed to go without the truss for a few days, when the missing- gland reappeared. Prof. Humphry refers to a case in which the organ similarly vanished dur- INFLAMMATORY AFFECTIONS OF THE TESTES. 1069 ing the act of masturbation, but in this instance the disappearance was unfortunately permanent. Inflammatory Affections of the Testes. Orchitis, or Inflammation of the Testicle, may result from traumatic causes, from rheumatism, from mumps, or from the spread of gonorrhoeal or other inflammation from the urethra. In the latter cases, the epididymis is commonly the part primarily affected, constituting the affection known as Epididymitis, Hernia Humoralis, or Swelled Testicle,. which has already been described at page 470. The symptoms of orchitis^ are those of inflammation in general, the pain being very intense, and! often radiating up the course of the spermatic cord. There is usually effusion into the tunica vaginalis (acute hydrocele), and there is often a great deal of constitutional disturbance. The treatment is essentially the same, no matter what may be the origin of the affection. When the symp- toms are very acute, I know of nothing which will afford such rapid relief as the puncture of the tunica albuginea, in the way recommended by Vidal (de Cassis) and H. Smith. In less acute cases, it may be sufficient to confine the patient to bed, and to keep the scrotum elevated and covered' with cold lead water and laudanum. Laxatives and anodyne diaphoretics, followed at a later period by quinia, may* be administered internally. In chronic cases, in which the enlargement of the organ continues after the subsidence of all acute symptoms, strapping the testicle may be resorted to with advantage. This may be done with simple adhesive plaster, or with the plaster of ammoniac and mercury, if there be any suspicion of a syphilitic taint. Strapping the Testicle.—The scrotum having been carefully washed and shaved, the surgeon draws the skin of the affected side upwards, so that the part which covers the testicle is tensely stretched over the organ. A strip of plaster is then applied circularly above the gland and drawn pretty* closely, so as to iso- late the part and prevent the other strips from slipping. These are now applied, in an imbricated manner, alter- nately in a longitudinal and transverse direction, until the whole organ is covered in, and firmly and evenly compressed, no one strip, however, being drawn so tightly* as to produce excoriation. When properly ap- plied, the effect of strapping in promoting absorption, and thus reducing the size of the part, is very striking. The dressing commonly requires renewal every day* or every other day, and upon each occasion the scrotum should be well washed with Castile soap and water, so as to keep the skin in a healthy condition. Dr. W. B. Hopkins, of this city, applies elastic pressure by means of strips of rubber bandage made to adhere by "rubber cement." " Dr. Hawes, of Colorado, employs a double- walled rubber bag, which, after adjustment, is inflated, so as to make the needful amount of compression. Abscess and Hernia of the Testicle.—Abscess is an occasional sequel of orchitis, the pus being usually formed in the tissues of the scrotum rather than in the testicle itself, but sometimes originating beneath the tunica albuginea, in the proper gland structure. In the former case, the affection is of but little consequence, the abscess healing without difficulty Fia. 630'.—Strapping the testicle. (Vel- PEAtt.) 1070 DISEASES OF THE GENERATIVE ORGANS. after the evacuation of its contents ; but when the testicle itself is the seat of suppuration, a fistulous opening is apt to remain, through which a por- tion of the seminiferous tubules may protrude, in the form of a vascular fungoid mass. The treatment of this Hernia of the Testis, as it is called, consists in the topical use of stimulating astringents, such as the red oxide of mercury, with pressure—which may be applied with ad- hesive strips, or, better, as recommended by Syme, by making elliptical incisions around the protruding mass and loosening the surrounding integument, which is then united over the pro- trusion with sutures—thus making the skin of the part exercise the requisite compression. If one testicle only* be affected, and the jiatient's r e*, u • • f.x. <. ♦■ i„ health begins to fail under the long continuance Fig. 631.—Hernia of the testicle. , ,. • .,11 (Cijrlinu.) of the disease, castration may occasionally be justifiable. Inflammation of the Seminal Vesicles is, according to Lloyd, of Birmingham, usually secondary to urethral inflammation, and particu- larly to urethral gonorrhoea; suppuration is rare, but if it occurs should be treated by an incision from the perineum and not through the rectum. Neuralgia of the Testis. The seat of pain may be the epididymis, the body of the testicle itself, or the spermatic cord. The part-is usually extremely sensitive to the touch, and there may be slight swelling without any* evidence of positive disease. The pain is often of a paroxysmal character. The affection is sometimes associated with an irritable condition of the urethra, and with the occurrence of involuntary seminal discharges. In other cases, it de- dends upon the existence of varicocele, or may be sympathetically excited by hemorrhoids. Often, however, neuralgia of the testicle exists without any apparent cause. The treatment consists in removing any source of irritation that can be discovered, and, in cases of obscure origin, in the administration of tonics and antispasmodics, and in the topical use of seda- tives and anodynes. Galvanism has occasionally proved serviceable in these cases. Castration has been recommended, and is often desired by the patient. It is, however, an unjustifiable operation under these circum- stances, as being totally uncalled for in cases of local origin, and only capable of affording temporary relief, if any, in those of a constitutional nature. Hammond recommends forcible compression of the spermatic cord—an operation somewhat analogous to that of nerve-stretching. Hydrocele and Hematocele. Hydrocele of the Tunica Vaginalis, or simply Hydrocele, consists in a collection of serous fluid in the tunica vaginalis. Several varieties of the disease are described by surgical writers, as the congenital, the acquired, and the encysted hydrocele. Inguinal hydrocele is a name used by Holt- house for hydrocele occurring in connection with an undescended testis. Congenital Hydrocele results from an imperfect closure of the com- munication between the tunica vaginalis and the peritoneal cavity. This form of hydrocele is observed in infants, and may be recognized by the fluid flowing back into the abdominal cavity* when the scrotum is elevated or acquired hydrocele. 1071 compressed. Congenital hydrocele usually undergoes a spontaneous cure by the closure of the vaginal process of peritoneum ; if, as often happens, the hydrocele be accompanied with hernia, a truss should be worn to prevent the descent of the intestine. Should a congenital hydrocele not disappear spontaneously, discutient remedies, such as a lotion containing muriate of ammonium (gr. v to fjj), or the tincture of iodine (diluted), may* be applied to the scrotum ; or acupuncture may* be tried ; or the fluid may* be evacuated with an exploring trocar and canula, and a little alcohol injected while compression is maintained upon the inguinal canal. This plan, which is recommended by Richard, is, however, necessarily attended with some risk of peritonitis. Acquired Hydrocele may originate in an attack of orchitis, which, as has been mentioned, is usually* accompanied with effusion into the tunica vaginalis, but more commonly begins as a chronic affection, sometimes following a blow, but often being assignable to no particular cause. It may occur at any age, but is probably* most common in infants, and in adults about the middle period of life. The symptoms are swelling, beginning at the lower part of the scrotum, and attended with a sensation of weight and dragging, but rarely with pain. The swelling is at first (usually) soft, fluctuating, and elastic, but ultimately becomes tense and hard, and assumes a pear-like shape which is very characteristic. The size varies from that of a hen's egg to that of a large orange, sometimes even exceeding the latter measurement. As the swelling creeps up the cord to the external abdominal ring, it covers over and partially* conceals the penis. The diagnosis can usually be made without difficulty, by noting the pyriform character of the tumor, and by observing that the swelling of hydrocele is translucent when examined by transmitted light. For this test the patient should be in a dark room, and the surgeon should grasp the neck of the hydrocele with one hand, so as to put the integument on the stretch, while the edge of the other hand is applied to the convexity of the swelling so as to shade it from side rays; a lighted candle or lamp being then held by an assistant close behind the tumor, this will in the large majority* of cases be found translucent. This test may, however, occasionally* fail, either from the dark color of the contained liquid, or from the thickness of the superincumbent tissues ; while on the other hand a solid tumor may occasionally be translucent, as in a case of round-celled sarcoma, recorded by Lucke, and in one of hernia (in a child) mentioned by Howse ; hence, in some circumstances, an exploratory puncture or incision may be required to reveal the true nature of the affection. For the diagnosis from hernia, see page 893. The fluid of a hydrocele varies in quantity in different cases, the amount being usually from six ounces to a pint, but occasionally reaching to several quarts ; it is commonly of a straw color and limpid, and is albuminous, coagulating sometimes into a solid mass when heated ; in other instances it is of a dark brown color, from the admixture of blood, and it then usually contains cholestearine. It is occasionally of a milky or chylous character, and contains leucocytes and fatty matter. Sonsino and Bancroft have found it to contain filariae. In some rare cases it coagulates spontaneously. The tunica vaginalis, or Sac of the Hydrocele, and its other coverings, are usually thinned by distention, but otherwise normal; in some cases, how- ever, the sac is thickened—becoming the seat of a pseudo-membranous formation which may send prolongations across the cavity in the form of bands or septa—or more rarely undergoes calcification ; in these cases the resulting pressure may cause atrophy of the testicle, but in most instances 1072 diseases of the generative organs. this organ is normal or slightly enlarged. The position of the testis, in hydrocele, is almost always at tlie lower and posterior jiart of the scrotum, but it may occasionally be in front (from congenital inversion of the organ), or its position may be altered by the formation of adhesions between the opposing surfaces of the tunica vaginalis. The position of the testis should always be, if possible, ascertained (by examination with transmitted light) before resorting to operation. The two tunica? vaginales are aflected with about equal frequency, and double hydrocele is occasionally observed ; in this case the existence of a communication with the abdominal cavity may always be suspected. The treatment of acquired hydrocele may be either palliative or radical. In infants and young children, a cure may often be effected by the appli- cation of discutients, or by acupuncture, as in the congenital form of the affection ; and, even in adults, a single tapping (which constitutes the palliative mode of treatment) will occasionally afford permanent relief, though, more commonly, the effusion returns after each tapping, the hydro- cele re-acquiring its original size in the course of a few months. Occasion- ally the intervals between the successive returns of the disease become gradually longer, until, after repeated tapjiings, the affection ultimately disappears. Tapping a Hydrocele, or the Palliative Operation, is attended with very little risk, though in aged subjects death may occasionally follow from the occurrence of diffuse inflam- mation of the connective tissue of the jiart. The surgeon, having de- termined the position of the testicle, grasps the hydrocele with his left hand so as to make the skin tense, and choosing a point which is at the opposite side from the gland, and free from subcutaneous veins, intro- duces, with a quick plunging motion, a small trocar and canula, at about the junction of the middle and lower thirds of the scrotum. The instru- ment should be at first thrust directly backwards, but as soon as the point has entered the sac should be inclined in an upward direction (Fig. 632), so as to avoid wounding the testicle— an accident which, though rarely followed by any evil result, should, if pos- sible, be avoided. The trocar is then withdrawn, when the fluid escapes through the canula, and is caught in any convenient receptacle. The opera- tion is attended with very* little pain, and the patient need not therefore be etherized; he may be placed in the recumbent position, or, which I prefer, if the hydrocele is not a very large one, may sit on the edge of a high chair, or stand, leaning against a table. The surgeon should examine his trocar before using it, to make sure that it has a good point, and that it fits and slips easily in the canula ; from neglect of this precaution, I have seen a surgeon introduce his instrument, and then find that the trocar could with great difficulty be extricated from'the canula, into which it was firmly rusted. After the withdrawal of the canula, a piece of sticking-plaster may be put over the puncture, but no further after-treatment is required. Bradley, of Manchester, recommends that the part should be tightly strapped after tapping, and believes that thus re-accumulation may be pre- vented. The palliative treatment may be properly employed if the patient Fig. 632.—Tapping for hydrocele ; a, introduc- tion of trocar; b, position of canuia. (Ekichse.n.) RADICAL TREATMENT OF HYDROCELE. 1073 cannot spare the requisite time from his ordinary avocations to undergo the operation for the radical cure, and in the case of very old or feeble men who might illy support the risk of the operation. Simple tapping may also be employed once or twice as a preliminary to the radical treatment, which is most apt to succeed when the disease is in a chronic condition. Radical Treatment of Hydrocele—Various ojierations are jier- formed with a view of effecting a permanent cure of hydrocele, those most worthy* of mention being the methods by injection, by* the formation of a seton, by incision, and by excision of the tunica vaginalis. 1. Injection.—The fluid of the hydrocele having been evacuated with the trocar and canula, some irritating substance may be injected through the latter, so as to excite inflammation in the tunica vaginalis. The modus operandi of injections, in cases of hydrocele, appears to be in most cases the formation of inflammatory lymph, which glues together more or less completely* the opposing surfaces of the sac; in some instances, how- ever, no adhesions have been found on dissection, and the cure has appeared, therefore, to be due to some intangible change in the tunica vaginalis itself. The injection treatment is very rarely* followed by sup- puration. Various substances1 have been employed for the injection of hydrocele, the best being the tincture of iodine, as originally suggested by Sir J. Ranald Martin. Some surgeons use the tincture largely diluted, allowing the injected fluid to flow out again through the canula before the latter is withdrawn; but Syme's plan, which I have alway*s followed, and which, when properly carried out, almost never fails, is to inject a small quantity* of the pure tincture (f5j to iij, according to the size of the swell- ing), and allow it to remain in the sac. The injection may* be made with an ordinary* hard-rubber syringe; or, which is more convenient, a gum- elastic bag with a nozzle and stopcock; and it is better to use a platinum canula instead of one made of silver, as the latter metal may be corroded by contact with the iodine. After the injection, the canula should be cautiously withdrawn, so as to prevent the escape of the fluid, which should then be diffused over the whole surface of the sac by giving the part a shake. A good deal of pain usually follows the operation, and the scrotum commonly swells to its original size in the course of a few day's, the swelling then gradually subsiding until the cure is complete. In this stage of the treat- ment, the progress of the cure may be hastened by systematically strap- ping the part with adhesive plaster. The patient should be confined to bed, or at least to a lounge, for two or three days; but after that may resume his ordinary occupations. 2. The Seton.—Should the injection treatment fail (which, I may re- peat, will very seldom happen if the surgeon use the pure tincture of iodine, and allow it to remain in the sac), the next best plan is to establish a seton. This may conveniently* be done by replacing the trocar in the canula, after evacuating the contents of the sac, and then making a counter- puncture from within outwards; the trocar is now withdrawn, and an eyed-probe, carrying two or three strands of silk, passed through the canula, which is finally removed, leaving the threads in place. The ends are then loosely knotted and the patient sent to bed. The threads may, in most instances, be removed the next day, or the day* after; but occa- sionally must be left a week or even longer, to produce the required 1 Among those most highly recommended of late years may be mentioned carbolic acid, as used by Levis and Weir ; ergot, as suggested by Walker; chloral hydrate, as advised by Cattaneo, of Pavia; and powdered iodoform, as employed by P. J. Hayes, of Dublin. 68 1074 DISEASES OF THE GENERATIVE ORGANS. amount of inflammation. Furneaux Jordan recommends that, to increase the irritation, the threads should be moistened with iodine liniment. The use of wire was recommended by Simpson, with the expectation that it would be less apt to excite troublesome suppuration than the seton made with silk. The experience of surgeons generally has, however, shown that such is not the case, while it has been found that the wire seton is by no means a certain remedy*. 3. Incision.—This consists in laying open the sac and stuffing the wound with lint, so as to induce suppuration. Though an efficient mode of treat- ment, this is in most cases unnecessarily severe,"and is not entirely free from risk. It is particularly adapted to'cases in which the thickness of the sac prevents the diagnosis from being made by the examination with trans- mitted light; if such a case be really one of hydrocele, the incision will suffice for its cure, while, if it turn out to be one of solid tumor, the wound can be utilized for the operation of castration. 4. Excision.—This consists in laying open the sac, and carefully dis- secting out the tunica vaginalis. If the operation succeeds, the cure is necessarily permanent; but the procedure is a dangerous one, and should be kept as a last resort for cases that resist all other modes of treatment. Encysted Hydrocele (Spermatocele).—In this affection the fluid is not contained, jiroperly* speaking, in the tunica vaginalis, but in an inde- pendent cy*st projecting from the surface of the testicle, or more commonly from the epididymis. In the latter case, the fluid of the cyst differs from that of an ordinary hydrocele in being watery or milky, and in containing spermatozoa; and the name spermatocele is therefore properly applied to these, which belong to the class of seminal cysts (see page 511). In some cases, which are properly called lymphocele or chylocele, the milky charac- ter of the fluid is due to the admixture of lymph from a communication with the lymphatics of the tunica vaginalis or cord, and in some of these the affection appears to be caused by the presence of the filaria sanguinis hominis, which has been detected under these circumstances by Bancroft, Sonsini, and W. M. Mastin, who has given an excellent account of the subject. Those comparatively rare specimens of encysted hydrocele, too, in which the cyst projects from the body of the testis, cannot be classed as seminal cysts, since they do not appear to contain spermatozoa—their fluid being of a serous character like that of the common hydrocele. This variety, as pointed out by Osborn, appears to originate in dilatation of the so-called " hydatid of Morgagni," a remnant of the Mullerian duct of foetal life. The diagnosis of the encysted from the other forms of hydrocele can usually be made by observing the position of the testis in relation to the sac, which, in the encysted variety of the disease, commonly projects from the surface of, but does not surround, the gland. The treatment is the same as for the ordinary acquired hydrocele. Fibrous or Fibro-cartilaginous bodies are sometimes found in the sac of a hydrocele; they resemble in structure the rice-like bodies found in syno- vial bursae, and, if recognized during life, may be removed by a simple incision. Hydrocele of the Spermatic Cord.—Three varieties are described by systematic writers, viz., (1) the simple hydrocele of the cord, which con- sists in an accumulation of serous fluid in the cavity which often persists in the funicular portion of the vaginal process of the peritoneum ; (2) the encysted hydrocele of the cord, in which the fluid is contained in an inde- pendent cyst developed in this situation; and (3) the diffused hydrocele of the cord, a rare affection, referred to by Pott and Scarpa, which appears to consist in an cedematous infiltration of the areolar tissue of the part. For HEMATOCELE. 1075 the diagnosis of hydrocele of the cord from hernia, see page 892. The treatment of the simple and encysted varieties consists in tapping, fol- lowed, if necessary, by the injection of iodine, or the formation of a seton. For the diffused hydrocele—if any treatment were required—the external use of iodine or other sorbefacients might be resorted to. Hydrocele of the Seminal Vesicle is the name applied by N. R. Smith to a cyst developed in connection with the organ referred to; it is a rare affection and may be mistaken for a distended bladder, but the diag- nosis can be readily made by the use of a catheter and by the introduc- tion of a finger into the rectum. The treatment consists in evacuating the contents of the cyst by tapping through the rectum, as in cases of urinary retention. (See page 1023.) Haematocele—Of this there are three varieties, viz., (1) haematocele of the tunica vaginalis, consisting in an effusion of blood into this sac, and often supervening upon an ordinary hydrocele; (2) encysted haemato- cele, in which the blood is effused into the sac of an encysted hydrocele ; and (3) haematocele of the cord, in which the effusion occupies a position corresponding to that of a hydrocele of this part. Haematocele may result from traumatic causes—such as a blow or squeeze, or possibly the wound of a small vessel inflicted in the operation for hydrocele—or may originate spontaneously from the rupture of a spermatic vein. According to Gos- selin and Riegel, haematocele often originates in inflammation of the tunica vaginalis with the formation of vascular false membranes from which the bleeding occurs. In the spontaneous cases the haematocele sometimes attains a very large size, and the affection is, under these circumstances, attended with considerable danger. The blood of a haematocele is at first of course fluid, and may continue in this state for many years ; in other cases it undergoes partial coagulation, the clots sometimes assuming a laminated arrangement like that seen in the sac of an aneurism; or the blood corpuscles may become disintegrated, when the fluid of the haemato- cele has a dark and grumous appearance, and often contains cholestearine ; if decomposition of the blood occurs, suppuration of the sac may ensue, and perhaps lead to fatal consequences. The symptoms are much the same as those of hydrocele, except that the part is not translucent when examined by transmitted light. The diag- nosis, in the early stages of the affection, can commonly be made by ob- serving that the swelling occurs rapidly, and usually after a blow—and yet is obviously not due to orchitis—while the absence of translucency, and the existence of ecchymosis, serve to distinguish the affection from hydrocele. When haematocele has passed into a chronic condition, the diagnosis is more difficult, and in many cases the disease has been mistaken for a malignant growth, and vice versct. Humphry points out that the malignant testis steadily increases in size, while the growth of a haemato- cele is irregular, and the swelling sometimes even undergoes diminution. The diagnosis from hernia has already been considered at page 893. Treatment.—In many cases haematocele undergoes a spontaneous cure ; the hemorrhage ceases, and absorption then gradually occurs, as in the case of blood effused in other parts of the body. Hence, in the early stages of the affection, the treatment should be merely palliative, consisting in the enforcement of rest, with elevation of the scrotum, the application of cold, etc. After a few days, the patient may go about with a suspensory band- age. If, however, the haematocele be in a chronic state, tapping may be resorted to, and will occasionally effect a cure; should the sac refill, its contents will probably be thinner and more serous than at first, and the case will thus gradually become assimilated to one of hydrocele, when it 1076 DISEASES OF THE GENERATIVE ORGANS. may be treated with iodine injections. If the haunatocelc contain a large proportion of coagulum, it will probably be necessary to lay the sac ojien and allow it to heal by granulation. This should not, however, be done during the early stages of the affection, particularly in a case of the sjion- taneous variety, lest dangerous or even fatal hemorrhage should take jilace from the ruptured vein, which is sometimes very much enlarged. Before either puncturing or incising a haematocele, the surgeon should, if possible, determine the position of the testis ; this cannot be ascertained, as in the case of hydrocele, by examination with transmitted light, but much infor- mation may often be gained by tracing down the cord, and by noting the sensations of the patient, who usually experiences a characteristic, sicken- ing pain when pressure is made on the testicle. Varicocele. Varicocele, or Cirsocele (varicose enlargement of the veins of the sper- matic cord) is a very common affection, existing, according to Humphry, in about ten per cent, of all male adults. The causes of varicocele are those of varix in general; the anatomical peculiarities of the spermatic veins render them particularly suscejitible to the affection, which is chiefly seen in those of lax and feeble habit, and is often hereditary. Varicocele is much more frequently seen on theleft side than on the right: this apjiears to be due to a combination of causes, such as the position of the left testicle, which is usually more dependent than the right; the obstacle to the return of blood which exists on the left side, from the left sjiermatic vein joining the renal vein at a right angle, instead of opening directly into the vena cava, as is done by the right spermatic vein ; the comparative deficiency of valves in the left spermatic vein as compared with the right (first pointed out by Prof. Brinton, of this city*) ; and the exposure of the left spermatic vein to pressure, from accumulations of fecal matterin the sigmoid flexure of the colon. Symptoms.—Varicocele forms a pyramidal swelling in the scrotum, with its base downwards, and its apex extending upwards towards the inguinal canal. The swelling has a peculiar knotted and convoluted feel, and the sensation conveyed to the hand is often compared to that which would be given by a bunch of earthworms. The tumor increases when the patient stands or walks, and almost if not quite disappears when he lies down. It is sometimes, but by no means always, attended with a feeling of weight, and even pain, which is increased by exercise, and is apt to be worse in summer, when the scrotum is more relaxed and pendulous than at other seasons. Varicocele sometimes attains a considerable size, filling the scrotum and enveloping the testicle, which may undergo diminu- tion in bulk from the pressure of the overlying veins. Rupture of a vari- cocele may occur from a blow or other injury, causing great effusion of blood ; Erichsen mentions a case of this kind in which, the tumor bavin"- been opened, the patient died from venous hemorrhage. The diagnosis of varicocele from hernia (the only* affection with which it is likely to be confounded) has been considered at" page 893. Treatment.—In the large majority* of cases, no treatment whatever is required: the patient may wear an elastic suspensory bandage, to support the jiart and relieve the feeling of weight which sometimes accompanies the affection, but even this apparatus is in many instances voluntarily thrown aside. To lessen the capacity of the scrotum, its lower part may be drawn through a soft metallic ring covered with leather, or one of vul- canized India-rubber ; this plan, which was suggested by AVormald, would radical cure of varicocele. 1077 certainly be attended with less risk than that by which it appears to have been suggested, viz., excision of the lower portion of the scrotum, as recom- mended by Cooper and Briggs, and more recently by M. H. Henry, of New York, and Andrews, of Chicago, who have devised ingenious clamps for the prevention of hemorrhage during the operation, an object sought to be attained by Hutchison, of Brooklyn, by first transfixing the scrotum half a dozen times with a large acupressure needle. The hypodermic injec- tion of ergotine is recommended by two Italian surgeons, Drs. Bertarelli and Cittaglia, and is certainly worthy of further trial. Hypodermic injec- tions of alcohol are employed by Dukhnovsky, a Russian surgeon. But the best palliative remedy for varicocele is, I think, the application of a light truss, as recommended by Curling and Ravoth, so as to break the column of blood in the sjiermatic veins (without compressing the artery), and thus remove the pressure from the dilated vessels. Radical Cure of Varicocele.—In a few cases, more energetic measures may be required ; a great many ojierations besides that of Cooper, above referred to, have been proposed for the radical cure of varicocele, the best, probably, being those of Ricord, Vidal (de Cassis), H. Lee, J. Wood, and Annandale. (1) Ricord's Method consists in introducing subcutaneously, in opposite directions but through the same apertures, two double ligatures, one be- neath the spermatic veins (isolated from the vas deferens), and the other above them,, so that there shall be a loop and two ends of ligature on each side; the ends are then threaded through the corresponding loops, and attached to a light yoke jirovided with a screw, by daily turning which they are constantly* drawn tight—thus effectually strangulating and ulti- mately cutting through the veins, from which the ligatures drop in the course of the second or third week. (2) VidaVs Operation consists in passing a steel pin, perforated at both ends, below the veins and between them and the vas deferens, and through the same apertures a silver wire above the veins, and between them and the skin ; the wire is threaded through the jierforations at each end of the pin, which is then rotated in such a way as to twist the wire and roll up and firmly* compress the veins. The wire is twisted more and more tightly each day until the veins are cut through (usually at the beginning of the second week), when the pin and wire are easily withdrawn together. Bradley has simplified this method by passing a long pin above and then below the veins, thus compressing them as in the "Aberdeen" method of acupressure. (3) Lee's Method consists in passing two needles beneath the veins, and between them and the vas deferens, about an inch apart—jiressure being then made by means of elastic bands passed over the extremities of the needles. The veins which are thus acupressed at two points are next divided subcutaneously between the needles, which maybe removed on the third or fourth day* after the operation. Should the division of the veins be followed by bleeding, which may happen from some vessel being cut that was not included by the needles, the hemorrhage can be readily arrested by the introduction of a third needle—below the point of division if the bleeding be venous, and above, if it be of an arterial character. I have varied this operation by acupressing the veins between harelip pins and loops of silver wire passed subcutaneously, or by substituting for the elastic bands stout silk ligatures which are removed the next day. Another method, also recommended by Mr. Lee, consists in cutting away a portion of the scrotum, compressing, dividing, and searing with a hot iron the affected veins, and finally closing the wound with a carbolized suture. Bogue, 1078 DISEASES OF THE GENERATIVE ORGANS. x*53> ,ff of Chicago, cuts into the scrotum antiseptically, and ties each vein sepa- rately* with a catgut ligature. (4) Wood's Method (Fig. 633) is an ingenious modification of Bicord's, in which the veins are surrounded subcutaneous- ly with a metallic ligature ; the ends of the ligature pass through and are se- cured to a light spring, by the action of which the wire is constantly drawn tight. Somewhat similar methods are practised by Barwell, by Roves Bell (Fig. 034), and by Weir, of New York. Gould surrounds the veins with a platinum wire, and divides them with the gal- vanic cautery. Keyes ties them subcutaneously with a catgut ligature. (5) Annandale's Method consists in excising a por- tion of the enlarged vein, as practised by Marshall and Steele in cases of varix of the extremities ; hemor- rhage may be arrested by acupressure as in Lee's operation. This mode of treatment has also been successfully employed by Mr. Howse and Mr. Banks. Rigaud simply exposes the vein without removing any portion of it. These operations (of which that by Lee's first method seems to me upon the whole the best) are all attended with some risk, and can only be justi- fiable in exceptional cases. Fib. 633.—Wood's instrument for varicocele. Fio. 634.—Royes Bell's instrument for varicocele. Sarcocele and Tumors of the Testis. Sarcocele is a general term, commonly but rather unfortunately apjilied to all solid enlargements of the testicle. Surgeons speak of several varie- ties of sarcocele, as the simple, the tuberculous or scrofulous, the syphilitic, the cystic, and the malignant. Simple Sarcocele is the chronic enlargement of the testis which re- sults from inflammation of the organ. The affected gland is moderately increased in size, smooth and rather hard to the touch, though occasionally semi-fluctuating in parts, and somewhat painful and tender; the cord also is, in most cases, thickened and indurated. When cut into, the testis is found to be infiltrated with lymph in various stages of organization or fatty degeneration, the latter condition giving the ajipearance of yellowish spots which are often mistaken for tubercle. Suppuration occurs in some cases, and may be followed by hernia of the testis. Simple or inflammatory sar- cocele is often accompanied with effusion into the tunica vaginalis, consti- tuting Hydrosarcocele. The treatment consists in strapping the testicle, with the occasional application of a few leeches, and attention to the state CYSTIC SARCOCELE. 1079 of the general health; hernia of the testis is to be treated as described at page 1070. Tuberculous Sarcocele—A deposit of true tubercle in the testis is, I believe, a less common affection than is ordinarily supposed, many of the cases which are called tuberculous sarcocele being really instances of simple enlargement from chronic inflammation, occurring in persons of scrofu- lous diathesis. True tubercle in the testis, according to Carswell, Curling, and Salleron, is first developed as an intra-tubular affection, but, according to Rindfleisch, Virchow, and other modern pathologists, originates prima- rily in the interstitial areolar tissue. Causes.—The causes of tuberculous sarcocele are involved in some ob- scurity. It is ordinarily said to follow gonorrhoea or sexual excess, or to be due to some traumatic injury of the part; but, according to Salleron (who has published an elaborate memoir on the subject, based upon an analysis of 51 eases), the true tuberculous sarcocele never follows these affections, which are common causes of the simple sarcocele, except as a coincidence. His theory is that tubercle is deposited in the testis in infancy*, as a manifestation of the tuberculous diathesis, but that the affection is not called into activity until after the period of puberty, when the generative organs become subject to functional excitement. Symptoms.—Tuberculous sarcocele commonly begins in the epididymis, but ultimately involves the whole testis, forming a large, nodulated, and usually indolent mass. In some cases, however, the enlargement is uniform, smooth, and semi elastic. In the nodulated variety of the disease, one or more of the nodules gradually inflame and become adherent to the skin, abscesses forming, and perhaps leading to the occurrence of fungous jiro- trusions, or herniae of the testis, and the greater part of the gland thus being, in some instances, gradually extruded from the scrotum. Both testi- cles are usually successively involved. The vasa deferentia, vesieulae seminales, and prostate are often similarly affected, and the patient may present evidences of phthisis, or of scrofu- lous disease of the lymphatic glands or other organs. The affection may be complicated with hydrocele. Treatment.—The treatment consists in attention to the state of the general health, in regulation of the diet, and in the administration of cod- liver oil, iron, iodine, etc. The patient should live as much as possible in the open air. The part should be supported in a well-fitting suspensory bandage, and advantage may be derived from the occasional application of iodine, or of local sedatives if there be much cutaneous inflammation. Humphry recommends that, in very bad cases, the sinuses should be laid open, the scrofulous matter turned out, and the parts stimulated to healthy action by the application of nitrate of silver. Verneuil recommends the actual cautery. Castration can be justifiable only when the general health is evidently suffering from the drain caused by the local affection. Syphilitic Sarcocele, in both of its varieties, has already been de- scribed (p 495). The treatment is that of syphilis in general—mercury being particularly applicable in the early or "interstitial," and iodide of potassium in the late, or "gummy," form of the disease. Cystic Sarcocele__This, which was called by Sir Astley Cooper the " Hydatid Testis," belongs to the fibro-cystic variety of tumor (see p. 518). The cysts themselves originate, as shown by Curling, in dilatations of the tubes of the rete testis, and may be classified according to the nature of their contents, as serous, sanguineous, or cutaneous proliferous cysts. The cystic sarcocele is often associated with cartilaginous growths, and sometimes with sarcoma or cancer. 1080 DISEASES OF THE GENERATIVE ORGANS. Diagnosis.—Cystic sarcocele very seldom occurs in jiersons under twenty years of age, though F. H. Gross has met with it in an infant; it may commonly be distinguished from hydrocele (the affection with which it is most likely to be con- founded) by observing its shajie, which is globular rather than jivriform, and its want of trans- lucency when examined with transmitted light. From malig- nant sarcocele it may be distin- guished by its slower growth, and the absence of glandular im- plication and of cachexia. In some instances, however, the diagnosis can only be made by puncturing the growth with a trocar and canula—when, if the case be one of cystic sarcocele, Fii*. 635.-Cystic sarcocele. (Bryant.) a few drops of SerOUS fluid will probably be evacuated by each puncture, from the successive opening of different cysts—or even by micro- scopical examination after removal. Treatment.—This consists in castration, which may be performed as soon as the nature of the case has been ascertained. Congenital Dermoid Cyst.—Another form of cystic disease of the testicle is the congenital dermoid cyst, which usually contains bone, teeth, or hair, and is believed by many writers to be an example of the malfor- mation known as " foetal inclusion." Cases of this affection, which is one of great rarity, have been recorded by several surgeons, among others by the late Prof. Van Buren. In the case observed by this distinguished surgeon, the patient, a child 2£ years old, had been treated (for what was supposed to be hydrocele) by the establishment of a seton, which led to much sujijiuration and the protrusion of a large fungous mass. The treat- ment consists in castration, unless, as occasionally happens, the growth be entirely external to the testicle, when excision of the tumor alone would be sufficient. Other Non-malignant Growths are occasionally found in the tes- ticle, as the fibrous, fibro-cellular, cartilaginous, etc. The diagnosis from the simple and syphilitic forms of sarcocele, with which alone they are apt to be confounded, can be made by watching the effect of remedies, which, in the case of tumor, would of course be negative. The treatment consists in castration. Fatty tumors have been observed in the spermatic cord, from which situation they* may be removed by excision. Malignant Sarcocele, if carcinomatous, is almost always of the encephaloid variety, though both scirrhous and melanotic growths have been occasionally* met with in this organ. Very many tumors of the testis, however, which would formerly* have been classed under the head of ence- phaloid cancer, are by modern pathologists described as sarcomata. Another variety of malignant growth met with in the testis is the lym- phadenoma, which has been particularly studied by Malassez, Monod, and Terrillon. It usually affects both testes, simultaneously or successively. In malignant sarcocele, the body of the testis is usually first involved, and the organ, when cut into, exhibits masses of a medullary character, in various stages of growth or degeneration, often mingled with cysts or CASTRATION. 1081 cartilaginous nodules, The affection may occur at any age, but is most common in youth and early adult life. The symptoms are the presence of a rapidly growing solid tumor—its growth is much more rapid than that of any other form of sarcocele—the mass being smooth, and at first uniformly firm to the touch, but afterwards soft, elastic, and semi-fluctuating in spots, with enlargement of the scrotal veins, and ultimately* turgescence and thickening of the cord. The deep iliac and lumbar lymphatic glands are involved at an early stage of the disease, the inguinal glands not being affected until a later period. The tunics of the testis become very much distended by the enlarging tumor, and ultimately give way—when the growth becomes adherent to the scrotum ; ulceration then follows, and allows the protrusion of a fungous mass. This stage of the disease is comparatively seldom seen at the present day, because the nature of the case is recognized, and castration resorted to, at an earlier period. The growth is attended with very little pain at any time, and the general health of the patient does not suffer in the early stage, though cachexia is ultimately developed. One testicle only is com- monly affected. The diagnosis from other forms of sarcocele can usually be made by ob- serving the very rapid growth of the tumor, its unilateral character, the enlargement of the scrotal veins, and the want of benefit from treatment; but the diagnosis from cystic sarcocele is often impossible until after removal, and even then without careful microscopical examination. From opaque hydrocele and from haematocele, malignant sarcocele may be dis- tinguished by observing its weight and the sense of fluctuation which it affords in spots, and, if necessary*, by an exjiloratory incision ; this is better than puncture with a trocar, because, as pointed out by Humphry, the quantity of blood which flows through the canula from an encephaloid testicle may* be so great as to lead to the supposition that the case is one of haematocele. The prognosis is very unfavorable, death commonly taking jilace within two years, from the implication of the deep-seated glands, and from the occurrence of secondary deposits in the lungs and other viscera. The only treatment which offers the slightest hope of benefit is castra- tion, and this operation is, as a rule, justifiable only in the early stages of the affection, before the pelvic and lumbar glands have become involved— a point which can usually be determined by careful palpation of the abdomen. Castration.—The operation of castration, or removal of a testicle, is thus performed : The part having been shaved, and the patient etherized, the surgeon grasps the posterior part of the tumor with his left hand, so as to make the scrotum tense in front; a longitudinal incision is now made from opposite the position of the external abdominal ring to near the bottom of the scrotum, which is then jieeled off, as it were, by a few strokes of the knife, until the gland, surrounded by its tunics, hangs merely by the sper- matic cord. The division of the cord is the most important part of the operation ; this may, I think, be best done with the ecraseur, but may be also well accomplished with the knife—bleeding in the latter case being prevented by previously ligating or acupressing the cord en masse; or the cord may be firmly held by an assistant, and its arteries tied separately after division. My reason for preferring the ecraseur in this operation is not only on account of the saving of blood, but also because its use seems to be attained by less shock than that of a cutting instrument. The precise point at which the cord is divided is of no consequence in the excision of non-malignant growths, and hence the surgeon may, if it be 1082 DISEASES OF THE GENERATIVE ORGANS. found more convenient, secure the cord before completing the dissection of the tumor. In castration for malignant disease, however, it is imjiortant to cut the cord at as high a jioint as jiossible, and in these cases it is therefore better to dissect out the testicle, and carry the dis- section up to the abdominal ring —then transfixing the cord with a double ligature, tying it in two halves, and dividing it a little lower down, in the way already described. It is always a good plan to pass a strong ligature through the cord about half an inch above the point at which it is to be divided, tying this in a loose loop by which the cord can be drawn down in case of sec- ondary hemorrhage : this liga- ture may be removed about the fourth day, by simply cutting it on one side and drawing it out. Fig. 636.—Division of spermatic cord in castration. It is Sometimes recommended (Erichsen.) that an elliptical portion of the scrotum should be removed, if the tumor be large ; but the skin of this part shrinks so much after the operation that such a course can rarely be necessary. The after-treatment consists in introducing a drainage-tube and bringing the edges of the wound together, with stitches, and in applying the ordinary antiseptic dressings. Functional Disorders of the Male Generative Apparatus. Impotence may result from several different conditions, of which some are, while others are not, remediable. 1. Malformation or Mutilation of the Genital Organs may cause impo- tence, occasionally curable by operation (see page 1060), but more commonly irremediable. 2. Debility of the Nervous Centres, following severe illnesses, or at- tendant upon diseases in which the general nutrition is impaired, may render the patient temporarily or permanently impotent. The treatment consists in the adoption of means to improve the general health, the exhi- bition of tonics, such as iron, quinia, strychnia, and phosphorus, sea-bath- ing, etc. 3. Traumatic or other Lesions of the Cerebro-Spinal Nervous System. —Impotence from this cause is commonly permanent; the treatment would be that of the particular affection to which the impotence was due. 4. Temporary, or rather imaginary, impotence may arise from Mental Perturbation or Over-excitement. This condition is chiefly met with in first attempts at coitus, whether sanctioned or not by the matrimonial tie. The affection is, I believe, never permanent. 5. Morbid Excitability of the Genital Organs, attended with involun- tory seminal emissions (spermatorrhoea), occasionally gives rise to im- potence, and is a very intractable affection, simply because it is often impossible to prevent the continued activity of the causes to which it is SPERMATORRHEA. 1083 originally due. The commonest cause of this condition is probably onan- ism ; though it may also arise from premature or excessive indulgence in venery—and is kept up by impure habits of thought or conversation, read- ing obscene books, or gloating over lascivious pictures—while in its milder forms it may originate from irritation of neighboring organs, as the bladder or rectum. Seminal Emissions are by no means necessarily a sign of disease ; indeed, during early manhood, an occasional discharge of spermatic fluid during sleep is an almost unavoidable attendant upon virtuous celibacy ; but when the emissions occur in the day as well as at night, and are very frequently rejieated, they certainly.indicate an unnatural state of debility and irritability of the sexual apparatus. In the worst cases the patient is rendered impotent, by the emission taking place without any or with such slight erection that penetration is impossible. Spermatorrhoea, as this affection is called—rather unfortunately, for the seminal flux is a mere symptom—is chiefly met with between the periods of puberty and early adult life, and is most common in young men of feeble frame and of sedentary habits. In advanced stages the patient's general health suffers, and he often falls into a state of great mental de- pression. At the same time, there can be no doubt that, in many cases, ill health and various nervous affections, such as epilepsy or insanity, are attributed without sufficient reason to morbid excitability of the genital organs and to onanism—when in point of fact the supposed causes are really the effects; physical debility often exists where the sexual appetite is fully if not inordinately developed, and an excitable .disposition, or an ill-balanced mind, renders its possessor less able to resist temptation, and more apt to fall into habits at which the moral sense revolts, than he who is blessed with both a healthy body and a healthy mind. The frightful pictures drawn by Tissot, Alibert, and other writers are no doubt strictly correct; but the unfortunate victims whose histories they narrate were not insane from onanism—they were onanists because they were insane. The diagnosis of spermatorrhoea from chronic prostatitis (prostator- rhoea) is readily made by microscopic examination of the discharge (see page 1017). The treatment, as far as the use of remedies is concerned, consists in diminishing the irritability of the genital organs, and in improving the general condition of the patient. The food should be abundant, but whole- some, and particular care should be taken not to overload the stomach at night ; alcoholic stimulants and spices should, as a rule, be avoided. The patient should take plenty of exercise in the open air, walking being better than riding or driving, as the motion of the horse or carriage sometimes excites the venereal orgasm ; he should sleep on a hard mattress—lying on either side rather than on the back—and should not be too warmly covered. Tonics, especially iron, quinia, strychnia, phosphorus, and occa- sionally cantharides, may be administered with advantage, while cold hip- baths, the cold douche or shower-bath, and sea-bathing (if this can be procured) will also prove of service. Bromide of potassium may be given in a full dose at bedtime, and will often procure sound rest, undisturbed by seminal emissions; the hydrate of chloral has been recommended for the same purpose, as have the monobromide of camphor, by Vogel, and anti- pyrin, by Thbr, of Bucharest. Nowatschek speaks favorably of hypoder- mic injections of atropia. The application of nitrate of silver in substance or solution (gr. xx-xl to fgj) to the prostatic and bulbous portions of the urethra may be of service in cases in which these parts are found by ex- ternal pressure to be morbidly sensitive; the application may be made 1084 DISEASES OF THE GENERATIVE ORGANS. with a porte-caustique or syringe-catheter (as in cases of chronic prosta- titis), and may be repeated at intervals of ten days or two weeks. Cold, applied as recommended by Winternitz (page 1017), may be of use in some cases. The course of treatment above described is addressed to the morbidly irritable condition of the genital organs, and may be employed with every prospect of success, provided that the causes of that condition have ceased to act, or can be removed. In cases originating in irritation of neighbor- ing parts—as from hemorrhoids, from the presence of ascarides, or from an abnormal condition of the urine—this can be readily done ; but when the unnatural irritability of the generative apparatus is kept up by con- stant excitation of the part, whether physical or mental, the prognosis is less favorable, because the removal of the cause is more difficult. Chastity in thought as well as deed is necessary to insure recovery ; but to attain this grace requires a prolonged struggle with temptation, which needs all the patient's fortitude and resolution. The treatment in these cases must be more moral than physical, and even when a purely physical cause, such as onanism, is to be dealt with, surgery offers remedies of but doubtful efficacy ; the application of blisters to the penis, or the operation of circum- cision, may be of use in compelling at least a suspension of a bad habit; but the benefit will be evanescent, unless the moral nature of the patient can be reached in the interval. In their despair at continued relajises, vic- tims of onanism have, it is said, occasionally made Abelards of themselves, with the hope that they would thus effectually banish temjitation ; and surgeons, even, have been induced to castrate their jiatients, in obedience to the earnest solicitations of the latter. The operation has, however, in the large majority* of cases, proved as unsuccessful as it is unphilosophical; there is no reason to believe that the testes are particularly at fault, and the disease is in all cases more of the mind than of the body ; moreover, the gain to the moral nature of the individual is not in cowardly fleeing from, but in manfully resisting, temptation. The benefit which has been apparently derived, in some instances, from this heroic mode of treatment, has been, in all probability, such merely as might have been obtained from any great and sudden shock to the nervous system. The surgeon is occasionally called upon for an opinion as to whether an individual, who has suffered from frequent seminal emissions, and who, perhaps, fears that he is in consequence impotent, may jiroperly enter into matrimonial engagements. The question is rather a delicate one, and no rule can, of course, be given which would be of universal application ; but it may probably be safely said that, though, if undertaken merely with the selfish hope of effecting a cure for himself, without regard for the happiness of his partner, marriage will, in all probability, disappoint the man's expec- tations, yet the happy circumstances of a union founded on mutual prefer- ence and pure affection will offer the very best prosjiects of recovery. Sterility in the male may exist in connection with impotence, or inde- pendently. It most frequently arises from some local source of obstruction to the passage of the spermatozoa—as from induration and thickening of the globus minor as the result of epididymitis, or from urethral stricture— but may also depend upon retention of the testes within the abdominal cavity, upon absence of spermatozoa from the semen, or upon obscure changes in the chemical constitution of that fluid, the nature of which is not very well understood. The only hope of cure would be in the removal of any disease of the genito-urinary apparatus which might be detected. MALFORMATIONS OF THE FEMALE GENITALS. 1085 DISEASES OF THE FEMALE GEXITALS. The limits of this volume will admit of merely a brief reference to those diseases of the Female Generative Apparatus which require operative, or distinctively surgical treatment; nor is a more extended account of these affections here necessary, for the whole subject properly belongs to the domain of Gynaecology, and is ably discussed in the numerous valuable works on Diseases of Women which are now accessible to the student. Malformations. The external genitals are subject to various malformations of very dif- ferent degrees of severity. Imperforate Vulva—This, which is the slightest form of imperforate vagina, consists in a congenital occlusion of the vagina at or just in front of the nymphae. The septum is at first very delicate, and, if the condition be recognized soon after birth, can be readily ruptured by simply separat- ing the parts with the thumbs, one placed upon each of the labia majora, or may be torn across with a probe or director, a strip of oiled lint being interposed to prevent reunion. At a later period a little dissection with the scaljiel may be required, but the affection is always readily amenable to treatment. Adhesion of the Vulva is a condition precisely* similar to the above, except that it is not congenital, but arises from adhesion of the opposing surfaces of mucous membrane, as the result of inflammatory action. The treatment consists in dissecting through the obstruction, and preventing its recurrence by the introduction of a tent. Imperforate Hymen.—The hymen may be partially perforate, or completely imperforate. 1. Partially perforate hymen allows the escape of the menstrual fluid, but interferes with sexual intercourse—the thickness and rigidity of the membrane preventing penetration. In some instances pregnancy has occurred in spite of this obstacle, and the condition of parts has been first recognized from the effect of the dense hymen in hindering parturition, by arresting the passage of the foetal head. The treatment of partially per- forate hy*men consists simply in incising the jiart with a probe-pointed bis- toury, dilatation being completed by means of a sponge-tent or bougie. 2. Imperforate hymen is a much more serious condition. If it were recognized before the age of puberty, it could be readily remedied by mak- ing a crucial incision, and by excising the flaps which would thus be formed; but, unfortunately, the malformation is seldom discovered until menstrua- tion has repeatedly occurred, and until the vagina and uterus have become distended, sometimes to a great extent, by the accumulating secretion— forming a large, elastic, fluctuating tumor in the hypogastrium. The opera- tion for the relief of this condition is easily* and quickly performed, but is not unfrequently followed by serious and even fatal consequences. Death may result from endometritis and septicaemia, due to decomposition of the uterine contents; or from peritonitis, due to the escape of blood through a laceration of the Fallopian tubes, or even through their natural orifices, into the abdominal cavity. To prevent these accidents, it is recommended by Bernutz and Goupil that the hymen should be punctured with a small trocar and canula, a piece of tubing being attached to the latter, so that the contents of the uterus may slowly drain away. The puncture should be made ei"-ht or ten days after a menstrual period, and no pressure should be 1086 DISEASES OF THE GENERATIVE ORGANS. made upon the abdomen during the process of evacuation. Emmet, on the other hand, recommends free incision followed by thorough washing out of the uterine cavity. Imperforate Vagina.—This may vary in degree from the slight affection already referred to as imjierforate vulva, up to complete absence of the vagina, accompanied, perhaps, with absence or imperfect develop- ment of the uterus. By simultaneous exploration with a sound in the bladder and a finger in the rectum, the thickness of tissue between those parts can be estimated, and, if it be such as to render the existence of the uterus and upper part of the vagina tolerably certain, an effort may be projierly* made to reach the upper part of the tube during early child- hood, when operations on these organs are less dangerous than in adult life. If, however, the bladder and rectum be in such close contact as to render the existence of a uterus doubtful, it will be proper to wait until the period of puberty, when the nature of the case will probably become more evident. In many instances the existence of malformation is not suspected until after puberty, when the attention of the patient and of her friends is aroused by the non-appearance of the menses, although the menstrual moli- men may recur at regular intervals. The treatment to be pursued under such circumstances is a matter worthy of the gravest consideration. Any operation in such a case will be attended with considerable risk, and yet if the womb is becoming every month more and more distended with menstrual fluid, an operation is absolutely neces- sary—for while unrelieved the patient is in constant danger of peritonitis (from leakage backwards through the Fallopian tubes), or even of rupture of the uterus. The treatment of imperforate vagina varies according to the condition of the uterus. (1) If the presence of an elastic fluctuating tumor in the region of the uterus, perceptible by rectal exploration and by abdominal palpation, shows that there is an accumulation of menstrual fluid in the womb, there can be no question as to the propriety of an ojieration. It has been pro- posed to evacuate the uterine contents by puncture with a trocar and canula through the rectum, but, beside the risk of wounding the perito- neum, in such an operation, the relief would probably be but temporary, and re-accumulation would occur. Hence, it is better in such a case to attempt the formation of a vagina, by placing the patient in the lithotomy position, and, after making a small transverse incision, working cautiously upwards with the finger and handle of the knife in the septum between the bowel and urethra (taking care not to open either of these), and guid- ing the dissection by keeping a sound in the bladder, and a finger in the rectum. When the sac containing the menstrual fluid is reached, it should be opened through a speculum with a small trocar, with the same precau- tions as in the case of imperforate hymen. The size of the newly-formed vagina must be subsequently maintained by the use of a bougie. In Amussat's method, which is preferred in these cases by Bernutz and Goupil, the knife is dispensed with altogether, and the vagina formed by simply stretching the vulvar mucous membrane, and pushing apart the rectum and urethra, with the fingers; the operation occupies several days, dilatation being maintained in the intervals between the sittings by the introduction of tents. Le Fort has reported a remarkable case°in which he formed a vagina by passing a weak galvanic current through the parts every night for a month; the negative pole was applied to the seat of occlu- sion and the positive pole to the wall of the abdomen, and the current used was at no time so strong as to inconvenience the patient. (2) If there be no uterine tumor, the course to be pursued is more SURGICAL DISEASES OF THE VULVA. 1087 doubtful. The menstrual molimen, it must be remembered, depends upon the ovaries, and not upon the uterus ; and a patient may suffer intensely at every monthly period, while having no womb, or at least none capable of menstruating, and therefore no menstrual accumulation. If in a case of this kind it be ascertained by careful rectal exploration, conjoined with abdominal palpation, that there is a well-formed womb—even though not distended—an operation such as was described in the last section might be justifiable, though full of danger from the risk of opening the peritoneal cavity. If, however, it be found that there is no womb, or merely a rudi- mentary uterus (as in a case under my care at the Episcopal Hospital), no operation whatever should be performed. A good deal is sometimes said in these cases about fitting a young woman for matrimony, enabling her to be a wife, etc.—but, in point of fact, a woman to whom nature has denied a womb can never be adapted for marriage, though she may be fitted for prostitution. The surgeon's art may, indeed, enable her to be a man's mistress, but can never fit her to be his wife and the mother of his children. The late Prof. Gross spoke none too strongly when he said that, in such cases, " nothing is to be done . . . ; the woman is impotent, and therefore disqualified for marriage." Non-Congenital Obliteration of the Vagina results from adhesion of the vaginal walls after sloughing or severe inflammation ; it is most com- mon in married women after labor, but may occur in young girls or children. The diagnosis from congenital absence of the vagina can be readily made by simultaneous rectal and vesical exploration, which will, in a case of non-congenital obliteration, reveal the existence of a dense septum, three-quarters of an inch or more in thickness—whereas, in a case of imperforate vagina, the instrument in the bladder and the finger in the rectum seem almost to be in apposition, and are evidently separated by a very thin layer of tissue. The treatment of the affection now under consideration consists in endeavoring to re-establish the canal, by cautious dissection between the urethra and rectum in the way already mentioned. The operation is attended with a great deal of danger, but is the only resource—and becomes imperatively necessary when the uterus is dis- tended by the menstrual accumulation. Double Vagina__In many cases this condition requires no treat- ment, and may be looked upon as merely a physiological curiosity. Should, however, it become necessary to divide the vaginal septum, this may be readily done with blunt-pointed scissors, adhesion of the cut sur- faces being prevented by the introduction of a strip of oiled lint, and cleanliness being secured by the frequent use of detergent injections. Surgical Diseases of the Vulva. Hypertrophy of the Labia Majora is usually an inflammatory condition, depending, as in the case of the lips, upon the presence of a fissure or excoriation, and slowly disajipearing when that is healed. Hypertrophy of the Labia Minora is occasionally met with, re- sembling anatomically what has been described as the " fibro-cellular out-growth." In warm climates this condition is comparatively common, and in some localities is said to be almost universal. The treatment, when the hypertrophy increases so much as to produce annoyance, consists in excision ; this operation is sometimes attended with a good deal of hemor- rhage, which mav be conveniently arrested, as advised by Hutchinson, by transfixing the base of the labium with harelip pins and applying figure-of- 8 ligatures, so as to acupress the pedicle, as it were en masse. 1088 DISEASES OF THE GENERATIVE ORGANS. Hypertrophy of the Clitoris is usually, I believe, the result of constitutional syphilis. The organ sometimes attains a very large size, and produces a great deal of irritation, requiring excision, which may be performed either with the knife or with the ecraseur. The bleeding in this operation may be quite profuse, and may possibly require the applica- tion of the actual cautery. ' Excision of the Clitoris, or Clitoridectomy, has been most unphilosoph- ically* proposed and practised as a remedy in cases of epilepsy and insanity. The operation has been forcibly* and properly condemned by the almost unanimous voice of the profession. Vegetations, the so-called venereal warts, are often seen upon the vulva, and require extirpation with the knife or scissors. Tumors of various kinds are met with in the labia, the most common being the cystic tumor, though fatty, fibrous, and vascular growths are also met with in this situation. Two kinds of cyst are met with in the neighborhood of the labium ; one consists in a dilatation of Cowper's gland, and is curable by making a simple incision, and stuffing the cavity with lint, while the other is a serous cyst, which is developed in the labium itself, and sometimes attains a very* large size. The treatment of the latter consists in excision, the ojieration requiring a rather troublesome dissection, and being attended with a good deal of bleeding, which can, however, alway*s be checked by pressure and the use of a "J" bandage. Fibrous and fatty tumors of the labium also require excision, while naevi in this part may be conveniently treated by ligation. Hydrocele of the Canal of Nuck is a rare affection, which was referred to in speaking of jiudendal hernia (page 903). The treatment consists in the formation of a seton, or in the injection of iodine. Malignant Disease of the External Genitals may be primary— in which case it is usually epitheliomatous—or secondary to cancer of the vagina or uterus, either of the scirrhous or encephaloid variety. The vulva is also, sometimes, the seat of rodent ulcer. The sole treatment for any of.these affections is excision, which is, however, only justifiable when the disease is so limited as to admit of complete extirpation. Vulvitis, in whatever way arising, presents the same symptoms, and demands the same treatment, as when of gonorrhoeal origin. (Seepage 472.) Noma Pudendi has already been referred to at page 433. Surgical Diseases of the Vagina. The Speculum is an instrument constantly required for exploration of the upper part of the vagina and the cervix uteri. For ordinary pur- poses, the best instruments are the simple cylindrical speculum made of glass, coated like a mirror with quicksilver or tinfoil, and covered with India-rubber (Fig. 637), and the bivalve sjieculum, of which the best form is that known as'disco's (Fig. 638). For special cases, other instruments may* be required, such as the duck-billed speculum (Fig. 617), either in its original form, or with the ingenious modifications of Emmet, Pallen, Thomas, Fryer, and others; Thomas's telescopic speculum; Ellis's expand- ing speculum; or the somewhat similar ingenious contrivances of Dr. Albert H. Smith and Prof. Goodell, of this city. Barnes highly com- mends Xeugebauer's speculum, which combines the features of both the bivalve and the duck-billed instruments. The speculum should always be introduced (well warmed and oiled) under cover of the jiatient's garments or bedclothes, without any exposure of the person. For ordinary examinations, the obstetric position on the surgical diseases of the vagina. 1089 left side will be satisfactory, but for the application of caustics, removal of polypi, etc., it will usually be more convenient to place the patient on her back, with the lower limbs separated and supported upon chairs. The Fig. 637.—Cylindrical speculum. Fig. 638.—Cusco's speculum. introduction of the speculum may be conveniently effected by separating the vaginal walls with the fore and middle fingers of the left hand, and slipping in the instrument beneath and between them. Painful Ulcer or Fissure of the Vagina—This affection is closely analogous to the painful ulcer of the rectum or anus, and requires precisely similar treatment. (See page 926.) Polypoid Growths, belonging to the class of fibro-cellular tumors, are occasionally met with in the vagina, and may be treated by avulsion (if the pedicle is very small), ligation, the ecraseur, or the wire loop and galvanic cautery. Cystic and other Tumors in the walls of the vagina are to be treated as similar affections of the vulva. Malignant growths of the vagina sel- dom admit of operative interference. Prolapsus of either the front or back wall of the vagina may take place, constituting, in the former case, a variety of hernia of the bladder or urethra (cystocele, urethrocele), and, in the latter case, a similar condi- tion of the rectum (rectocele). In most instances, sufficient relief may be afforded by the use of a suitable pessary or bandage, but occasionally a more radical measure may be required ; this may, in a case of cystocele or rectocele, consist in denuding a circular strip of the vagina near its orifice, and bringing the sides together with sutures, so as to obtain adhesion of the labia majora for the lower three-fourths of their extent; or, if the case be complicated with prolapsus of the uterus, in denuding a longitudinal strip on either side of the vagina (or, which is better, a broad triangular space on the posterior wall of the canal), and then bringing the raw surfaces together, so as to reduce the calibre of the vagina through the entire length. The former operation is known as Episiorrhaphy, Fl0.639.-Thomas'8 damp for eiytrorrhaphy. and the latter as Elytrorrhaphy. Episiorrhaphy has been modified by* J. Bell by splitting instead of paring the labia, as in Langenbeck's and Collis's operations for vesico-vaginal 69 1090 DISEASES OF THE GENERATIVE ORGANS. fistula. Thomas has modified the operation of elytrorrhaphy by sejiarating the layers of the vaginal wall by a subcutaneous or rather submucous jiro- cedure, then clamping the separated tissue with the instrument shown in Fig. 639, and cutting off the part which protrudes. Schroeder and B. F. Dawson treat cystocele by denuding the anterior wall of the vagina and bringing the parts together with sutures, the latter surgeon folding the vesical wall upon itself by jiressure with a sound, so as to bring the sides of the raw surface into close apposition. The treatment of urethrocele has already been referred to at page 1032. Vaginismus is the name given by Sims to an affection which consists in a hypenesthetic condition of the nerves distributed to the vaginal mucous membrane at the position of the hymen, leading to a spasmodic contraction of the sphincter vaginae muscle, which renders coitus intensely jiainful, and, indeed, usually imjiossible, and thus practically makes the patient sterile. The spasm of the sphincter may be elicited by the slightest touch of the finger, or even of a camel's-hair brush. Vaginismus may be an idiopathic affection occurring in persons of a hysterical temperament, or may be due to some local cause, such as fissure of the vagina or rectum, papillary tumor of the meatus, inflammation of the womb or vagina, eczema or prurigo of the vulva, neuralgic tumors, etc. The treatment consists in removing the cause, if this can be ascertained, and in the administration of tonics and the use of sedatives, iodoform being specially recommended by Tarnier. Attempts may be made to relieve the spasm by the use of vaginal dilators, or, if necessary, by a resort to operative treatment. The simplest operation for vaginismus consists in sudden dilatation or partial rupture of the sphinc- ter vaginae muscle, effected by introducing the thumbs and forcibly separat- ing them (the patient being etherized), as in Recamier's and Van Buren's method of treating fissure of the anus. If this fails, the remains of the hymen may be excised, and the sphincter partially divided by a deep incision on either side of the perineal raphe (as recommended by Sims), or the pudic nerve may* be cut—by direct incision, as originally recommended by Burns —or subcutaneously, as preferred by Simpson. These operations sometimes afford only temporary relief, and the constitutional treatment approjiriate to neuralgia must therefore not be neglected after their employment. Surgical Diseases of the Uterus. Fibrous or Fibro-Muscular Tumors (Uterine Fibroids, Myo- mata).—These, which are the most common of the uterine tumors, may occupy any portion of the structure of the womb. They may project on the outer surface of the organ beneath its peritoneal investment ; may grow inwards, filling the uterine cavity, and perhaps descending through the vagina and protruding between the labia; or may be developed in the midst of the uterine wall. They are classified according to their situation into subserous or sub-peritoneal; submucous; and interstitial or intermural fibroids. They are but loosely attached to the surrounding tissues, and sometimes attain a very large size. In the majority of cases palliative treatment only is required ; and it must always be remembered that uterine fibroids seem to disappear spontaneously in some instances ; or may become detached, and may be expelled by the contractions of the womb. The most promising mode of treatment is, I think, the hypodermic use of ergot or ergotin, as recommended by Hildebrandt, Scanzoni, and Keating, of this city ; my own experience with this remedy, though limited, confirms, as far as it goes, the favorable reports of those gentlemen. The following formula will be found satisfactory: R. Ext. ergot, fluid. f3iss; Glycerinse SURGICAL DISEASES OF THE UTERUS. 1091 j3j ; Aquae fjij. M. Twenty minims are to be injected once daily in the hypogastric or, which Lee advises, the gluteal region. Dr. Schueckin«- pre- fers parenchymatous injections into the lips of the cervix Fig. 640.—Fibro-cellular uterine polypus -with long pedicle. (Boivijt and Duafis. In cases of submucous fibroids, excision or avulsion may be practised, a convenient instrument for the purpose being the " serrated scoop" or "spoon-saw," devised by Thomas; but if the growth be attached by a somewhat narrow pedicle (constituting the fibrous polypus of the uterus), it will usually be better to remove the tumor by means of the ecraseur, for the chain of which a wire rope may be substituted, as recommended by Braxton Hicks, or a steel wire, as preferred by Kidd, of Dublin. The Ecraseur may be applied by the aid of the ingenious " portechaine" of Dr. Marion Sims ; or the simpler form of instrument devised by* Dr. Emmet, may be substituted ; or a ligature may be first thrown around the pedicle with a double canula, and the chain of the ecraseur subsequently drawn into place. The operation may be facilitated by seizing the part to be removed with shouldered tenacula, which may then be fixed in a handle, as suggested by Dr. A. H. Smith, of this city. In the case of interstitial growths, enucleation has been resorted to by Amussat, Atlee, Fordyce Barker, Thomas, and others. The operation consists in dilating or incising the cervix uteri, laying bare the tumor by cutting through its capsule, and then turning it out of its bed with the fingers, Thomas's "spoon-saw," or other suitable instrument. This pro- 1092 DISEASES OF THE GENERATIVE ORGANS. cedure has not unfrequently jiroved fatal, from hemorrhage, peritonitis, or jiv;cmia, and, though doubtless justifiable in exceptional cases, cannot, in my judgment, be recommended ^vv.^ 641.—Interstitial uterine fibroid. (Barnes.) as a general mode of treatment. A similar opinion is exjiressed by Pozzi, who has collected 64 cases of this ojieration, 16 of which terminated fatally. Baker Brown modified this operation by simply* incising the tumor, or even the mouth and neck of the uterus, so as to de- stroy the vitality of the growth, and promote its expulsion by sloughing. Apostoli and Carlet recommend the intra-uterine ap- plication of galvanism, one elec- trode (usually from the negative pole) being introduced into the uterine cavity, while a broad electrode, from the positive pole, and, as Apostoli prefers, made of clay, is apjilied to the abdo- minal wall. The results obtained by this method are, according to the reports of Keith, Skene, and numerous other observers, remarkably successful. Accord- to Braxton Hicks, an intermural fibroid may sometimes be converted into a polypus by the administration of ergot. Emmet advises frequent trac- tion upon the tumor with tenacula or forceps, so as to excite contraction in the uterus, and thus promote enucleation and guard against hemorrhage. Subserous uterine fibroids have, in a number of instances, been removed bv abdominal section, the operation sometimes involving the extirpation of the entire uterus and both ovaries (see page 947). This mode of treatment under any circumstances is rejilete with danger, and can only be justifiable in exceptional cases. The statistics of the jirocedure have been investi- gated by several writers, the most recent being Dr. Bigelow, who fiuds that 359 cases, collected from all available sources, gave 132 deaths, a mor- tality of nearly 37 per cent. Keith, himself the most successful living hysterectomist, has abandoned the ojieration in favor of Apostoli's galvanic method. Dr. Sutton has removed a subserous fibroid through an incision in the posterior wall of the vagina, but the patient died in six hours. The operation of oophorectomy, which has been somewhat extensively employed in cases of bleeding uterine fibroid, has already been referred to on pa ire 946. Fibrocystic Tumors of the Uterus have been particularly studied in this country by C. C. Lee, Atlee, Peaslee, and Thomas. They have often been mistaken for ovarian cysts (see page 940). Only palliative treatment is as a rule to be recommended. Polypi of the Uterus usually belong to the fibro-cellular or myxo- matous varieties of tumor, and are often very vascular, and accomjianied with an increased development of the glandular structures of the part. The hard or fibrous polypus, a variety of the uterine fibroid, has already been referred to. Polypi are usually attended by more or less profuse niff PROCIDENTIA OR THE UTERUS. 1093 hemorrhage, which exhausts the patient and urgently demands surgical interference. The treatment consists in effecting the extrusion of the poly- pus from the uterus by drawing it down with forceps, or, if this cannot be done, by dilating or incising the neck of the womb and administering ergot, and in then dealing with the growth by excision, avulsion, ligation, or the use of the ecraseur, in the way already mentioned (page 1091). Dr. McClintock, of Dublin, recommends the "employment of a hemp saw-; a loop of twisted cord is made to surround the base of the polypus by aid of a double canula, the latter being then held by an assistant while the growth is cut through by drawing the cord backwards and forwards as in using an ordinary chain saw. It may be occasionally necessary to attack the polypus while etill within the uterus, but the operation is under such circumstances attended with great danger. Myeloid and Recurrent Fibroid Tumors (Sarcomata) have been occasionally observed in the uterus; the treatment would consist in excision, if the growth could be entirely extirpated without too much risk to the patient. Malignant Tumors of the Uterus may be either carcinomatous or epitheliomatous. Carcinoma of the uterus is usually* of the encephaloid variety, though scirrhous and colloid growths are also met with in this organ ; the treatment, should, in a very large majority of cases, be merely palliative, total extirpation being attended with great risk, and partial excision, unless in very* exceptional instances, being worse than useless. Epithelioma commonly attacks the os and cervix uteri, and may appear in one of two forms, viz., as the so-called "corroding ulcer," or as the "cauli- flower excrescence." The treatment consists in amputation of the neck of the uterus, if the affection be recognized sufficiently early to allow of com- plete removal, or, if not seen until a later period, in cauterization of the surface of the growth with caustics or the hot iron, or in extirpation of as much as can be reached by* means of the ecraseur or curette, a palliative measure which has been employed with advantage by A. R. Simpson, Simon, Munde", Parry, Goodell, and others. Sims carries the exsection quite up to the inner os. Sanger has collected 143 cases of total extirpation of the uterus through the vagina, only 40 cases, or 28 per cent., having ter- minated fatally, and Munde tabulates 255 cases with only 72 deaths, about the same percentage of mortality ; but Verneuil finds that 109 cases occur- ring in Parisian hospitals since 1885, have given 66 deaths, or 60 percent. (35 from the operation, 31 from speedy recurrence), 18 instances of recur- rence in a hopeless form, and only 25 recoveries. Procidentia or Extreme Prolapsus of the Uterus may occa- sionally demand operative treatment; this consists in first amjiutating the neck of the organ (if it be much enlarged), and then performing an epi- siorrhaphy or elytrorraphy (page 1089), or a transverse obliteration of the vagina (p. 1059). This mode of treatment has been adopted in several cases bv Prof. Goodell, of this city*, with most gratifying results. Kolpo- perineoplasty is another operation for the same purpose, devised by Bis- choff; it consists in dissecting up a tongue-shaped flap of mucous membrane from the posterior wall of the vagina, and denuding a triangular space on either side; the edges of the flap are then stitched to the anterior edges of the denuded spaces, and the wound closed below with deep sutures, as in the operation for ruptured perineum. Pallen, of Xew York, substituted for amputation of the cervix an ojieration which he called vagino-cerviplasty. This consisted in denuding the cervix circularly, dissecting the mucous membrane upwards from the junction of the body and neck of the womb, 1091 DISEASES OF THE GENERATIVE ORGANS. "# jiushing the neck up into the sheath thus formed, and finally closing the wound with silk sutures. Amputation of the Cervix Uteri may be performed by the aid of cutting instruments, by means of the ecraseur (Fig. 642), or by the use of the wire loop and galvanic cautery. When the first method is resorted to, the part to be removed should be fully exposed by means of a duck-billed speculum ; the neck of the womb is then slit up on either side, and its lips successively excised with suitable scissors, the uterine mucous membrane being finally drawn forward (as advised by Sims), and at- tached to that of the vagina by means of silver sutures. Dr. C. F. Clark, of Brooklyn, employs toothed scissors, dis- pensing with the preliminary slitting of the part, and leav- ing the stump to heal by granulation. An Operation for Shortening the Round Ligaments, in order to correct uterine disjilacements (apparently first suggested by Alquie*, in 1844), has been introduced into practice by Alexander, of Liverpool, and Adams, of Glasgow, and has been repeated with more or less success by Reid, Elder, Burton, Lediard, Imlade, Munde, Polk, Doleris, and other surgeons. Wylie short- ens the ligaments by folding them on themselves after a preliminary lapa- rotomy. Hysterorraphy, a procedure by which after opening the peritoneal cavity- the disjilaced uterus is stitched to the abdominal wall, has been employed by numerous operators, including Koeberle, Tait, Olshausen, Bardenheuer, Hennig, Sanger., Zweifel, Stande, Brennecke, Werth, Lee' and Kelly. Schiicking, of Pyrmont, jiasses a strong ligature through the fundus of the uterus and secures it to the vagina. The subjects of Lacerations of the Female Perineum and of the Cervix Uteri, Vaginal Fistulas, Ovarian Tumors, and Diseases of the Mammary Gland, have already been referred to in previous portions of the volume. Fn>. 642.—Amputation of the neck of the uterus by means of the icraseur. a. Shows the neck of the organ,dragged to the vulva by means of the forceps, e, d. The chain of the instrument passed around the part at its base. (Chas- saigkac.) INDEX. ABDOMEN, injuries of, 398 kneading, in hemorrhage, 190 operations on, 937 Abdominal abscesses, 957 aneurism, 613 muscles, rupture of, 399 organs, diseases of, 937 parietes, abscess of, 399 taxis, 907 tourniquet, 136 viscera, statistics of injuries of, 404 Abernethy, ligation of external iliac ar- tery, 214 Abortion from injury to pregnant uterus, 418 Abortive treatment of gonorrhoea, 467 Abrasion, 40 Abscess, acute or phlegmonous, 421 chronic or cold, 424 disappearance of, by absorption, 422 hemorrhage into, 424 inflation of, 425 metastatic or multiple. See Pyaemia. residual, 425 after arthritis, 642 temperature of, 422 varieties of, 421 Abscess, abdominal, 957 of abdominal parietes, 399 alveolar, 822 of antrum, 824 areola of breast, 850 in auditory meatus, 780 biliary, 958 of bone, 624 breast, 851, 853 cornea, 725 fecal or stercoraceous, 958 of frontal sinus, 803 gum, 822 hepatic, 957 iliac, 712 ilio-pelvic, 959 intra-cranial, trephining for, 339 of larynx, 846 lung, evacuation of, 396 mammary, 851 et seq. mediastinal, 257, 389 of orbit, 776 ovarian, 959 palmar, 557 beneath pectoral muscle, 387 perineal, 470 Abscess— perinephric, 958 perityphlitis 958 of prostate, 1016 psoas, 712 retro-pharyngeal, 838 spinal, 711, 712 splenic, 958 subperiosteal, 619 of testis, 1069 tongue, 817 urethral, 470 Abscission of staphyloma, 730 Absorbents, inflammation of. See An- geio-leucitis. Absorption, interstitial, 45, 46, 626 of spine. See Antero-posterior curvature. of bone after fracture, 248 lymph, 38 purulent. See Pyaemia. of pus, in abscesses, 422 Accommodation of ear, 792 eye, 758 Accumulator for making extension, 643 Acetabulum, fracture of, 257 perforation of, in hip disease, 647 Acetic acid in cancer, 541 Acorn-pointed bougies, 1026 Acritochromacy. See Color-blindness. Acromion, fracture of, 263 Actinomycosis, 823 Actual cautery, 87 Acupressure, 199 in amputation, 101 aneurism, 597 comparison of, with torsion and liga- ture, 202 modified, 201 repair of arteries after, 201 in secondary hemorrhage, 201 statistics of, 202 Acupuncturation, 88 in aneurism, 602 for radical cure of hernia, 867 of spleen, 953 in ununited fracture, 250 Adenitis, 555 Adenocele. See Glandular tumor. Adenoid tumor, 522. See Glandular tu- mor. vegetations of nose and pharynx, 796 Adenoma, 522. See Glandular tumor. 1096 INDEX. Adhesion, union by, 148 secondary, 149 of vulva, 1085 Adhesions in hernia, 864, 883 ovariotomy, 943 Adhesive plaster, 153 aseptic, 158 Advancement of tendons for strabismus, 767 Aerteriversion, 201 Age, effect of, on results of operations, 63 Agglutinative method for foreign bodies, in ear, 365 Agnew, radical cure of hernia, 894 Air in veins, 182 Air-passages, diseases of, 845 foreign bodies in, 371 Alae nasi, restoration of, 800 Alanson, mode of amputating, 93 Albinism, 752 Albugo, 727 Albumen in blood, in inflammation, 36 Albuminous degeneration, 246 Albuminuria in strangulated hernia, 874 Albuminuric retinitis, 754 Aloes in treatment of joint-wounds, 224 Alopecia, syphilitic, 491, 493, 505 Alteratives in inflammation, 58, 61 Alternating calculus, 964 strabismus, 765 Alveolar abscess, 822 cancer. See Colloid. sarcoma, 528 Amaurosis, 747 from extra-ocular causes, 757 Amber cataract, 738 Amblyopia. See Amaurosis. central, 756 Ametrometer, 759 Ametropia, 759 Ammonia in chloroform poisoning, 76 in shock, 67 Amcebaform or amoeboid movement of cells, 37 Amputated limb, skin-grafting from, 429 Amputation, 92 causes of death after, 116 conditions requiring, 94 contraction of tendons after, 112 dressing stump after, 108, 109 elongation of bone after, 110 hemorrhage (secondary) after, 111 history of, 93 instruments used in, 96 intermediate, 114 mortality after, 112 compared with excision, 664 operative procedures used in, 102 relative merits of, 105 position of surgeon in, 102, 104 primary or immediate, 114 quadruple, 107 results of, circumstances which influ- ence, 112 et seq. secondary or consecutive, 114 during shock, 143 Amputation— simultaneous or synchronous, 106 statistics of, 113 et seq. stumps, affections of, after, 110 Amputation for aneurism, 95, 602 subclavian, 611 for arthritis, 644 burn, 317 caries, 627 deformity, 114 dislocation, compound, 289 fracture, badly united, 247 compound, 243, 246 ununited, 250 frost-bite, 322 gunshot injury, 175 hemorrhage, secondary, 206 hospital gangrene, 436 joint-wounds, 225 lacerated wounds, 157 malignant disease in bone, 636 necrosis, 631 onychia, 550 osteo-myelitis, 623, 624 tetanus, 571 traumatic gangrene, 94, 157 ulcer, 430 Amputation at ankle, 127 of arm, 121 cervix uteri, 1094 at elbow-joint, 121 of fingers, 117 foot, 124, 128 forearm, 120 hand, 117 et seq. at hip-joint, 133, 678, 679 knee, 132 knee-joint, 131 of leg, 129 metatarsus, 124, 125 penis, 1066 above shoulder, 123 at shoulder-joint, 121 sub-astragaloid, 126 of thigh, 132 tarsus, 126 et seq. thumb, 118 toes, 124 at wrist-joint, 120 Amussat, colotomy, 910 Amygdaline chancre, 489 Amygdaloid bubo, 488 Amyl, nitrite of, in chloroform poisoning, 76 in chordee, 469 tetanus, 571 vesical catarrh, 1008 Amyloid degeneration, 246 of conjunctiva, 721 Anaesthesia by chloroform, pupil in, 76 fatty degeneration after, 77 history of, 73 local, 80, 81 rectal, 78 retinal, 753 various modes of producing, 74, 77 et seq. INDEX. 1097 Anaesthetics, 72 cases in which they may be used, 73 in cataract operations, 739 death from, 76 in dislocations, 288 effects of, 75, 76 erotic dreams produced by, 81 in fractures, 234 precautions in use of, 75 results of operations, how influenced by, 73 in strangulated hernia, 877 Analgesia from rapid breathing, 75 Anastomosis, lateral, of bowels, etc., 913 Anatomical origin of cancer, 540 Ankyloblepharon, 773 Anchylosis, 653 in arthritis, 654 continuous extension in, 655 of elbow, 656, 658 false, 654 fibrous, 653 excision in, 655 of hip, 656 jaws, 831 from burns, 320 knee, 655, 658 spine, 715 passive motion in, 654 rupturing adhesions in, 655 of shoulder, 658 in spine-disease, 710 of stapes to fenestra ovalis, 791 Anel, operation for aneurism, 592 Aneurism or aneurisms, 583 amputation for, 95, 602 by anastomosis, 576 arterio-venous, 602 bruit of, 587 causes of, 585 cirsoid. See Arterial varix. death from, modes of, 591 diagnosis of, 589 diffused, 588 dissecting, 584 erosion of bones by, 588 fusiform, 583 after gunshot wounds, 180 hernial, 208 intra-cranial, from embolism, 585 miliary, in apoplexy, 586 orbital, 776 osteoid, 636 pressure-effects of, 587 pulsation in, 587 racemose. See Aneurism by anasto- mosis. rupture of, 590, 591 sac of, 586 sacculated, 583 secondary, 594 size of, 586 special. See the particular Arteries. spontaneous cure of, 590 structure of, 586 in stumps, 111 Aneurism— symptoms of, 586 terminations of, 590 thrill of, 587 traumatic, 207 after tenotomy, 701 treatment of, 591 by acupressure, 597 acupuncturation, 602 amputation, 602 caustic, 602 coagulating injections, 602, 618 compression, 597 digital, 599 instrumental, 598 rapid, 598 flexion, 600 galvano-puncture, 601 ligation, 592 on cardiac side, 592 distal side, 596 manipulation, 601 medical, 591 by " old operation," 592 strangulation, 602 of particular. See special Ar- teries. tubular, 583 varicose, 208 varieties of, 583 venous, 181 Aneurismal diathesis, 585 needle, 193, 194 varix, 208 non-traumatic, 602 in stumps, 111 Angeioleucitis, 555 Angeioma, 524, 576 of larynx, 846 of penis, 1066 Angle of jaw, excision of, 832 Angular displacement in fractures, 231 extension in dislocated hip, 311 Animals, rabid, bites of. See Bites. Anisometropia, 759 Ankle, amputation at, 127 diseases and injuries of. See under Joints. dislocation of, 313 excision of, 225, 684 for gunshot injury, 178 fracture of, 283 weak, 703 Ankylosis. See Anchylosis. Annular stricture of urethra, 1036 Anodynes in inflammation, 58, 61 Antepyretic amputations, 114 Anterior curvature of bones of leg, (if»S splint, Smith's, 277, 278, 282 Antero-posterior curvature of spine, 709 trephining for, 715 Anthrax. See Carbuncle. Antimony in inflammation, 60 Antipyrine in spermatorrhoea, 1083 1098 INDEX. Antiseptic adhesive plaster, 158 bath for wounds, 154 collodion, 154 dressing of stumps, 109 irrigation of joints, 640 ligatures, 101 treatment of wounds, 157 Antiseptics in inflammation, 58 Antrum, diseases of, 824 Antyllus, operation for aneurism, 592 Anus, artificial. See Fistula, fecal. false, 411 fissure of, 926 fistula of. See Fistula in ano. malformations of, 913 malignant disease of, 920 neuralgia of, 937 pruritus of, 937 sacciform disease of, 936 ulcer of, painful, 926 tuberculous, 927 Aorta, aneurism of abdominal, 613 thoracic, 602 compressor for, 98, 99, 136 ligation of, 214, 613 rupture of, spontaneous, 185 wounds of, 397 Aphakia, 759 Aphthous ulceration of penis, 1064 Aplastic lymph, 37 Apnoea, treatment of, 375 in wounds of neck, 367 Apoplexy of marrow, 622 of retina, 754 Apostoli's method for uterine tumors, 1092 Appendages, uterine, removal of, 947 Appolito's suture, 406 Aqua Conradi, 716 Arachnitis, erysipelatous. See Erysipe- las. traumatic, 331 Areola of breast, condition of, preceding mammary cancer, 851 diseases of, 850 et seq. Areolar tissue, diseases of, 554 syphilitic, 495 lesions of, in pyaemia, 453 Arm, amputation of, 121 avulsion of, 123 Aromatic wine, 479 Arrow-wounds. See Wounds. Arrows, caustic, in cancer, 541 in carbuncle, 438 Arsenic in cancer, 541 Arterial pyaemia. See Pyaemia. thrombosis, 184. See Thrombosis. transfusion, 91 varix, 576 Arteriotomy, 91 Arterio-venous aneurism, 602 wounds, 208 Arteritis, 580 Artery or arteries, acupressure of. See Acupressure. aneurism of. See Aneurism, and special Arteries. Artery— constrictor for, 193 contraction and retraction of, 188 contusion of, 1S4 diseases of, 580 syphilitic, 495 forceps for, 100 hemorrhage from, 186 injuries of, 184 ligation of, 193 et seq. for inflammation, 59 joint-wounds, 226 lines of incision for, 209 secondary hemorrhage after, 206 occlusion of, 580 gangrene after, 206 from injury, 184 remote consequences of, 207 in pyaemia, condition of, 453 ruptured, 184, 399 amputation for, 95 in dislocation, 290, 291 fracture, 241 wounds of, 185 in compound fractures, 243 process of repair in, 188 rules for ligation in, 195 Artery or arteries of arm and forearm, aneurism of, 612 axillary, aneurism of, 612 ligation of, 213, 612 brachial, aneurism of, 612 ligation of, 213, 613 brachio-cephalic. See Artery, inno- minate. carotid, aneurism of, 607 external, ligation of, 211, 798 internal, ligation of, 211, 609 ligation of, 211, 607 cerebral disease after, 595, 608 in excision of upper jaw, 828 wounds of neck, 366 for neuralgia, 566 facial, ligation of, 211 femoral, common, acupressure of, 617 aneurism of, 616 ligation of, 215, 617 deep, aneurism of, 617 ligation of, 216 superficial, aneurism of, 617 diffused, 618 ligation of, 215, 617 gluteal, aneurism of, 615 ligation of, 214, 615 iliac, common, aneurism of, 613 ligation of, 214, 615 external, aneurism of, 616 ligation of, 214, 617 internal, aneurism of, 615 ligation of, 214, 615, 616 innominate, aneurism of, 604 ligation of, 209, 210, 609 intercostal, hemorrhage from, in chest wounds, 389, 392 injury of, in fractured ribs, 256 INDEX. 1099 Artery— interosseous, ligation of, 214 intra-cranial, aneurism of, 608 intra-orbital, aneurism of, 608 isehiatic or sciatic, aneurism of, 615 ligation of, 214 of leg and foot, aneurisms of, 618 lingual, ligation of, 211 for malignant tumor of tongue, 821 for prolapsus of tongue, 817 mammary, internal, hemorrhage from, in chest wounds, 389, 392 obturator, relations of, in femoral hernia, 899 occipital, ligation of, 211 peroneal, ligation of, 217 popliteal, aneurism of, 617 ligation and compression in, compared, 595, 596, 600 ligation of, 216 rupture of, in fractured knee, 241 pudic, aneurism of, 615 radial, ligation of, 213 sciatic. See Artery, isehiatic. subclavian, aneurism of, 609 ligation of, 211, 609, 611, 612 intra-thoracic inflammation after, 595 temporal, ligation of, 211 thyroid, ligation of, 211 for bronchocele, 813 tibial, ligation of, 216, 217 posterior, rupture of, in fracture of knee, 241 ulnar, ligation of, 213 vertebral, aneurism of, 609 ligation of, 211, 609 Arthrectomy, 644 Arthritis, 640 acute, of infants, 642 amputation for, 644 anchylosis in, 654 causes of, 641 chronic rheumatic. See Arthritis, rheumatoid. deformans, 651 excision for, 644 gelatinous, 640 excision for, 644 of hip-joint. See Hip-disease. intervertebral joints, 715 residual abscess after, 642. rheumatoid, 651 of hip, diagnosis of, from fracture, 274 of sacro-iliac joint. See Sacro-iliac disease. suppuration in, 642, 644 tenotomy in, 643 traumatic, 224 Arthropathy from nerve-lesion, 653 Arthrotomy in old luxation of elbow, 302 Articular changes in dislocation, 287 neuralgia, 662 Artificial anus. See Fistula, fecal. limb, adaptation of, 110 membrana tympani, 786 pupil, 737 respiration, 375 sponge, 66 Arytenoid cartilage, luxation of, 370 Ascites, diagnosis of from ovarian tumor, 939 Aseptic traumatic fever, 51 Asphyxia. See Apnoea. local, 440 < Aspiration, 92 of aneurism, 591 pneumatic, 108 Assistants, duties of, in operations, 71 Asthenopia, 760 neurasthenic, 753 Astigmatism, 759 Astragalo scaphoid joint, excision of, 703 ligament, section of, 701 Astragalus, dislocation of, 314 excision of, 685 fracture of, 284 Astringents in inflammation, 58 Ataxia, locomotor, a cause of fracture, 228 Atheroma of arteries, 581 Atheromasia, 582 Atheromatous ulcer, 582 Atlo-axoid joint, arthritis of, 715 Atony of bladder, 1013 Atrophic scirrhus of breast, 856 Atrophy, eccentric, 249 optic, 756 Atropia in hydrophobia, 164 in shock, 67 in spermatorrhoea, 1083 Atropine conjunctivitis, 721 Auditory meatus. See Meatus. nerve, lesions of, 790 Aural polypi, 781 speculum, 779 Auricle, diseases of, 777 Auricular appendages, with macrostoma, 812 Avulsion of limbs, 123, 155 amputation for, 94 in reducing dislocations, 290, 291 of nasal polypi, 796 toe-nail, 550 Axilla, dislocation of humerus into, 295 Axillary artery. See Artery. glands, management of, in excision of breast, 858, 859 BACILLUS of carcinoma, 540 inflammation, 42 malignant pustule, 439 pyocyanine, 39 senile gangrene, 431 suppuration, 40 tetanus, 568 tubercle, 459 Back, injuries of, 343 Bacteria in pyaemia, 454 Balanitis, 472, 1064 11 GO INDEX. Balano-posthitis, 472 Balls, encysted, 180 Bandages, 81 for eye, 473, 718, 736, 737 Bands, extending, in reducing disloca- tions, 289 internal strangulation by, 904 intrabursal, 560 membranous, in tympanum, 788 Bar at neck of bladder, 1011 Barbados leg, 516, 554, 555 Barometer, state of, influencing results of amputation, 112 Barren cysts, 509. See Cysts. Basedow's disease. See Goitre, exoph- thalmic. Bath, antiseptic, for wounds, 154 hot-air, in hydrophobia, 165 Battey's operation, 946 Bavarian dressing for fractures, 246 Bayonet wounds. See Wounds. Bed, fracture, 237 Bed-sores, 432 after spinal injuries, 349, 356 Bell, instrument for varicocele, 1078 Belladonna in shock, 67 Bellows for artificial respiration, 375 Bending of bone, 222 Bert's mode of producing anaesthesia, 80 Bibron's antidote, 163 Biceps tendon, displacement of, 298 division of, 692 Bichloride of methylene, 80 Bifid uvula, 832 Bigelow, dislocation of hip, 304 et seq. litholapaxy, 975 Bilateral lithotomy, 992 Biliary abscess, 958 fistula, 411 Bistoury, 99 Bites of rabid animals, 163 snake, 162 syphilis from, 162 Bivalve speculum, 1088, 1089 Black cataract, 738 Bladder, absence of, 1001 atony of, 1013 complicating lithotrity, 980 bar at neck of, 1011 calculus of. See Calculus, vesical. cancer of, 1010 catarrh of, 1008 clots in, 1012 diseases of, 1001 malignant, complicating litho- trity, 980 structural, 1009 electric illumination of, 1030. See Cystoscope. exploration of. See Sounding. extroversion or exstrophy of, 1001 table of cases of, 1005 fissure of neck of, 1011 fistulae of. See Fistulae. foreign bodies in, 415 hemorrhage from, 1012 Bladder— hernia of, 865, 1006 calculus in, 1000 inflammation of. See Cystitis. after spinal injuries, 348 injuries of, 414 inversion of, 1006 irritability of, 1007, 1015 malformations of, 1001 malpositions of, 1006 missing the, in lithotomy, 987 neuralgia of, 1015 paralysis of, 1013 puncture of, 1022 et seq. for stricture, 1049 resection of, 415 rupture of, 414 from retention of urine, 1049 sacculated, 1009 complicating lithotrity, 980 spasm of, 1015 in lithotomy. 988 stone in. See Calculus, vesical. suture of, 415 tubercle of, 1011 tumors of, 1010 washing out the, after lithotrity, 976 wounds of, 415 Blear-eye, 768. See Ophthalmia tarsi. Bleeding piles, 928 Blennorrhagia. See Gonorrhoea. Blennorrhea, 466 of lachrymal sac. See Mucocele. Blepharitis, 768 pediculosa, 769 Blepharoplasty, 770 Blepharospasm, 724, 725, 770 Blind fistula in ano, 923 urinary, 1053 piles, 928 Blindness, nervous, 747 Blisters in gonorrhoea, 469 in indolent ulcers, 428 Blood in gangrenous stomatitis, 433 in inflammation, 35 inhalation of, 92 intra-peritoneal injection of, 92 loss of. See Hemorrhage. peptonized, transfusion of, 91 in pyaemia, 453 re-infusion of, 91 transfusion of, 190 in pyaemia, 457 Blood-calculi, 963 Bloodless method of operating, Esmarch's, 96 Blood-letting, 89 et seq. in aneurism, 591 inflammation, 59 lung wounds, 391 shock, 142 strangulated hernia, 878 Bloodvessels in inflammation, 35 injuries of, 181 in pyaemia, 453 Blue pus, 39 INDEX. 1101 Boil. See Furuncle. Bond, splint for fracture of radius, 270, 271 Bone, abscess of, 624 absorption of, after fracture, 248 aneurism in, 636 atrophy of, 632 eccentric, 249 bending of, 222 caries of. Sec Caries. contusion of, 180, 222 cysts of, 634 death of. See Necrosis. decalcification of, 620 decalcified, for drainage tubes, 159 diseases of, inflammatory, 618 non-inflammatory, 631 eburnation of, 620, 621 elongation of, after amputation, 110 excision in continuity of, 178, 631 exfoliation of, 628 fracture of. See Fracture. gangrene of. See Necrosis. mephitic, 627, 628 grafting of, 250, 671 hemorrhage from, 108 hydatids in, 634 hypertrophy of, 631 injuries of, 222 malignant disease of, 635 meduUization of, 620 necrosis of. See Necrosis. in nervous affections, 634 osteo-porosis of, 620 in pyaemia, 453 rarefaction of, 620 in rickets, 462 sarcoma of, 635 sclerosis of, 620, 621 scrofula of, 461, 633 suppuration in, 622 et seq. syphilitic affections of, 496, 634 transplantation of, 250, 671 tubercle in, 633 tumors in, 634 pulsating, 636 turbinated, removal of, for nasal polypus, 797 ulceration of. See Caries. Bone-earth calculus, 962 Bone-nippers, 100 Bone-plates, decalcified, in operations on bowels, 913 Bony anchylosis, 654 et seq. deposits in choroid, 752 Borborvgmus in hernia, 865 Bouchon,188 Bougie, Eustachian, 789 medicated, 469 oesophageal, 841 rectal, 918 urethral, 1026 Bouton. See Malignant pustule. Boutonniere operation for urethral stric- ture, 1043 et seq. Bowel, See Intestines. Bow-legs. See Genu extrorsum. Brachial artery. See Artery, brachial. Brachiocephalic artery. See Artery, in- nominate. Brachymetropia. See Myopia. Bracketed splint, 278, 682, 684 Brain, aneurism in. See Arteries, intra- cranial. changes in, after amputation, 110 in hydrophobia, 165 compression of. See Compression. concussion of. See Concussion. congestion of, from injuries of chest, 389 contusion of, 325 foreign bodies in, 336, 339 fungus of, 705 hernia of. See Hernia cerebri. inflammation of, 331 injuries of, 325, 336 operations on, 339 in pyaemia, 453 syphilitic affections of, 495 tumors of, 705 wounds of, 336 Bran dressing for compound fracture, 245, 283 Brasdor, operation for aneurism, 596 Breast, abscess of, 851, 853 cancer of, 856 state of areola preceding, 851 cysts of, proliferous, 855 simple, 854 diseases of, 849 in male, 860 excision of, 858 gathered, 851 hydrocele of, 854 hypertrophy of, 849 inflammation of, 851 milk-tumor of, 849 neuralgia of, 853 painful subcutaneous tubercle of, 855 sarcoma of, 856 sero-cystic sarcoma of, 855 strapping the, 852, 853 tumor of, glandular or adenoid, 855 irritable, 524, 855 sarcomatous, 856 Bridle stricture, 1036 Bromine in hospital gangrene, 436 Bronchitis in throat wounds, 367 Bronchocele, 812 Bronehotomy, 378 et seq. Bruise. See Contusion. Bruit in aneurism, 587 Brush-burn, 157 Bryant's line, 273 Bubo, chancroidal, 477, 480 gonorrhoeal, 470 parotid, 814 primary, 482. 488, 555 syphilitic, 487 Bubon d'emblee. See Bubo, primary. Bubonocele. See Hernia, inguinal. Buchanan, radical treatment of hernia, 895 1102 INDEX. Bnffy coat of blood in inflammation, 36 Bullet forceps, 174 wounds, 168 Bunion, 561 Buphthalmos, 729 Buried sutures, 420 Burning pain in nerve injuries, 219 Burns and scalds, 315 amputation for, 95, 317 anchylosis of jaw from, 320 cicatrices of, 318 duodenal ulcer in, 316 of mouth, pharynx, and glottis, 370 Burow, plastic operation, sol Burr-head drill, 627 Bursa, hyoid, hygroma of, 816 Bursae, diseases of, 559 syphilitic, 492, 496 injuries of, 221 sarcoma of, 561 Bushe, needle and needle-carrier for piles, 932 Butcher, forceps, knife-bladed, 666 saw for excisions, 127, 130, 665 Button-cautery, 86 Button-hole'fracture. See Fracture. Button-suture, 1057, 1058 CACHEXIA, cancerous, 532 Cadaver, skin-grafting from, 429 Caecal hernia, 865 Caesarean section, 947 Calcaneo cuboid ligament, section of, 701 Calcaneo-scaphoid ligament, section of, 700 Calcaneum, dislocation of, 314 excision of, 685 fracture of, 2s4 Calcareous deposits in membrana tym- pani, 7b3 film of cornea, 728 Calcification of arteries, 582 Calcis, os. See Calcaneum. Calculus, lacteal or mammary, 850 nasal. See Rhinolite. prostatic, 998, 1025 renal, 963 nephrotomy for, 948 urachal, 1000 ureteral, 9U4 urethral, 998 urinary, varieties of, 960 vesical, 964 causes of, 965 diagnosis of, 967 extra-pelvic, 1000 localities in which prevails, 966 mode in which originates, 964 nature and size of, suitable for lithotrity, 979 prognosis of, 970 proportion of cases requiring li- thotomy, 9 SI recurrent, 997 sounding for, 967. See Sounding. structure of, 964 Calculus, vesical— . symptoms of, 966 treatment of, 970 by lithectasy, 999 litholapaxy, 975 litholysis, 971 lithotomy, 9sl, 999. See Lithotomy. lithotrity, 971,999. See Lithotrity. in women, 999 Calf, ligature from nerve of, 194 Callisen, lumbar colotomy, 910 Callous ulcer. See Ulcer. Callus, 236 bending and breaking, in badly- united fractures, 247 Calomel in head injuries, 328 Canal of Nuck, hernia into, 891 hydrocele of, 903, 1088 Canaliculi, obstruction and slitting of, 774 Canalization of veins, 182 Cancellous exostosis, 521 Canula, tracheal, 380 Canula scissors, 74(i Canule a chemise in lithotomy, 990 Cancer, 530 bacillus of, 540 chimney-sweeper's or soot, 1067 colloid, alveolar, or gum, 538 diagnosis of, 540 epithelial. See Epithelioma. fibrous, 519, 539 haematoid, 537 hard. See Scirrhus. local origin of, 539 lymphatic, 532 medullary. See Encephaloid. melanoid or melanotic, 537 nature and general pathology of, 539 osteoid, 537 prognosis of, 540 recurrent, treatment of, 542 scirrhus. See Scirrhus. soft. See Encephaloid. treatment of, 540 villous, 538 Cancer of bladder, 1010 bone, 636 breast, 856 state of areola preceding, 851 ear, 778, 782 jaws, 824, 825, 830 oesophagus, 840, 841 palate, 836 parotid gland, 814 penis, 1066 prostate, 1024 rectum, 919, 920 testis, 1080 tongue, 820 tonsils, 837 urethra, 1050 uterus, 1093 vagina, 1089 vulva, 1088 INDEX. 1103 Cancer-juice, 533, 536 Cancer-serum, 537 Cancerous cachexia, 532 diathesis, 540 ulcer, 531 Cancrum oris. See Stomatitis, gan- grenous. Cannon-ball, wounds by, 169 Canthoplasty, 721, 740, 771 Canthus, division of, 474. See Cantho- plasty. Capillaries in pyaemia, 453 Capillary naevi, 577 Capsular cataract, 738, 746 Capsulated scirrhus, 530, 857 Capsulo-lenticular cataract, 738 Caput obstipum. See Wry-neck. succedaneum, 323 Carbolic acid, antiseptic treatment by, 157 in diabetic cases, 70 hemorrhoids, 934 hydrocele, 1073 local anaesthesia by, 80 Carbolized ligatures, 194 in aneurism, 594 Carbon ate-of-lime calculus, 963 Carbuncle, 437 facial, 439 Carcinoma. See Cancer. Carden, amputation through condyles of femur, 132 Cardiac end of stomach, dilatation of, 954 resection of, 953 Carditis from contusion of chest, 389 Caries, 625 of orbit, 776 in stumps, 112 syphilitic, 496 of vertebrae. See Spine, antero-pos- terior curvature of. Carnification of marrow, 621 Carotid artery. See Artery, carotid. Carpus, dislocations of, 303 fractures of, 271 Carrageen poultice, 57 Carron oil for burns, 318 Cartilage in callus, 236, 237 cricoid, dislocation of, 370 ensiform, excision of, 669 fracture of, 257 ulceration of, in arthritis, 641 Cartilages, costal, fractures of, 256 epiphyseal, in rickets, 463 loose, in joints, 519, 660 semilunar, dislocation of, 313 excision of, 313 Cartilaginous tumors, 519 Castration, 1081, 1082 for onanism, 1084 radical cure of hernia, 867 tumors of testis, 1079 et seq. Cat, transplantatiou of tendon from, 221 Cataract, 738 capsular and secondary, 746 Cataract— diagnosis of, 738, 739 operation for ripening, 739 treatment of, 739 by discission from behind, 745, 746 extraction in capsule, 745 flap operation, 740 short, 745 linear extraction, 743 needle operation, or solution, 745 Pagenstecher's method, 745 peripheral linear extraction, 743 reclination, depression, or couching, 740 suction, 746 traction, 743 Von Graefe's method, 743 Wecker's method, 745 Catarrh, spring, 721 vesical, 1008 Catarrhal inflammation of tympanum, 788 ophthalmia, 715 Catgut rings for lateral anastomosis of bowels, 913 Cathartics in septic peritonitis, 402 Catheter, 1025 Eustachian, 789 female, 1050 introduction of, 1027 by tour de maitre, 1028 metallic and flexible, choice between, 1029 mode of fastening, in urethra, 1021 Nelaton's, 1025 prostatic, 1019, 1020 self-retaining, 1021 sigmoid, 946 use of, in enlarged prostate, 1019 et seq. fractured pelvis, 258 gonorrhoea, 470 spasm of urethra, 1034 spinal injuries, 356 stricture of urethra, 1039 et seq. vesico-vaginal fistula, 1058 vertebrated, 1020, 1021 Catheterization, 1027. of larynx. See Intubation. posterior, 1029 of ureters, 963, 1000 Catlin, 99 Catoptric test for cataract, 738 Caustic in aneurisms, 602 arrows. See Arrows. in carcinoma, 541 epithelioma, 545 for piles, 933 prolapsus of rectum, 936 Cauterisation en fleches, 541 Cautery, actual, 87 in tetanus, 572 button, 86 galvanic, 87 1104 IND EX. Cautery, galvanic— for laryngeal growths, 846 nasal polypi, 797 in hemorrhage, 192 hospital gangrene, 436 inflammation, 59 Paquelin's, 87 for hemorrhoids, 934 in tracheotomy, 380 ununited fracture, 250 urethral tumors, 1050 Cavernous bodies of penis, rupture of, 417 Cells, amoeboid, movement of, 37 mastoid, inflammation of, 787 new, origin of, 37 Cellular and cellulo-cutaneous erysipe- las. See Erysipelas. Cellulitis, 554. Cephalhaematoma, 323 Cephalhydrocele, traumatic, 333 Cerebral complications of head injuries, 325 irritation. See Concussion of brain. localization, 340 Cerumen, accumulation of, in auditory meatus, 779 Cervical glands, enlargement of, 816 Chain-saw, 665, 666 Chalazion, 773 Chancre. Syphilis. mixed, 487, 499, 502 soft or non-infecting. See Chancroid. Chancroid, 476 complications of, 477, 480 et seq. diagnosis of, 478 from syphilis, 498, 499 in female, 479 localities of, 476 phagedaenic, 477, 481 phimosis and paraphimosis with, 480, 481 prognosis of, 478 serpiginous, 478, 481 treatment of, 478 urethral, 479 Charbon. See Pustule, malignant. Chaude-pisse, 466 Cheek, diseases of, 804 fistulae of, 365 operations on, 804 wounds of, 365 Cheek compressor for harelip, 809, 810 Cheiloplasty of lower lip, 319, 806 uj>per lip and angle of mouth, 320, 807, 808 Cheloid. See Keloid. Chest, contusions of, 387 foreign bodies in, 396, 397 incision of, 396 tapping the. See Paracentesis tho- racis. wounds of, 389 et seq. Chian turpentine in cancer, 541 Chilblain. See Pernio. Chilling in operations, 67 Chimney-sweeper's cancer, 1067 Chloral, intravenous use of, SO for wounds, 156 Chloroform, administration of, 78 danger of, by gaslight, 79 in fissure of anus, 927 compared with ether, 74 primary anaesthesia from, 75 pupil in anaesthesia by, 76 Choked disk, 755 Cholecystectomy, 957 Cholecysto-enterostomy, 957 Cholecystorraphy, 411 Cholecystotomy, 956 Cholelithotrity, 957 Chondroid tumor, 518 Chopart, amputation through tarsus, 126 Chordee, 469 Chorea after amputation, 110 complicating fracture, 242 syphilitic, 495 Choroid, diseases of, 750 Choroiditis, 750 et seq. anterior, 731 syphilitic, 491 Chromicised catgut ligatures, 594 Chylocele, 1074 Cicatrices from burns, operations for, 318 contraction of, 47 depressed, 320 growth of, 48 warty tumors or ulcers of, 551 Cicatrization, 47 subcrustaceous, 149 Cilia. See Eyelashes. Ciliary body, diseases of, 732 muscle, division of. See Cylicotomy. paralysis and spasm of, 760 staphyloma, 729, 731 zone, 723, 732, 733 Circular amputation, 102 resection of rectum, 920, 921 Circulation, collateral, 203 Circumcision, 1062 Cirsocele, 1076. See Varicocele. Cirsoid aneurism. See Arterial varix. Citric acid in gonorrhoea, 468 Clamp and cautery for piles, 932 prolapsus of rectum, 936 Clamp for ovariotomy, 945 Clamp-forceps for piles, 933 Clamp-shield for ovariotomy, 945 Clap. See Gonorrhoea. dry, 466 Clavicle, dislocation of, 294, 295 excision of, 262, 668 for dislocation, 295 fracture of, 258 Cleft palate, 832 scrotum, 1060 Climate, influence of, on aneurism, 585 Clitoridectomy, 1088 Clitoris, hypertrophy and excision of, 10b8 Cloacae in necrosis, 628 Clove-hitch knot, 289 INDEX. 1105 Clover, apparatus for giving chloroform, 79 washing out bladder, 976, 977 Club-foot. See Talipes. Club-hand, 692 Coagulating injections in aneurism, 602, 618 Coagulation of blood in inflammation, 36 Coagulum, external and internal, in wounds of arteries, 188 Coat-sleeve amputation, 103 Cocaine, local anaesthesia by, 81, 564, 571, 721, 727, 734 ctseq., 847 Cocaine-conjunctivitis, 721 Coccygeal fistula, 512 Coccygodynia, 258 Coccyx, excision of, in imperforate rec- tum, 915 fracture of, 258 osteoplastic resection of, 921 Cock, impermeable stricture of urethra, 1047 Cohnheim, origin of lymph-corpuscle, 37 pus-corpuscle, 40 Coil, Leit^r's, 56 Cold abscess. See Abscesses. ana^thesia by use of, 80 apparent death from, 321 in cancer, 541 effects of, 320 in hemorrhage, 190 inflammation, 55 mechanism of death from, 320 in spine disease, 713 strangulated hernia, 878 traumatic fever, 56 Colectomy, 913 Collapse. See Shock. of lung, 390 in strangulated hernia, 874 Collar for cicatrices of neck, 319 Collateral circulation, 203 Colles, fracture of radius, 270 Colles's law, 506 Collodion, 153 Colloid cancer, 538, 856 cysts, 510 styptic, 153 Coloboma of choroid, 752 eyelids, 774 iris, 735 Colo-colostomy, 955 Colon, syphilitic ulceration of, 494 Color-blindness, 758 Colotomy, 910, 916 for imperforate rectum, 915 intestinal obstruction, 910 recto-vesical fistula, 922 stricture of rectum, 919, 921 Columna nasi, restoration of, 800 Coma in spinal injuries, 349 Combined oesophagotomy, 841 Come, Frere, lithotome cache, 986, 987 Complaisance, operations of, 63, 114 Complex cystigerous cysts, 511 Compress, graduated, 191 70 Compressing bandage for eye, 736, 737 Compression in aneurism, 597 of brain, 329 in cancer, 541 for granular lids, 720 hemorrhage, 191 in inflammation, 59 of spermatic cord for neuralgia of testis, 1070 spinal cord, 344 Compressors, arterial, 98, 598, 990 Concomitant squint, 764 Concussion of auditory nerve, 791 brain, 325 cerebral irritation following, 327 lung, 388 retina, 360 solar plexus, 399 spinal cord, 343 Condyle of lower jaw, excision of, 832 Condylomata. See Mucous patches. Confrontation in diagnosis of syphilis, 499 Congenital absence of tibiae, 698 cystic hygroma, 509 fistula of ureter, 1002 hernia, 888 hydrocele, 1070 inequality in length of limbs, 276 tumor of sterno-mastoid, 220, 496, 816 Congestion, 34 Congestive stricture of urethra, 1034 Conical cornea, 728, 737 stump, 110 trephine, 342 Conjugate deviation of eyes, 768 Conjunctiva, diseases of, 715 et seq. dryness of. See Xerosis. tumors of, 723 Conjunctivitis, 715 etseq. gonorrhoeal. See Gonorrhoea. syphilitic, 491 Conoidal bullet, wounds by, 168 Consent of patient to operation, 69 Constipation in strangulated hernia, 873 Constriction, seat of, in strangulated her- nia, 871 Constrictor, artery, 193 Contiguity, amputation in, 93 Continued suture, 151 Continuity, amputation in, 93 of bones, excision in, 178, 631 Continuous dilatation in stricture of oesophagus, 841 pulverization, 159 Contractile stricture of urethra, 1036, 1040, 1042 Contraction of cicatrices, 47 elbow, 692 fingers, 693 forearm and hand, 692 hip, 694 knee, 697 shoulder, 692 tendons after amputation, 112 | toes, 703 1106 INDEX. Contre-coup, 226 Contused wounds. .S«e Wounds. Contusion, 144 of arteries. See Arteries. bones. See Bones. brain. See Concussion. Convergent strabismus, 765 Convulsions after operations in children 8d9 from nerve-wounds, 21S in injuries of the head, 331 spine, 346 Coover's splints, 271 Copaiba in gonorrhoea, 469 Coracoid process, fracture of, 263, 264 Cord, spermatic, compression of. for neu- ralgia of testis, 1070 haematocele of, 1075 hydrocele of, 1074 tumors of, 1080 wounds of, 418 spinal, tumors of, 715 Corelysis, 737 Cornea, abscess of, 725 calcareous film of, 728 conical, 728, 737 diseases of, 723 et seq. fistula of, 727 foreign bodies in, 360 hernia of, 726 herpes of, 724 inflammation of, 723,.728 opacities of, 727 paracentesis of, 725 for glaucoma, 762 plastic operations on, 728 staphyloma of, 729, 730 tattooing the, 728 trephining the, 762 ulcers of, 726 Corneitis, 723 Corning, mode of hastening anaesthesia, 78 Corns, 549 Coronoid process, fracture of, 269 Corpora cavernosa, affections of, 1064, 1065 Corpse, grafting bone from, 631 Corpuscles, lymph, 36 pus, 39 red and white blood, in inflammation, 35 Corpuscular lymph, 37 Corrosive liquids, injuries by drinking, 370 sublimate in dressing wounds, 158, 159 el seq. gonorrhoea, 468 Coryza in hereditary syphilis, 497 Costal cartilages. See Cartilages. Costiveness in spinal injuries, 347 Cotton-wool dressing, 10S, 154, 156 Couching for cataract, 740 Counter-extension in fractures, 276 Counter-irritation, 85 in arthritis, 643 hip disease, 649 inflammation, 58 spine disease, 713 Counter-stroke, fracture by, 226 Coup-de-fouet. 220 Couvercle, 188 Coxalgia. Ste Hip disease. Cradle, Salter's, for fractured leg, 2s2 Oraniotabes in rickets, 463 Creoline in cystitis, 1008 gonorrhoea, 468 Creeping chancroid, 478 Crepitation in chronic synovitis, 638 Crepitus in fractures, 233 spinal injuries, 353 Cretinoid condition following thyroidec- tomy, 814 Cricoid cartilage, dislocation of, 370 Crico-thyrotomy, 378 Critical days in burns, 317 Cross-eyes. See Strabismus. Cross-legged progression, 694 Croup, 845 of conjunctiva, 719 Croupous lymph, 37 ophthalmia, 719 Crural hernia. See Hernia, femoral. Cruro-properitoneal hernia. 898 Crushing calculus. See Lithotrity. in lateral lithotomy, 988 Cryptorchids, 1068 Crystalline lens. See Lens. Cubebs in gonorrhoea, 469 Cuboid bone, dislocation of, 314 Cucaine. See Cocaine. Cuirass like scirrhus of breast, 534, 856 Cuneiform bone, dislocation of, 314 Cup of optic papilla, 756 Cupped blood in inflammation, 36 Cupping, 89 Curdy pus, 39 Curette, 425, 741 urethral, 978 Curvature, anterior, of bones of leg, 698 antero-posterior, of spine, 709 lateral, of spine, 689 Cutaneous erysipelas. See Erysipelas. proliferous cysts, 512 Cuticle, transplantation of, for ulcers, 429 Cutting for stone. See Lithotomy. Cyclitis, 732 serous, 733 syphilitic, 494 Cycloplegia, 768 Cylicotomy for glaucoma, 762 Cylindroma, 528 Cyphosis, 689 Cyst or cysts, autogenous, 509 colloid, 510 complex cystigerous, 511 compound, 511 cutaneous proliferous, 512 dentigerous, 513 ■ endogenous and exogenous growth of, 511 multilocular, 511 mucous, 510 oily, 510 origin of, 509 INDEX. 1107 Cyst or cysts— parent, 511 primary and secondary, 509 proliferous, 511, 512 retention, 509 sanguineous, 510 sebaceous, 513 seminal, 511 serous, 509 simple or barren, 509 synovial, 510 Cysts, abdominal, 959 of antrum, 824 back, congenital, 709 bladder, dermoid, 1010 in bone, 634 of breast, 854 broad ligament, 940, 942 labia majora, 1088 neck, 815 omentum, 864, 882, 960 ovary. See Ovarian tumors. parotid region, 814 prostate, 1025 submaxillary gland, 815 testis, 1079, 1080 tongue, 818 urachus, 960 Cystic hygroma, congenital, 509 sarcocele, 1079, 10S0 tumor. See Cyst. Cysticercus of vitreous, 750 Cystine calculus, 962 Cystitis, 1006 complicating lithotrity, 980 in spinal injuries, 348 Cystocele, 862, 1062, 1089 calculus in, 1000 obturator, 901 Cystorraphy, 415 Cystoscope, 1010, 1012, 1029 Cystotome, 741 Cystotomy. See Lithotomy. for cystitis, 1009 . enlarged prostate, 1024 ruptured bladder, 415 DACRYO-ADENITIS, 774 Dacryocystitis, 775 Dactylitis, syphilitic, 496, 498 Dance's symptom, 906 Day-blindness. See Hemeralopia. Day-sight. See Nyctalopia. Deafness, nervous, 790 Debridement, 175 for protrusion of intestine, 405 Decalcification of bone, 620 Decalcified bone for drainage tubes, 159, 224 plates in operations on bowels, 913 Deer, ligature from sinew of, 194 Deformities, treatment Of. See Ortho- paedic surgery. Deformity, amputation for, 96, 114 in fractures, 231 Deformity in— separation of epiphyses, 230 spinal injuries, 352 Degeneration of lymph, 38 fatty, after anaesthesia, 77 Deligation. See Ligation. Delirium in spinal injuries, 349 traumatic, 141, 143 Demarcation, line of, 49 Dementia, syphilitic, 495 Dentigerous cysts, 513 of antrum, 825 Depletion in inflammation, 59 Deposits, urinary, 960 Depressed fracture of skull, 334, 335, 337 nose, 803 Depression of cataract, 740 Dermatolysis, 555 Dermoid cyst of bladder, 1010 Descending neuritis, 755 Desmoid tumor, 518 Destructive changes in inflammation, 40 Detachment of retina, 754 Determination, 34 Development of lymph, 38 Deviation, conjugate, of eyes, 768 Dextrine bandage, 85 Diabetes, connection of, with gangrene, 431 influence of, on results of operations, 64 predisposing to ununited fracture, 249 syphilitic, 495 Diabetic cataract, 738, 746 patients, preparation of, for opera- tions, 70 retinitis, 754 Diagnosis, anaesthetics to aid, 73 Diaphoretics in inflammation, 61 Diaphragm, injuries of, 398 suture of, 398 Diaphragmatic breathing in spinal inju- ries, 347 hernia, 398, 885 Diastasis, 285 of pelvis, 256, 294 sternum, 257, 294 Diatheses, urinary, 960 Diathesis, aneurismal, 585 cancerous, 540 hemorrhagic, 187 purulent or pyogenic. See Pyaemia. Diathetic diseases, 458 Dieffenbach, amputation at hip, 136 lace-suture, 1052 Diet in inflammation, 53 after operations, 65 Diffuse inflammation. See Inflammation. Diffused hydrocele of spermatic cord, 1074 suppuration, 426 Digitalis in inflammation, 61 shock,67 Dilatation of oe-ophageal stricture, 841 retrograde, 844 of orifices of stomach, 954 liny INDEX. Dilatation of— pharynx, 839 of sphincter ani in fissure of anus, 927 in piles, 932 of urethral strictures, 1039 et seq. Dilated oesophagus, 840 Dilator oesophageal, 841 urethral, 999 Dip of conoidal bullet, 168 Diphtheria, 845 Diphtheritic conjunctivitis, 718 deposit on wounds, 69 Dire.-t method of artificial respiration, 375 Director, grooved, 197, 198 Disarticulation, 93. See Amputation. of lower jaw, 831 Discission of cataract from behind, 745, 746 Disk, choked, 755 Dislocation, 285 articular changes produced by, 287 causes of, 285 complete, 285 complicated, 285, 290 complicating fractures, 242, 244 compound, 285, 289 amputation for, 95, 289 congenital, 285, 291 diagnosis of, 286 old, 285, 290 partial, 285 pathological and spontaneous, 285, 291 prognosis of, 287 reduction of, 287 et seq, symptoms of, 286 treatment of, 287 et seq. Dislocation of ankle, 313 astragalus, 314 carpal bones, 303 clavicle, 294 cricoid cartilage, 370 crystalline lens, 362, 363 elbow, 300 et sea. eyeball, 363 hip, 304 et seq. in hip disease, 647 hyoid bone, 294 knee, 312 lower jaw, 292, 293 metacarpus and fingers, 303, 304 metatarsus and toes, 315 patella, 312 pelvis, 294 penis. 417 ribs. 21)4 scapula, 295 semilunar cartilages, 313 shoulder, 295 et seq. spine, 351 sternum, 256, 294 tarsus, 314 wrist, 303 Displacement in fractures, 231 et seq. Dissecting aneurism, 584 Dissection wounds. See Wounds. Distichiasis, 769 Diuretics in inflammation, 61 Divergent strabismus, 765 Division of tendons. See Tenotomy. Dogs, transplantation of bone from, 221, 250 periosteum from, 671 tendon from, 221 Dorsal disease of toes, 553 Double extension in hip-disease, 649 sacro-iliac disease, 651 spine-disease, 713 Double-lip, 805 Double vagina, 1087 Douche, Thudichum's, for ozaena, 795 foreign bodies in nose and ear, 364, 365 Drainage by catgut, 158 in ovarian cysts, 942 after ovariotomy, 945 in suppurating joints, 224 suppurative peritonitis, 402 Drainage-anchor, 424 Drainage-tube, Chassaignac's, 224 after paracentesis thoracis, 395 introduction of, in abscess, 423, 424 Dressing of operation wounds, 72 Drill, burr-head, 627 for ununited fracture, 250, 251 Drilling vesical calculi, 988 Dropsy of antrum, 824 encysted, 399 Drumine, 81 Dry-dressing, 108 Duck-billed speculum, 1054, 1055, 1088 Duct, nasal, obstruction of, 775 Duodenal ulcer in burns, 316 Duodenostomy. See Enterostomy. Dura mater, fungus of, 704 Dysphagia from aneurism, 588 conditions which produce, 838 et seq. in spinal injuries. 347 wounds of throat, 367 Dyspnoea from aneurism, 588 in spinal injuries, 347 wounds of lung, 387 throat, 367 EAR, accumulation of wax in, 779 cancer of, 778, 782 diseases of, 777 syphilitic, 492 foreign bodies in, 365 hemorrhage from, 334 inflammation of, fatal, 788 neuralgia of, 792 ringing in. See Tinnitus aurium. watery discharge from, 334 Ear-ache, 786 Ear-speculum, 779 Earth dressing for wounds, 154, 156 Eau de luce, 163 Eburnation of bone, 620, 621 Ecchymosis, 144 INDEX. 1109 Ecchymosis— in fractures, 233 intra-orbital, 334 lumbar, in haemothorax, 393 Ecraseur in amputation of penis, 1066 laryngeal, 846 rectilinear, 933 in removal of epithelioma, 546 hemorrhoids, 933 tongue, 819 et seq. Ectropion, 771 Eczema of auricle, 777, 778 mercurial, 504 Eczematous ulcer. See Ulcer. Effusion, intra-articular, in fracture, 233 rupture of muscle, 220 Egyptian ophthalmia, 719 Eiloides, 555 Elastic bandage in hemorrhage, 190 taxis, 878 compression in orchitis, 1069 ligature for epithelioma, 546 rectal fistula, 924 salivary fistula, 365 pressure in irreducible hernia, 869 Elbow, anchylosis of, 658 amputation at, 121 contraction of, 692 diseases and injuries of. See under Joints. dislocations of, 300 excision of, 176, 671 Election, operations of, 63 Electric bath for ulcers, 427 cystoscope, 1010, 1012, 1029 illumination of bladder and urethra, 1030 Electricity, battery for storing, 87 in cancer, 541 keloid, 551 Electro-puncturation, 88 for neuroma, 563 ununited fracture, 250 Elephantiasis Arabum, 516, 554 of scrotum, 1065 Elevator for depressed bone, 341 Elliptical amputation, 104 Elongation of uvula, 836 Elytrorrhaphy, 1089, 1090 Embolism, 184 causing intra-cranial aneurism, 585 of central artery of retina, 755 death from, after operations, 68, 144 by fat, 144, 239 fragments of liver, 144, 399 in pyaemia, 451 reduction of dislocations, 291 transference of tumors by, 532. Emissions, seminal, 1083 Emmetropia, 758 Emphysema from fractured ribs, 255 of orbit, 360 from puncture of bladder through rectum, 1023 ruptured intestine, 400 wounds of chest, 389, 390 et seq. Emphysema from wounds of— throat, 367 Emprosthotonos, 567 Empyema, 390, 394 Encephalitis, traumatic, 331 Encephalocele, 705 Encephaloid, 534 et seq. in bone, 535, 635 of breast, 856 microscopic appearances of, 536 morbid anatomy of, 536 natural history of, 534 treatment of. See Cancer, treatment of. Enchondroma, 519 following fracture, 228 Encysted balls, 180 calculus, 965, 988 dropsy, 399 haematocele, 1075 hernia, 890 hydrocele, 1074 rectum, 936 Endermic use of drugs, 86 Endocarditis, gonorrhoeal, 476 Endogenous growth of cells, 37 Endoscope, 1029, 1030 in gonorrhoea, 469 urethral chancroid, 479 Endothelioma, 529 Enemata in hernia, 870, 878, 882 saline, in hemorrhage, 92 Ensiform cartilage. See Cartilage. Enterectomy, 913 Enteritis, intestinal obstruction from, 904, 908 syphilitic, 494 Enterocele. See Hernia, intestinal. Entero-epiplocele. See Hernia, mixed. Enterorraphy, 401, 406, 913 Enterostomy, 954 Enterotome for fecal fistula, 412 Enterotomy for foreign bodies in intes- tines, 413 for intestinal obstruction, 909 polypoid growths, 921 Enterotomy-tube, 911 Entero-vaginal fistula, 923 Entrance, wound of, 170 Entropion, 770 Enucleation. See Excision. of ovarian and uterine tumors, 944 Eperon, division of, in fecal fistula, 411 Epicanthus, 774 Epididymitis, gonorrhoeal, 470 Epigastric hernia, 885 Epiglottis, scarification of, 370 tumors of, 820, 838 Epilepsy, ligation of vertebral artery for, 609 syphilitic, 495 trephining for, 339 Epiphora, 774 Epiphyseal cartilages in rickets, 463 Epiphyses, separation of, 230, 237, 244. See also under Fractures. 1110 INDEX. Epiphysitis, 624 Epiplocele. See Hernia, omental. Episcleritis, 731 Episiorrhaphy, 1089 Kpi^padia, 1031 Epistaxis, 792 Epithelial cancer. See Epithelioma. Epithelioma, 542 et seq. diagnosis of, 54.") melanotic, 545 microscopic appearances of, 514 paraffin, 1067 prognosis of, 545 recurrent, 546 treatment of, 545 warty or villous, 543 Epithelioma of anus, 920 larynx, 846 lip, 805 penis, 1066 scrotum, 1067 tongue, 820 uterus, 1093 vulva, 1088 Epitheliomatous ulcer, 544 Epulis, 822, 823 Erasion of joints, 644 in lupus, 554 Erectile tumors, 524, 576 Ergot in enlarged prostate, 1021 hemorrhoids, 931 uterine fibroids, 88, 1090 Erosion, chancrous. See Syphilis. Eruption in periostitis, 619 Erysipelas, 441 cellular, 442, 447 cutaneous or simple, 441. 446 erratic or wandering, 442 oedematous, 442 phlegmonous or cellulo-cutaneous, 442. 446 traumatic, 442, 447 treatment of, 444 tt seq. Erysipelas of air-passages, 445, 447 arachnoid, 443, 445, 447 auricle, 777 fauces and larynx, 443,445, 447 mucous membranes, 443 orbit, 447 peritoneum, 443, 445, 447 pharynx, 838 scalp, 324, 447 scrotum, 447 serous membranes, 443 stumps, 111 Erythema after operations, 69 Erythropsia, 758 Eschars, neuropathic, 349 Esmarch, anchylosis of jaw, 320, 8.32 apparatus for bloodless operations, 96, 160 bandage in aneurism, 597 Ether, administration of, 77 compared with chloroform, 74 deep injections of, in neuralgia, 564 first insensibility from, 75 Ether- hypodermic use of, 67, 8S, 142 rectal use of, 78 Eucalyptus, oil of, in antiseptic surgery, 158 Eustachian catheter, 789 tube, dilatation of, 789 obstruction of; 785 et seq. Eversion of upper eyelid, 361 Evisceration of eye, 764 Evulsion of tonsils, 837 Evidement in caries, 627 Exarticulation, 93. See Amputation. Excavation of optic papilla, 756 Excision, 663 in arthritis, 644 caries, 627 compound dislocation, 289 fracture, badly united, 247 compound, 243 ununited, 250, 251 gunshot injuries, 175 indications and contra-indications for, 663 in joint wounds, 225 malignant disease of bone, 636 mortality after, compared with am- putation, 664 for necrosis, 631 repair after, 664 sub-periosteal, advantages of, 664 Excision of ankle, 178, 225, 684 astragalus, 314, 685 axillary glands, 859 bones in continuity, 178, 631 breast, 858 calcaneum, 685 cancer, 542 clavicle, 262, 295, 668 clitoris, li>88 coccyx, 258, 915 cysts of ovary and broad ligament, 942 elbow, 176, 671 ensiform cartilage, 669 epithelioma, 546 eye, 731, 763 eyelashes, 769, 771 Fallopian tubes, 947 femur, 679 fibula, 684 foot, bones of, 685 hand, bones of, 674 hemorrhoids, 931, 932 hernial sac, 867 hip, 176, 225, 653, 657, 674 inguinal glands, 480 iris. See Iridectomy. jaw, lower, 254, 83(i, 832 upper, 798, 826, 827 kidney, 950 knee, 177, 225, 569, 660, 679 lachrymal gland, 774 larynx, 847 lung, 394, 396 malleus, 784 INDEX. 1111 Excision of— membrana tympani, 784 naevus, 578 ' nasal tumors, 799 nerves, 111, 428, 689 (esophagus, 842 orbital contents, 764 omentum, 405, 882 ovary. See Ovariotomy. parotid gland, 815 patella, 684 pharynx, 839 prepuce, 1062 radius, 673 rectum, 921 ribs, 395, 397, 668, 669, 958, 959 scapula, 667 et seq. scrotum, 1065 semilunar cartilages, 313 shoulder, 176, 669 sphincter ani, 936 spleen, 951 sternum, 668, 669 tarsal bones, 685, 701, 703 testis. See Castration. undescended, 1068 thyroid gland, 813 tibia, 684 tongue, 820 et seq. tonsils, 837, 838 tumors, 546 tunica vaginalis, 1074 ulna, 673 urethral stricture, 1048 uterine fibroids, 1091 uterus, 947, 1092 wrist, 176, 673 Exenteration of eye, 764 Exfoliation, 628, 630 in stumps, 112 Exit, wound of, 170 Exomphalos. See Hernia, umbilical. Exostoses, cancellous, 521 of ear, 782 ivory-like, 522 near joints, 634 Expanding speculum, 1088 Expediency, amputations of, 114. also Election. Exstrophy of bladder, 1001,1005 Extension, angular, 311 continuous, 639 et seq. in dislocation, 289, 290, 298 spinal injuries, 355 for stumps, 110 by weight, 275 et seq. External piles, 928 urethrotomy, 1043, 1045 Extirpation. See Excision. Extraction of cataract. See Cataract. Extractor, screw, 174 Extra-uterine pregnancy, 948. Extravasation, 144, 186 fecal, 400, 402, 880, 882 in fractures, 233, 239 trephining for, 337 See Extravasation— of urine, 403, 417, 1049 Extroversion of bladder, 1001, 1005 Exudation in inflammation, 37 Eye, or eyeball, contusion of, 361 dislocation of, 363 diseases of, 715 syphilitic, 491, 494, 498 excision of, 763 for staphyloma, 731 exenteration of, 764 foreign bodies on, 360 inflammation of, 762 lesions of, in pyaemia, 453 spinal disease, 711 wounds of, 360 Eyelashes, displacement of. See Trichi- asis. double row of. See Distichiasis. excision of, 769, 771 transplantation of, 769, 771 Eyelid, upper, eversion of, 361 falling of. See Ptosis. Eyelids, adhesion of. See Anehyloble- pharon. coloboma of, 774 diseases of, 768 eversion of. See Ectropion. inversion of. See Entropion. tumors of, 773 wounds of, 359, 363 FACE, diseases of, 792 injuries of, 359 Facial artery. See Artery. carbuncle. See Carbuncle. Fallopian tubes, excision of, 947 False aneurism, 584 anus, 411 joint. See Fracture, ununited. passage of urethra, 417, 1040 Far-sight. See Presbyopia. Fat-embolism, 144, 239 Fatty degeneration in arteries, 581 after anaesthesia, 77 matters in calculi, 963 tumors, 513. See Tumors. usure, 581 Fauces, erysipelas of. See Erysipelas. syphilitic affections of, 489, 494 Fecal abscess, 958 discharges, involuntary, in spinal injuries, 347 fistula. See Fistula. Feces, extravasation of. »See Extravasa- tion. impacted, 910 diagnosis of, from ovarian tumor, 939 Felon. See Paronychia. Felt jacket for spinal disease, 713 Female catheter, 1050 Femoral artery. See Artery. hernia, 898. See Hernia. Femur, dislocation of, 304 excision of, 679 1112 INDEX. Femur, excision of— head of. See Excision of hip. fracture of. See Fracture. primary cancer of, 636 separation of epiphyses of, 278 Fever, hectic, 51 ^ hemorrhagic, 1S7 inflammatory, 49 aseptic, 51 pyogenic or suppurative. See Pyae- mia. scarlet, after operations, 69. secondary, 51 urethral, 1037 Fibrinous or fibrinous lymph, 37 Fibrin in inflammation, 36 Fibrinous calculi, 963 iritis, 734 Fibro-calcareous tumors, 517 Fibro-cartilaginous tumors, 519 Fibro-cellular tumors, 515 Fibro-cystic tumors, 517, 1092 Fibro-fatty tumors, 514 Fibro-lipoma, 514 Fibro-muscular tumors, 517 Fibro-nucleated tumors, 526, 528 Fibro-plastic tumors, 526, 528 Fibroid tumors, 518 malignant, 519, 539 recurrent, 525 uterine, 1090 Fibroma, 517 soft, 515 Fibrous and fibro-cellular bodies in sac of hydrocele, 1074 cancer, 519, 539 epulis, 823 tissue, syphilitic affections of, 496 tumors, 517 Fibula, curvature of, 698 dislocation of, 313 excision of, 684 fractures of, 280, 283 Figure-of-8 bandage, 83 suture, 151, 152 Filaria, 1074 Filiform bougies, 1026 Filopressure, 201, 597 Fingers, amputation of, 117 chancre of, 500 contraction of, 693 dislocation of, 304 excision of, 674 fracture of, 272 strangulation of, by ring, 146 webbed, 694 First intention, union by, 148 Fissure of anus, 926 lower lip and angle of mouth, 811, 812 neck of bladder, 1011 scrotum, 1060 upper lip. See Harelip. urethra, 1050, 1051 vagina, 1089 Fistula, 426 aerial, 367, 368 Fistula— in ano, 923 biliary, 411 blind urinary, 1053 of cheek, 365 coccygeal, 512 of cornea, 727 entero-vaginal, 923 fecal or intestinal, 411, 873 etseq. gastric, 411 of lachrymal gland, 774 lachrymalis, 775 of nose, 800 oesophageal, 367 penile, 1052 perineal, 989, 1052 pilo-nidal, 512, 924 rectal, 922 recto-labial. 923 recto-urethral, 922 recto-vaginal, 922 recto-vesical, 922 salivary, 365, 774 of umbilicus, 937 urachal, 1054 of ureter, 1002 uretero-vaginal, 1054, 1058 urethral, 1051 urethro-rectal, 1054 urethro-vaginal, 1054 urinary, in female, 1054 et seq. in male, 1051 et seq. vesico-rectal, 1054 vesico-uterine, 1054, 1059 vesico-utero-vaginal, 1054, 1058 vesico-vaginal, 1054 et seq. Fixed bandages, 84 Flame, inhalation of, 317 Flap-amputation, 103 rectangular, 105 operation for cataract, 740 short, 745 Flat foot. See Talipes valgus. Flexible probes, 174 Flexion in aneurism, 600 hemorrhage, 191 Floating kidney, operation for, 951 tumors, 525 Flour-paste bandage, 84 Fluctuation of abscess, 421 Fluid of spina bifida, 708 Flushed-face in spinal injuries, 348 Fluxion, 34 Follicular abscesses of ear, 780 conjunctivitis, 721 Fomentations in inflammation, 56 Foot, amputations of, 124, 128 dislocations of, 314, 315 excisions of, 685 flat or splay. See Talipes valgus. fractures of, 284 perforating ulcer of, 552 tubercular disease of, 553 Forbes, operation on pianist's finger, 694 Forceps, artery, 100 for aural polypus, 781, 782 INDEX. 1113 Forceps— bone, 630, 665 bullet, 174 entropion, 770, 771 gouge, 627 iris, 736 knife-bladed, 666 laryngeal, 846 lion-jawed, 665 lithotomy, 983 oesophageal, 384 polypus, 796 sequestrum, 630 Snellen's, 770 tracheal, 374 urethral, 998 uterine, 1092, 1093 Forceps-scissors for cutting uvula, 836 Forearm, amputation of, 120 contraction of, 692 dislocations of, 301 fractures of, 269 Foreign bodies in air-passages, 371 bladder, 415 brain, 336, 339 ear, 365 eye, 360 gunshot wounds, 173 incised wounds, 150 nose, 364 oesophagus, 383 pharynx, 366, 383 rectum, 416 stomach and bowels, 413 thoracic cavity, 396 tongue, 366 urethra, 417 vagina, 419 Formative changes in inflammation, 36 Four-tailed bandage, 83 Fracture, 226 absorption of bone after, 248 badly united, 247 button-hole and perforating, 168, 228 causes of, 226 comminuted and multiple, 229 complete, 228 complicated, 229, 241 compound, 228 amputation of, 95, 243, 246 complications of, 243, 244 excision for, 243 treatment of, 243 et seq. from counterstroke, 226 crepitus in, 233 delayed union of, 248 diagnosis of, 234, 286 directions of, 229 displacement in, 231, 232 double, 229 epiphyseal. See Epiphyses, separa- tion of. false joint after. See Fracture, un- united. fissured and grooving, 228 | Fracture— gangrene from tight bandaging in, 239, 240 green-stick and partial, 228, 247 gunshot, 175 et seq. impacted, 229, 247 implicating joints, 242 et seq. incomplete, 228 intra-articular effusion in, 233 intra-periosteal, 229 longitudinal, 230 from muscular action, 227 oblique, 230 partial, 228, 247 reduction or setting of, 238 simple, 228, 237 splints for, 238 statistics of, 227 in stumps, 242 symptoms of, 231 et seq. temporary lengthening in, 276 transverse, 229 treatment of, 237 et seq. by immovable dressings, 246 union of, 235 delayed, 248 ununited, 248 et seq. varieties of, 228 Fracture-beds, 237 Fracture-box, 281 Fractures of acetabulum, 257 acromion, 263 ankle, 283 astragalus, 284 calcaneum, 284 clavicle, 258 coccyx, 258 coracoid process of scapula, 263, 264 coronoid process of ulna, 269 costal cartilages, 256 femur, condyles of, 278 head of, 257 shaft of, 276 upper extremity of, 272 fibula, 280, 283 fingers, 272 foot, 284 forearm, 269 humerus, lower extremity of, 266 shaft of, 266 upper extremity of, 264 hyoid bone, 254 jaw, lower, 253 upper, 252 lachrymal bone, 252 larynx, 368 leg, 280 malar bone, 252 nasal bones, 252 olecranon, 268 patella, 278 pelvis, 257 radius, 269, 270 ribs, 255 sacrum, 258 scapula, 262 1114 IND EX. Fractures of— skull, 333 spine, 351 sternum, 256 tibia, 280 trachea, 370 ulna, 269 vertebrae, 351 zygoma, 252 Fragilitas ossium. See Osteomalacia. Friction in inflammation, 59 subscapular, 654 Frog-face, 797, 798 Frontal sinus, affections of, 777, 803 Frost-bite, 321 amputation for, 95 Fruehjahrscatarrh, 721 Fumigation, mercurial, in syphilis, 503 Functional changes in inflammation, 34, 45 Fungus of brain, 705 dura mater, 704 haematodes, 535, 537 of skull, 704 Furuncle, or boil, 437 of auditory meatus, 780 Fusible calculus, 962 Fusiform aneurism, 583 GALACTOCELE, 849 Gall-bladder, abscess in, '.^>S distended, puncture of, 960 operations on, 956 rupture of, 399 suture of, 411 Gall-stone, impacted, 909 Galli, tubes of, 219 Galvanic cautery, 87, 797, 846 in tracheotomy, 380 urethral stricture, 1039 Galvanism for gonorrhoea, 469 ulcers, 430 uterine fibroids, 1092 Galvano-puncture for aneurism, 601 ovarian cysts, 942 Ganglion, 558 Gangraena oris. See Stomatitis, gan- grenous. Gangrene, 40, 48 amputation for, 94 with diabetes and granular kidney, 431 from arterial occlusion, 206 of bone. See Necrosis. mephitic, 627, 628 dry, 49, 431 hospital, 433 amputation for, 95 of iutestine in hernia, 872 in lacerated and contused wounds, 155 moist, 49, 431 of penis, 1064 scrotum, 431 senile, 431 spontaneous, 431 symmetrical, 440 Gangrene— of thyroid gland, 814 from tight bandaging, 239, 240 traumatic or spreading, 94, 155 white, 440 Gangrenous diseases, 431, 440 stomatitis. See Stomatitis. Gaping, dislocation of jaw from, 294 fracture of hyoid bone from, 254 of wounds, 147 Garrot, 98 Gastrectomy, 953 Gastric fistula. See Fistula. Gastrocele. See Hernia of Stomach. Gastroenterostomy, 954, 955 Gastrorraphy, 404, 406 Gastrostomy, 840, 843, 844 Gastrotomy for intestinal obstruction, 907. -See Laparotomy. removal of foreign bodies, 413 stricture of oesophagus. See Gas- trostomy. Gathered breast, 851 Gauze-and-collodion dressing, 153 Gelatinous arthritis, 640 Gelsemium in hydrophobia, 164 Gely's suture, 406 Genital organs, female, diseases of, 1085 gonorrhoea of, 472 injuries of, 418, 419 malformations of, 1085 male, diseases of, 1060 functional, 1082 injuries of, 416 et seq. zone, 419 Genu-extrorsum, 696 Genu-valgum, 694 Genu-varum, 696 Giant-celled sarcoma, 526 Gland or glands, axillary, in excision of breast, 858, 859 cervical, enlargement of, 816 lachrymal, diseases of, 774 lymphatic. See Lymphatic glands. mammary. See Breast. parotid. See Parotid gland. submaxillary, tumors of, 815 thyroid, extirpation of, 813 hypertrophy of. See Goitre. Glandular tumors, 522 of breast, 855 Glass, liquid or soluble, 85 drainage tubes, 224 Glaucoma, 760 Glaucomatous cup of optic papilla, 756, 760 Glazing of wounds, 150 Gleet, 466 Glioma, 528 of brain, 705 retina, 755 Globes, concentric, of epithelioma, 544, 545 Glossitis, 816 Glottis, burns and scalds of, 370 scarification of, 447 INDEX. 1115 Glover's suture, 151 Glue-and-zinc bandage, 85 Gluteal artery. See Artery. Glycerin for hemorrhoids, 930 wounds, 156 Glycogen in lymph corpuscles, 37 Glvcosuria in spinal injuries, 348 Goitre, 812 exophthalmic, 814 Gonococcus, 465 Gonorrhoea, 465 complications of, 469 external, 472 of female genitals, 472 nose, mouth, rectum, and urn cus, 475 ophthalmic, 473 Gonorrhoeal iritis, 475, 734 pleurisy, 476 rheumatic ophthalmia, 475 rheumatism, 475 analogy of, with pyaemia, 475 urethral fever, 1038 Gorget, blunt. 983 cutting, 986, 987 Gouge and gouge-forceps, 627 Graduated compress, 191 Grafting bone, 250, 631, 669, 671 muscle, 557 periosteum. 671, 709 rabbit's nerve, 565 skin, etc., 429, 430 sponge, l49, 426 tendons, 221 Granular condition of auditory me; 781 membrana tympani, 783 conjunctivitis, 719 kidney in gangrene, 431 lids, 719 Granulation and cicatrization, 47 union by, 149 Granulations, 47 true or vesicular, of eyelids, 719 Uranulation-tissue in arthritis, 640 Gravel, 960 Graves's disease. See Goitre, exoph mic. Green-stick-fracture. See Fracture. Gritti's amputation, 132 Grooved director, 197, 198 Grooving the tarsal cartilage, 770 Guillotine, laryngeal, 846 for tonsils, 837 Gullet. -See (Esophagus. Gum, diseases of, 822 lancing the, S22 Gum-and-chalk bandage, 84 Gum-cancer. See Cancer, colloid. Gummatous or gummy tumors in s ilis, 495 scleritis, 731 Gunshot fracture. See Fracture. injury, amputation for, 95 wounds. See Wounds. Gurgling in hernia, 865 Gustatory nerve, division of, for malig*- nant tumor of tongue, 821 Gypsum bandage, 84 tbili- atus, ithal- syph- H HEMATOCELE, 1075 Haematoid cancer, 537 Haematoma, 144, 510 auris, 778 Haematuria, 400, 1012 intermittent or paroxysmal, 1012 in spinal injuries, 347 Haemoptysis in lung wounds, 390 Haemostatic forceps, 547 Haemothorax, 387, 390, 392 Hair, falling of, in syphilis, 491, 493 transplantation of, 429 Hallux flexus, 704 valgus, 562, 704 Hammer, thermal, 86 Hammer-toe, 704 Hamstring tendons, division of, 697 Hand, amputations of, 117 et seq. contraction of, 692 dislocations of, 303 excisions of, 674 exploration of rectum by, 918 fractures of, 271 hemorrhage from, 191, 197, 201, 213 perforating ulcer of, 553 Handkerchief bandages, 84 Hanging, dislocation of cervical spine in, 352 Hare-eye. See Lagophthalmos. Harelip, 808 double, 811 Harelip-suture, 151 Haya poison, 81 Hays, knife-needle for cataract, 745 Head, diseases of, 704 injuries of, 323 tapping the, 706 Health, general, influence of, on results of operations, 63 Heart, lesions of, in pyaemia, 453 rupture of, 388, 569 suture of, 397 wounds of, 396 Heart-clot, death from, after operation, 67, 144 Heat, effects of, 315 increased, in inflammation, 43 in treatment of inflammation, 56 synovitis, 639 Heotic fever, 51 Hemeralopia, 758 Hemi-glossitis, 817 Hemiopia, 757 Hemiplegia in injuries of head, 329 spine, 346 syphilitic,-492 Hemorrhage into abscesses, 424 in amputation, prevention of, 96,100, 108 arrest of, process of nature in, 187 arterial, 186 1116 INDEX. Hemorrhage— from bladder, 1012 bone, 108 in compound fractures, 243, 245 constitutional effects of, 186 death from, after operations, 68 in fractured skull, 334 gunshot wounds, 172 habitual or periodic, 187 intermittent, 204 into hernial sac, 873 in herniotomy, 8^3 hospital gancrrene, 434 et seq. from incised wounds, 150 internal or concealed, 186 from kidneys, 1012 in lithotomy, 989 from nose. See Epistaxis. in operations, 71 parenchymatous, 108, 204 in pyaemia, 453 from piles, 928, 929 prostate, 1012 rectum, 921, 928 et seq. saline enemata in, 92 secondary, 204 after ligation in continuity, 206 from stumps, 111, 205 spontaneous, 187 subperiosteal, 463 after tooth extraction, 192 in tracheotomy, 380 transfusion of blood for, 190 treatment of, 189 et seq. by acupressure, 199 cauterization, 192 cold, 190 constitutional, 189 by elastic bandage, 190 ligation, 193 position, 190 pressure, 191 styptics, 191 torsion, 192 urethral, 1012 in gonorrhoea, 470 venous, 181 into vitreous humor, 750 in wounds of heart, 396 lung, 390, 392 throat, 366 Hemorrhagic diathesis, 187 fever, 187 periostitis, 619 retinitis, 754 ulcer. See Ulcer. Hemorrhoidal effort, 929 flux,929 Hemorrhoids, 927 diagnosis of, 929, 930 operations for, 931 causes of death after, 933 treatment of, 930 varieties of, 928 Hemp saw, 1093 Hepatectomy, 955 Hepatic abscess, 957 phlebotomy, 956 Hepatization of marrow, 621 Hepatotomy, 955 Hermaphrodism, 1031, 1060 Hermetically sealed gunshot wounds of chest, 391 Hernia, causes of, 860 classification of various forms of, 862, 884, 885 double, truss for, 866 inflamed, 869 intestinal, 865 irreducible, S68 Littre's, 863 mixed, 865 obstructed or incarcerated, 870 omental, 865 radical cure of, 866. See also under special Herniae. reducible. See Hernia. sac of, 862 changes in, in strangulation, 873 contents of, 863 hour-glass shape of, 872, 8S8 hydrocele of, 864 interparietal, 879 mode of recognizing, in herni- otomy, 881 removal of, 896 sloughing of, after herniotomy, 883 strangulated, 871 albuminuria in, 874 causes of, 871 diagnosis of, 874 fecal fistula after, 872, 880 etseq. mechanism of, 871 operation for. See Herniotomy. peritonitis in, 874, 883 prognosis of, 874 reduction of, 876 in mass, 879 persistence of symptoms after, 879 rupture of intestine in, 880 seat of constriction in, 871 structural changes in, 872 symptoms of, 873 taxis in, 876. See Taxis. treatment of, 875 et seq. structure of, 862 symptoms of, 864 trusses for, 865 Herniae (special), 884 abdominal, 860 of bladder, 865, 1006 calculus in, 1000 caecal, 865 cerebri, 336, 705 of cornea, 726 cruro-properitoneal, 898 diaphragmatic, 398, 885 epigastric, 885 femoral or crural, 898 humoralis. See Epididymitis. INDEX. 1117 Herniae— inguinal, 887 anomalous forms of, 892 into canal of Nuck, 891 congenital, 888 diagnosis of, 892 direct, 891 encysted, 890 into funicular portion of vaginal process, 889 herniotomy for, 897 infantile, 889, 890 intermuscular and interparietal, 889 oblique, 888 in female, 891 radical cure of, 893 taxis for, 897 trusses for, 893 into vaginal process of perito- neum, 888 inguino-crural, 889 inguino-labial, 891 inguino-properitoneal, 889 inguino-scrotal, 889 isehiatic or sciatic, 903 labial, 902 lumbar, 887 of lungs, 390, 392, 393 obturator, 901 of ovary, 865 perineal, 902 pudendal, 902 scrotal, 864, 888, 889 of stomach, 865 testis, 1069, 1070 trachea, 846 umbilical, 886 vaginal, 903 ventral, 399, 403, 885 Hernia-knife, 881 Hernies en bissac, 889 Herniotomy, 880 for femoral hernia, 900 hemorrhage in, 883 for incarcerated hernia, 870 inguinal hernia, 897 isehiatic hernia, 903 obturator hernia, 902 opening the sac, 881 peritonitis after, 883 puncture of distended bowel in, 883 for pudendal hernia, 903 sloughing of sac after, 883 treatment of adhesions in, 883 intestines in, 882 omentum in, 882 for umbilical hernia, 887 without opening sac, 883 Herpes corneae, 724 Herpetic ulceration of penis, 1064 Hewson, torsion forceps, 192, 193 Hey, amputation of metatarsus, 125 126 infantile hernia, 890 Hey's saw, 338 High operation for stone. See Lithotomy, snpra-pubio. Hip, amputation at, 133, 676, 678, 679 anchylosis of, 656 arthritis of. See Hip-disease. rheumatoid, 651 contraction of, 694 diseases and injuries of. See under Joints. dislocations of, 304 excision of, 176, 225, 674 Hip-disease, 644 amputation for, 676, 678, 679 diagnosis of, 647 excision for, 674 prognosis of, 648 symptoms of, 645 tenotomy in, 649 terminations of, 647 treatment of, 649 Hoang-nan in hydrophobia, 164 Holt, splitting strictures, 1041, 1042 Hopkins, compressor for aneurism, 598 trephining forceps, 341 Hordeolum, 769 Horns of face, 512, 513, 548 Horseshoe tourniquet, 98 Hospital gangrene. See Gangrene. Hot-air baths in hydrophobia, 165 Hot water in affections of eyes, 716 hemorrhage, 71, 190 Hour-glass hernia, 872, 888 Housemaid's knee, 559 Howard, direct method of artificial respi- ration, 375 poisoning by chloroform, 76 Humerus, dislocations of, 295 excision of, 176, 179, 670, 671 fractures of, 264. See Fracture. Hyaline degeneration of conjunctiva, 721 Hyalitis, 750 Hydatid mole, 517 cysts of, 511 testis, 1079, 1080 Hydatids in bone, 634 liver, mode of opening, 959 Hydrarthrosis, 639 Hydrencephalocele. See Meningocele. Hydrocele, 1070 acute, 471, 1069 of breast, 854 canal of Nuck, 903, 1088 congenital, 1070 encysted, 1074 of hernial sac, 864 inguinal, 1070 of neck, 815 position of testis in, 1072, 1074 of seminal vesicle, 1075 spermatic cord, 1074 treatment of, 1072,1073 of tunica vaginalis. See Hydrocele. I Hydrocephalus, paracentesis for, 706 i Hydromyelocele, 707 [ Hydronephrosis, 949 1118 INDEX. Hydrophobia, 163 amputation for, 96 Pasteur's method in, 165 Hydrophthalmia, 729 Hydrops autri, 824 articuli, 639 Hydro-rachitis. >V»e Spina bifida. Hydro-sarcocele, 1078 Hydrothorax, 390, 394 Hygienic condition, influence of, on result of operations, 64 Hygromata, 509, 560 congenital cystic, 509 of hyoid bursa, 816 Hymen, imperforate, 1085 Hyoid bone, dislocation of, 294 fracture of, 254 bursa, hygromata of, 816 Hyperaemia, 34 of conjunctiva, 71 (5 Hyperaesthesia after ligature of arteries, 593 retinal, 753 in spinal injuries, 347 Hypermetropia or hyperopia, 759 Hyperphoria, 760 Hypertrophy, continuous and discontin- uous, 513 of corpora cavernosa, 1065 labia, 1087 temporary, in inflammation, 36 Hypodermic injection, 88 use of atropia, 67 ergot, 88 ether, 67, 88, 142 mercury in syphilis, 88, 503 Hypopyon, 725 Hypospadia, 1031 Hysterical joints, 662 Hysterorraphy, 1094 TCE. See Cold. 1 in intestinal obstruction, 907 rectum, for chloroform poisoning, 76 Ice-bags, 55 Ice-blindness, 758 Ichorous pus, 39 Ichorrhaemia. See Pyaemia. Ichthyosis of tongue, 816, 818 Idiosyncrasy, influence of, on result of operations, 64 Ignipuncture for enlarged tonsils, 837 Ileo-colostomy, 955 Iliac abscess, 712 aneurism, 616 artery. See Artery, iliac. Ilio-pelvic abscess, 959 Ilio-sciatic dislocation, 305 Ilium, trephining, for psoas abscess, 715 Illaqueatio, 769 Illumination, oblique, 361, 739 Immediate union of wounds, 148 Immovable bandages, 84, 246 Impacted calculus, 963, 977, 998 feces, 910, 939 fracture, 229 Impacted— gall-stones, 909 Imperforate anus, 914 hymen, 1085 nostril, 792 rectum, 914 vagina, 10*6 vulva, 1085 Impermeable stricture, 1036, 1044 Impotence, 1082 after lithotomy, 989 Impulse on coughing, in hernia, 865 Incarcerated hernia, 870 Incised wounds. See Wounds. Incision of abscesses, 423 artificial pupil by, 737 of chest, 396 for hydrocele, 1074 ovarian cyst, 942 of pericardium, 397 in peritonitis, 402 for phimosis, 1062 Incisions in carbuncle, 438 erysipelas, 446 indolent ulcers, 429 inflammation, 59 Operations, 71 removal of tumors, 546 Incontinence of feces in injuries of spine, 347 after operation for fistula, 926 Incontinence of urine, 1014. See Urine. Incrustation, healing by, 149 Incurvation of penis, 1060 India-rubber collar for caries of cervical spine, 714 rings for suture of bowels, 913 suture, 151, 152 Indian method of rhinoplasty, 801 puzzle for dislocations of fingers, 304 Indican in urine, in fractures, 234 Indicator for detection of calculous frag- ments, 977 Indigo in renal calculus, 963 Indolent ulcer. See Ulcer. Induration, 45 of chancre, 485 congenital, of sterno mastoid, 816 of lymphatics and lymphatic glands in syphilis, 487, 490 Infantile hernia, 889, 890 Infarctus, 184, 450 Infiltration of urine after lithotomy, 990 Inflamed hernia, 869 Inflammation, 33 acute, subacute, and chronic, 45 bacilli of, 42 blood in, 35 bloodvessels in, 35 causes of, 41 clinical view of, 41 coagulation of blood in, 36 course of, 45 destructive changes in, 40 diffuse, of areolar tissue, 442 after lithotomy, 990 INDEX. 1119 Inflammation, diffuse— of penis and scrotum, 1064 in stumps, 111 diseases resulting from, 420 extension of, 51 exudation in, 37 fever in, 49 formative changes in, 36 functional changes in, 34, 45 gangrene in, 48 induration from, 45 lymph in, 36 nerve-changes in, 36 neuro-paralytical, 42 nutritive changes in, 34, 35 pain in, 44 parenchymatous tissue in, 36 pathology of, 34 phlegmonous, 45 pus in, 38 redness in, 42 resolution in, 52 scrofulous, 460 softening from, 45 of special tissue or organs. See the parts themselves. stages of, 46 suppuration in, 46 swelling in, 43 symptoms of, 42 temperature in, 43 temporary hypertrophy in, 36 terminations of, 52 treatment of, 52 et seq. alteratives in, 58, 61 anodynes in, 58, 61 antiseptics in, 58 astringents in, 58 bleeding, general, in, 59 local, in, 59 cauterization in, 59 cold in, 55 compression in, 59 counter-irritants in, 58 diaphoretics and diureties in, 61 diet in, 53 friction in, 59 heat in, 56 incisions in, 59 ligation of arteries in, 59 moisture in, 56 position in, 53 purgatives in, 61 rest in, 53 sedatives in, 60 stimulants in, 54, 58 tonics in, 62 ulceration in, 46 Inflammatory fever, 49 Inflation of abscesses, 425 lungs in apnoea, 375 bowel in intestinal obstruction, 907 strangulated hernia, 878 tympanum, 785 et seq. urethra, 1028 Inguinal aneurism, 613 Inguinal— hernia, 887. See Hernia. Inguino-crural hernia, 889 Inguino-labial hernia, 891 Inguino-properitoneal hernia, 889 Inguino-scrotal hernia, 889 Inhalation of blood, 92 Inhalers for anaesthetics, 78, 79 Inheritance, influence of, on occurrence of hernia, 861 Injections of blood, intra-peritoneal, 92 coagulating, in aneurism, 602, 605 hemorrhoids, 934 vascular tumors, 577, 578 disinfectant, after ovariotomy, 946 in gonorrhoea, 467 et seq. hydrocele, 1073 hypodermic, 88 of iodine. See Iodine. Injury, amputation for, 114 effects of, constitutional, 138, 144 local, 144 of special tissues or organs. See the parts themselves. Innocent tumors. See Tumors. Innominate artery. See Artery, innomi- nate. Inoculation in diagnosis of syphilis, 499 treatment of granular lids, 720 Insanity after operations, 72 Insects, stings of, 162 Insomnia in spinal injuries, 349 Instruments. See the various operations. Intercostal artery. See Artery, intercos- tal. Intermaxillary bone, in harelip, 809 et seq. Intermediate amputations, 114 Intermittent hemorrhage, 2(14 ligature, 163 Intermuscular hernia, 889 Internal organs, state of, influencing re- sult of operations, 64 cesophagotomy, 841, 842 piles, 929, 932 strangulation of bowel, 880, 904 et seq urethrotomy, 1042 Interosseous artery. See Artery. Interparietal hernia, 889 Interrupted suture, 151 Interstitial absorption, 45, 46, 626 keratitis, 724 Intervertebral joints, arthritis of, 715 Intestinal canal, diseases of, 903 fistula. See Fistula. hernia, 865 obstruction, 903 acute, 903 chronic, 905 colotomy for, 910 from contusion of abdomen, 399 diagnosis of, 905 enterotomy for, 909 gastrotomy for, 907. See Lapa- rotomy. 11'20 INDEX. Intestinal obstruction— inflation of bowel in, 907 laparotomy for, 907 locality of lesion in, 905 puncture of intestine for, 910 secretion of urine in, 906 >tatisiics of, 905 stercoraceous vomiting in, 905 symptoms of, 904, 905 symptoms due to, in strangu- lated hernia, 873 treatment of, 906 washing out stomach for, 907 Intestine, abscesses connected with, 958 changes in, in strangulated hernia, 872 diseases of, 903 foreign bodies in, 413 impacted feces in, 910, 939 internal strangulation of, S80, 904 et seq. intussusception or invagination of, 904 et seq. knotting of, 906 management of, after herniotomy, 882 paralysis of, in strangulated hernia, 879 protrusion of, 405 puncture of, 401 after herniotomy, 883 for intestinal obstruction, 910 in pvaemia, 453 resection of, 4o4, 413, 913, 919, 920 rupture of, 399 in taxis, 880 spasm of, 904 stricture of, 906 suture of, 401, 406, 413 syphilitic affections of, 494 tumors of, 906 twisting or volvulus of, 904 et seq. wounds of, 403, 406 in herniotomy, 882 Intra-articular effusion in fracture, 233 rupture of muscle, 220 irrigation, 639 Intra-bursal bands, 560 Intra-cranial aneurism, 608 hemorrhage, 326, 329, 337 suppuration, 331, 339 Intra-cystic growths, 511 Intra-orbital aneurism, 608 ecchymosis, 334 Intra-periosteal fracture, 229 Intra-peritoneal injection of blood, 92 saline solutions, 92 Intra-pyretic amputation, 114 Intubation of larynx and trachea, 376 et seq. Intussusception, 904 diagnosis of, 905 recovery from, by sloughing, 908 retrograde, 904 statistics of, 905, 908, 909 Intussusception— of trachea, 370 treatment of, 907, 908 Inunction, mercurial, in syphilis, 503 Invagination of bowel. Sic Intussuscep- tion. sequestra, 628 Inversion in chloroform poisoning, 76 of testis, 1068 ureter, 1006 Involncrum in necrosis, 628 Iodide of potassium in aneurism, 591 inflammation, 61 syphilis, 504, 505 Iodine, counter-iritation by, 86 injections in cold abscesses, 425 hydrocele, 1073 hydrocephalus, 707 ovarian cysts, 942 for radical cure of hernia, 867 in spina bifida, 708 Iodoform in carbuncle, 438 cold abscess, 425 hydrocele, 1073 noma pudendi, 433 tuberculous ulcer of rectum, 927 venereal diseases, 471 et seq. Iridectomy, 735 for artificial pupil, 737 glaucoma, 761 Iridectomy knife, 736 Irideremia, 735 Irido-choroiditis, 732 Irido-cyclitis, 732 Iri.lodesis, 737 Iridodialysis, 738 Iridoplegia, 768 Iridotomy, 737 Iris, diseases of, 732 operations on, 735 staphyloma of, 729 Iris-forceps, 736 Iris-hook, 737 Iritis, 732 gonorrhoeal, 475, 734 spongy or fibrinous, 734 syphilitic, 491, 494, 498, 504 Iron in calculus, 963 I Irrigation, 56, 57 for foreign bodies in ear, 365 intra-articular, 224, 639, 640 of kidney, 950 mediate, 55 Irritable stricture, 1037 et seq. tumor of breast, 524, 855 ulcer. See Ulcer. Irritation, sympathetic, of eye, 762 Isehiatic hernia, 903 notch, dislocation into, 305 Ischio-rectal abscess, 923, 924 Isinglass plaster, 153 Issues, *(j Itching of anus, 937 Ivory pegs for ununited fracture, 250 Ivory-like exostoses, 521, 522 INDEX. 1121 JACOB'S ulcer, 551 fJ Jarvis's adjuster, 289 Jaundice in spinal injuries, 347 Jaw, lower, dislocation of, 292 excision of, 830, 832 for gunshot fracture, 254 fracture of, 253 necrosis of, 823, 824 subluxation of, 294 tumors of, 830 upper, cysts of, 824 excision of, 826 fracture of, 252 necrosis of, 823, 824 osteo-plastic resection of, 798 tumors of, 824, 825 Jaws, anchylosis of, 831 from burns, 320 diseases of, 822 Jequirity in eye-diseases, 720 Joints, abscess of, 639. See Pyarthrosis. amputation at. See Amputation, and special joints. anchylosis of, 653. See Anchylosis, and special joints. contusions of, 222 diseases of, 637 syphilitic, 492 dropsy of, 639. See Hydrarthrosis. erasionof, 644 excision of, 663. See Excision, and special joints. false. See Fractures, ununited. fractures through, 242 et seq. gunshot injuries of, 175 et seq. hysterical, 662 inflammation of. See Synovitis and Arthritis. injuries of, 222 irrigation of, 224, 639, 640 loose cartilages in, 660 neuralgia of, 662 rheumatoid arthritis of. See Arthri- tis, rheumatoid. scrofula in, 461 sprains of, 222 state of, in pyaemia, 453 stiff. See Anchylosis. suppurating, incisions in, 224 wounds of, 223 et seq. amputation and excision in, 225 ligation of arteries for, 226 Jordan, amputation at hip, 136 Jorg, apparatus for wry neck, 688 Jugular vein, internal, wounds of, 181 Junks for fractured thigh, 276 Jury-mast for disease of cervical verte- brae, 714 KANGAROO, ligature from tendon of, 194, 617 Kava-Kava, 81 Keloid, 551 in cicatrices of burns, 320 Kelotomy. See Herniotomy. Keratectomy, 727, 762 71 Keratitis, 723 et seq. syphilitic, 491, 498 Keratocele, 726 Kerato-globus, 729 Kerato-malacia, 728 Keratome, 736 Kid, grafting bone from, 631 Kidney, abscess in, 949, 958 calculus in. See Calculus, renal. diseases of, complicating lithotomy and lithotrity, 980 influencing results of operations, 64, 68 from stricture of urethra, 1037 vesical calculus, 970 disseminated suppuration of, 1037 extirpation of, 950 floating, operation for, 951 granular, in gangrene, 431 hemorrhage from, 1012 lesions of, in pyaemia, 453 spinal injuries, 347 rupture of, 400 Kneading abdomen in hemorrhage, 190 Knee, amputation at, 132 anchylosis of, 655, 658 deformities of, 694 et seq. diseases and injuries of. See under Joints. dislocations of, 312 excision of, 177, 225, 679 fractures involving, 241, 278, 283 gunshot wounds of, 177 internal derangement of, 313 pain in, in hip-disease, 645 subluxation of, 313 wounds of, 225 Knife-bladed forceps, 666 Knife-needle for cataract, 745 Knives, amputating, 99 cataract, 740, 741, 743 hernia, 869, 881, 882 iridectomy, 736 lithotomy, 983 Knock-knee, 694 Knot, clove-hitch, 289 reef, 101 surgeon's, 101 Kolpoperineoplasty, 1093 Kolpo-uretero-cystotomy, 950 LABIA, affections of, 1087, 1088 Labial hernia, 902 Lace suture, 1052 Lacerated wounds. See Wounds. Laceration of cervix uteri, 1094 Lachrymal apparatus, syphilis of, 492 bone, fracture of, 252 gland, diseases of, 774 sac, diseases of, 775 Lachrymation, excessive. See Epiphora. in spinal injuries, 348 Lacs, extending. See Bands. Lacteal calculus, 850 Lagophthalmos, 772 Lamellar cataract, 738 et seq. 1122 INDEX. Lancing the gums, 822 Laparotomy, 907 statistics of, 909 for extra-uterine pregnancy, 948 rupture of bladder, 415 uterus, 948 suppurative peritonitis, 959 Laparo-elytrotomy, 948 Lardaceous scirrhus of breast, 856 Larrey, amputation at hip, 136 shoulder, 121 Laryngeal instruments, 846 sac, prolapsus of, 846 stertor, 76 Laryngectomy, 847, 848 Laryngitis, 845 erysipelatous. See Erysipelas. Laryngoscope, mode of using, 373 in treating laryngeal growths, 847 Laryngo-fissure, 847 Laryngotomy, 378 compared with tracheotomy, 382 in erysipelas of air-passages, 445 pharynx, 838 for foreign bodies in air-passages, 373 oedema of glottis, 383 restricted thyroideal, 847 for spasm of glottis, 368 sub-hyoidean. See Pharyngotomy. true, 847 Laryngo-tracheotomy, 380 Larynx, catheterization of. See Intuba- tion. diseases of, 845 syphilitic, 494, 497 erysipelas of. See Erysipelas. excision of 847 foreign bodies in, 371 et seq. injuries of, 368 Lateral anastomosis of bowels, 913 curvature of the spine, 689 ligature. See Ligature. lithotomy, 982. See Lithotomy. Lateritious deposits, 961 Laughing gas. See Nitrous oxide. Lead ribbon, 154 Leeching, 89 Leg, amputation of, 129 Barbadoes, 516, 554, 555 deformities of, 694 et seq. fractures of, 280 Legouest's periosteotome, 100 Leiter's coil, 56 Lembert's suture, 406 Lengthening in arthritis, 642 in fractures, 276 after joint excisions, 665 Lens, crystalline, dislocation of, 362, 363 opacity of. See Cataract. ossification of, 738 Lenticular cataract, 738 Leucocythaemic retinitis, 754 Leucocytosis in pyaemia, 450, 453 Leucoma, 727 Lids, granular, 719 Liebreich, bandage for eye,,737 ophthalmoscope, 747 Ligament, Y, 305 Ligaments, laceration of. See Sprains. of jaw, relaxation of, 294 knee, relaxation of, 694, 696 round, operation for shortening, 1094 tarsal, section of, 700 et seq. Ligation of arteries for aneurism, 592. See Aneurism and Arteries. by anastomosis, 577 bronchocele, 813 hemorrhage, 193. See Arteries, wounds of, and Ligatures. inflammation, 59 lines of incision for, 209 et seq for malignant tumor of tongue, 821 osteoid aneurism, 636 special. See the particular ar- teries. for wounds of joints, 226 epithelioma, 546 fistula in ano, 924, 926 fecal, 412 hernial sac, 867 naevus, 579 piles, 932 polypi, nasal, 797 rectal, 921 uterine, 1092 vaginal, 1089 prolapsus of rectum, 936 simultaneous, of artery and vein, 181 of tumors of tongue, 819, 820 urethra, 1050, 1051 veins, 181 for pyaemia, 457 Ligature, 101 animal, 194 antiseptic, 101, 194 application of, in continuity of arte- ries, 193, 197 in stumps, 101 compared with acupressure and tor- sion, 202 elastic, for rectal fistula, 924, 926 salivary fistula, 365 intermittent, 163 lateral, 181 mechanism of, in controlling hemor- rhage, 193, 194 metallic, 195 quadruple, 579 rules for applying, in wound of ar- teries, 195 et seq. short-cut, 101, 108 subcutaneous, for naevus, 579 in wounds of scalp, 323 Lightning, injuries of eye from, 363 Limbs, artificial adaptation of, 110 Linear extraction of cataract, 743, 745 rectotomy, 416, 919, 92(1 stricture of urethra, 1036 INDEX. 1123 Lingual artery. See Artery. tonsil, 820 Lion-jawed forceps, 665 Lipoma. See Tumor, fatty. of nose, 792, 793 Lippitudo, 768 Lips, aneurism by anastomosis of, 577 chancre of, 500 •* congenital fissures of, 812. See also Harelip. diseases of, 804 epithelioma of, 805 eversion of, 319 hypertrophy of, 804 injuries of, 365 malformations of, 804, 808 et seg. restoration of. See Cheiloplasty. tumors of, 805 wounds of, 365 Liquid glass, 85 Liquor puris, 39 Lister, treatment of wounds, 157 Litheetasy, 999 Lithic acid. See Uric acid. Lithoclast, 972 Lithoclysmy, 971 Litholapaxy, 975 Litholysis, 971 Lithotome cache, double, 992 single, 986, 987 Lithotomy, 981 choice of operation in, 995 compared with lithotrity, 979 preparation of patient for, 981 proportion of cases requiring, 981 recurrent of calculus after, 997 in women, 999 Lithotomy, bilateral, 992 lateral, 982 accidents after, 988. 989 after-treatment in, 986 complications of, 988, 990 crushing the stone in, 988 dangers of, 988 difficulties in, 987, 988 diffuse inflammation after, 990 division of prostate in, 985, 987 right side of prostate in, 988 extraction of stone in, 986 hemorrhage after, 989 instruments required for, 982 introduction of forceps in, 9S5, 986 lateralization of knife in, 985 opening urethra in, 985 position of patient in, 984 surgeon in, 982 results of, 991 spasm of bladder in, 988 staff, how held in, 984 use of scoop in, 986 variations in mode of perform- ing, 986 in women, 1000 wounds of rectum in, 990 Marian. See Lithotomy, median. Lithotomy— median, 993 medio-bilateral, 993 medio-lateral, 994 pre-rectal, 993 recto-vesical, 995 supra-pubic, 996 in women, 1000 urethral, 999 vaginal, 1000 Lithotrite, construction of, 972 introduction of, 973 position of, in crushing stone, 974, 975 Lithotrity, 971 accidents and complications of, 977 after-treatment in, 976 anaesthetics in, 973 in children, 979 compared with lithotomy, 979 contra-indications to, 979 et seq. crushing the stone in, 974 finding and seizing stone in, 974 history of, 971 impaction of fragments in, 977 injection of bladder in, 973 introduction of lithotrite in, 973 perineal, 978, 994 position of patient in, 973 surgeon in, 973 preparation of patient for, 972 rapid, with evacuation, 975 recurrence of calculus after, 997 retention of urine after, 978 results of, 978 test for success of, 976 washing out bladder after, 977 in women, 999 Littre's hernia, 863 Liver, abscess in, 957 cysts in, 959, 960 disease of, influencing results of ope- rations, 68 embolism by fragments of, 144, 399 excision of, 404. See Hepatectomy. hydatids in, 959. lesions of, in pyaemia, 453 operations on, 955 rupture of, 399 wound of, in lithotomy, 989 Lobster-tailed tracheal trocar, 381 Local anaesthesia, 80 asphyxia, 440 Localization, cerebral, 339 Lock-jaw. See Trismus. Long-sight. See Presbyopia. Longitudinal fracture, 230 piles, 928, 929 Loose bodies in bursae, 560 in ganglia, 558 sac of hernia, 864 hydrocele, 1074 cartilages in joints, 519, 660 Lordosis, 689 in rickets, 463 Loring, ophthalmoscope, 747 Lower jaw. See Jaw. 1124 IND EX. Lumbar colotomy, 910. See Colotomy. hernia, 887. See Hernia. Lung, abscess of. 396 collapse of, 390 concussion of, 388 excision of, 394, 396 hernia of, 390, 394 lesions of, in pyaemia, 452 rupture of, 387 wounds of, 389 complications of, 392 et seq. Lupous ulcer, 553 Lupus, 553, 721 Luxatio humeri erecta, 297 Luxation. See Dislocation. Lymph, 36 absorption of, 38 corpuscles in, 36 degeneration and development of, 38 varieties of, 37 Lymphadenoma of testis, 1080* Lymphangeiomata, 556 Lymphangeitis. See Angeioleucitis. Lymphatic cancer, 532 glands, axillary, in excision of breast, 858, 859 cervical, enlargement of, 816 diseases of, 555, 556 syphilitic, 4S7, 490 scrofula in, 461 vascular tumors, 524 Lymphatics, absorption of pus by, 450 diseases of, 555 spread of inflammation by, 52 state of, in pyaemia, 453 varicose, 556 wounds of, 221 Lymphocele, 1074 Lymphoid tumor, 523 Lymphoma, 523 Lymphorrhoea, 221, 556 McBURNEY, radical cure of hernia, 867, 896 Macewen, radical cure of hernia, 867, 897 Macrostoma, 811, 812 Macula lutea as seen with ophthalmo- scope, 749 Madelung, modified colotomy, 911 Magnetic probe, 174 Malar bone, fracture of, 252 tumors of, 826 Malformations of anus and rectum, 913 el seq. auricle, 777 bladder, 1001 ear, 777 female genitals, 1085 head, 705 lips, 804, 808 et seq. male genitals, 1060, 1068 palate, 832 spine, 707 tongue, 817 et seq. Malformations of— urethra, 1030 See also Congenital affections, and Orthopaedic surgery. Malignant epulis, 823 oedema, 155 onychia, 549 pustule, 439 sarcocele, 1080 stricture of oesophagus, 840, 842 rectum, 919 tumors, 530. See Cancer, Encepha- loid, Epithelioma, and Scirrhus. Malleus, excision of, 784 Mammae, supernumerary, 849 Mammary abscess, 851, 853 calculus, 850 gland. See Breast. tumors, 854 Mammitis, 851 Manipulation in aneurism, 601 in dislocations, 288, 299, 307 et seq. intestinal obstruction, 907 Marrow, agency of, in repair of fractures, 235, 236 inflammatory conditions of, 621 Massage, 59, 145, 234 Mastoid cells, inflammation of, 787 process, perforation of, 788 Maxilla. See Jaw. Mayor, handkerchief bandages, 84 Meatus, auditory, diseases of, 778 foreign bodies in, 365 furuncles of, 780 malformations of, 777 polypi of, 781 tumors of, 782 vegetable parasites in, 780 Median lithotomy, 993 Mediastinum, abscess of, 257, 389 wounds of, 397 Mediate irrigation, 55 Medio-bilateral lithotomy, 993 Medio-lateral lithotomy, 994 Medulla. See Marrow. Medullary cancer. See Encephaloid. MeduUization of bone, 620 Meerschaum probe, 174 Megalopsia, 758 Melanoid or melanotic cancer, 537, 856 Melanotic epithelioma, 545 sarcoma, 528 Melon-seed-like bodies in bursae, 560 in ganglia, 558 Membrana tympani, artificial, 786 diseases of, 782 excision and incision of, 784 inflammation of, 782, 783 syphilitic, 492 perforation of, 784 rupture of, 783 Membrane, Schneiderian, thickening of, 794 Membranous bands in tympanum, 790 ophthalmia, 719 Meniere's disease, 791 INDEX. 1125 Meninges, suppuration of, 331 wounds of, 336 Meningitis, 331 in spinal injuries, 350 spinal, 345 Meningocele, 705 spinal, 707 Meningomyelocele, 707 Menstrual discharge, syphilis conveyed by, 483 J Mephitic gangrene of bone, 627, 628 Mercury, bichloride of, in dressing wounds, 158, 159 et seq. in inflammation, 61 scalds of glottis, 370 syphilis, 501 et seq. Merocele. See Hernia, femoral. Mesentery, elongation of, in hernia, 861 rupture of, 399 Meso-phlebitis, 450 Metacarpus, amputation through, 119 dislocations of, 303 excisions of, 674 fractures of, 271 Metapyretic amputations, 114 Metastasis, 52 Metastatic abscess. See Pyaemia. Metatarso-phalangeal joint, excision of, for bunion, 562 Metatarsus, amputation through, 125 dislocations of, 315 fractures of, 284 Microbes in pyaemia, 449 et seq. of gonorrhoea, 465 Microphone, detection of calculi by, 969 Micropsia, 758 Migratory ophthalmitis, 763 Mikulicz, amputation of foot, 129, 686 resection of prolapsed rectum, 908,936 Miliary aneurisms, 586 extravasation, 326 Milk-tumor, 849 Miner's elbow, 560 Minor surgery, 81 Mirror, laryngoscopic, 374 Mixed calculus. 962 hernia, 865 tumors, 519 Mobility in fractures, 232 Modified circular amputation, 104 Moist gangrene, 49. See Gangrene. Moisture in inflammation, 56 Molecular death, 40 Moles, 548, 580 hydatid, 511, 517 Mollifies ossium. See Osteomalacia. Molluscum fibrosum, 555 Momentum of projectiles, 168 Monocular strabismus, 765 Monorchids, 1068 Monsel's salt, 191 Morbus coxae or m. coxarius. See Hip disease. senilis. See Arthritis, rheuma- toid. Morel's tourniquet, 93 Morphaea. See Keloid of Addison. Mortification. See Gangrene. Motor paralysis in spinal injuries, 345 Mouth, burns and scalds of, 370 contraction and closure of, 804 diseases of. 816 fissure at angle of, 811, 812 gonorrhoea of, 475 injuries of, 365 noma of. See Stomatitis, gangrenous. syphilitic lesions of, 487 et seq. Mouth to mouth inflation of chest. 375 Moxa, 86 Mucocele, 775 Muco-pus, 39 Mucous cysts, 510 membranes, erysipelas of, 443 scrofula in, 461 syphilitic affections of, 490, 493, 497 patches. See Syphilis. polypf, 796 tumors. See Myxoma. Mulberry calculus, .961 Multilocular cysts, 511 Multiple abscesses. See Pyaemia. wedge for stricture, 1040 Mummification, 431 Mumps, 814 Muscae volitantes, 750 Muscles, contraction of, 556. See also Orthopaedic surgery. diseases of, 556 syphilitic, 496 injuries of, 220 lesions of, in pyaemia, 453 retraction of, after amputation, 110 spasm of, in dislocations, 288 fractures, 233, 239 transplantation of, 557 tumors of, 557 Muscular action in fractures, 227, 231 tumor, 518 Mycetoma, 552 Mydriasis, 735 paralytic, 768 Myelitis, 345 Myeloid tumor, 526 Myoma, 518 of uterus, 1090 Myopia, 758 Myosis, 735 paralytic, 768 spinal, 348, 757 Myositis, 556 Myotomy. See Tenotomy. Myringitis. See Membrana tympani, in- flammation of. Myxoma, 517 NiEVUS, 577 Nails, growth of, in fractures, 249 hypertrophy of, 550 ingrowing, 550 ulceration of matrix of, 549 syphilitic, 493 1126 INDEX. Narcotics in inflammation, 58 Nares. See Nostrils. Narrowing rectum for prolapsus, 936 Nasal bones, fractures of, 252 necrosis of, 794 calculi, 799 duct, obstructions of, 775 polypus, 796 septum, diseases of, 799 displacements of, 252 Naso-pharyngeal polypi, 797, 798, 826 vegetations, 796 Navel, ruptured. See Hernia, umbilical. Nebula, 723, 727 Neck, diseases of, 812 hydrocele of, 815 injuries of, 366 tumors of, 815 Necrosis, 627 acute. 631 amputation for, 631 causes of, 627 central, 623, 628 cloacae in, 628 dry, 628 excision for, 631 exfoliation in, 628, 630 instruments used for, 630 involucrum in, 628 of jaws, 823 moist, 627, 628 of orbit, 776 peripheral, 623, 628 prognosis of, 629 repair of, 628 after scalp wounds, 324 secondary risks in, 629 sequestra in, 628 in stumps, 112 symptoms of, 629 syphilitic, 496 total, 623, 628 treatment of, 629 of vertebrae, 715 without suppuration, 629 Needle, aneurismal, 193,194 cataract, 745 in flesh, 160 mounted, 150 naevus, 579 surgeon's, 101 tubular, 834 Needle-carrier for piles, 933 Needle-guard, 151 Needle-operation for cataract, 745 Nelaton's line, 273 Nephrectomy, 950, 951 Nephritic colic, 963 Nephro-lithotomy, 948, 949 Nephrorraphy, 951 Nephrotomy, 948, 949 Nerves, anaesthesia by compressing, 74 auditory, lesions of, 790 division or excision of, 111, 218 for elephantiasis, 516 irritable ulcer, 428 Nerves, division or excision of, for— malignant tumor of tongue, 821 neuralgia, 565 tetanus, 572 wry-neck, 689 inflammation of. See Neuritis. inflammation from lesions of, 41 injuries of, 217 in dislocations, 290 fractures, 242 optic, atrophy of, 444, 756 ophthalmoscopic appearance of, 749 stretching of, 757 tumors of, 756 repair of, after division, 218 sciatic, resection of, .in elephantiasis, 516 wounds of, 217 Nerve-grafting, 219 Nerve-stretching, 219, 566, 571, 689, 757, 762, 818 subcutaneous, 220 Nervous blindness, 747 deafness, 790 system, diseases of, 562 bone changes due to, 634 syphilitic, 492, 495 tissues in inflammation, 36 Neuralgia, 144, 563 alveolar, 566 of anus, 937 articular, 662 of bladder, 1015 breast, 853 ear, 792 excision of nerves for, 565 of testis, 1070 tongue, 818 Neuralgic tumors, 524 ulcer. See Ulcer. Neurasthenic asthenopia, 753 Neuritis, 562 optic, 755 syphilitic, 494 retro-ocular, 756 Neuroma, 519, 562 in stumps, 111 Neuromimesis, 662 Neuroparalytic keratitis, 728 I Neuropathic eschars, 349 [ Neuro-retinitis, 755 | Neurosis, sympathetic, 763 Neurotomy, optico-ciliary, 764 of roots of spinal nerves, 565 Night-blindness. See Heuieralopia. Nipple, fissures and excoriations of, 850 j retraction of, in cancer, 531, 857 supernumerary, 849 Nitrate of lead in onychia, 550 Nitric acid in hospital gangrene, 436 Nitrite of amyl, 76, 571 Nitrous oxide, 74, 80 j Nodes, 496 I Noli-me-tangere. See Lupous ulcer. INDEX. 1127 Noma. See Stomatitis, gangrenous. pudendi, 433, 1088 Non-deforming club-foot, 699 Normal ovariotomy, 946 Nose, calculi in, 799 depressed, 803 diseases of, 792. See also Nostrils. fractures of, 252 fistulous openings into, 800 foreign bodies in, 364 gonorrhoea of, 475 hemorrhage from, 792 in fractured skull, 334 hypertrophy of, 792 muco-purulent discharge from, 794 operation for lengthening, 800 restoration of, 800. See Rhinoplasty. turned up, operation for, 803 wounds of, 359 Nostrils, imperforate, 792 malignant tumors of, 799 plugging the, 793, 794 polypi of, 796 sarcoma of, 799 Nuclear paralysis, 768 Nucleus of calculus, 964 Nunneley, clips for hemorrhage, 547 Nutritive changes in inflammation, 34, 45 from nerve wounds, 218 spinal injuries, 349 Nyctalopia, 757 Nystagmus, 739 OAKUM in dressing wounds, 154 seton, 425, 627, 1052 Oblique illumination, 361, 739 Obliteration of urethra, 1036, 1047 vagina, non-congenital, 1087 transverse, 1059 Obstructed hernia, 870 Obstruction of canaliculi, 774 Eustachian tube, 785 et seq. intestinal, 903. See Intestinal ob- struction. of nasal duct, 775 Obturator artery. See Artery. for cleft palate, 835 foramen, dislocation into, 308 hernia, 901 Occipital artery. See Artery. Occipito-atloid joint, arthritis of, 715. Occlusion of anus, 913, 914 of arteries. See Artery. ear, 777, 779 mouth, 804 nostrils, 792 pneumatic, 108 of vulva, 1085 See also Imperforate, and Obstruction. (Edema, inflammatory, of scrotum, 1064 malignant, 155 (Edematous erysipelas. See Erysipelas. ulcer. See Ulcer. (Esophageal bougies, 841 dilator, 841 forceps, 384 GEsophagismus, 839 ffisophagostomy, 842, 843 CEsophagotomy, 385, 386 combined, 841 internal, 841, 842 for stricture of oesophagus, 842, 843 (Esophagus, auscultation of, 839 dilatation of, 841 retrograde, 844 dilated, 840 diseases of, 838 syphilitic, 494 excision of, 842 foreign bodies in, 383 rupture of, 383 stricture of, 840 et seq. wounds of, 383 Oily cysts, 510, 854 Old operation for aneurism, 592 Olecranon, fracture of, 268 osteoplastic resection of, 302, 671 Omentum, cysts of, 960 in hernia, 863, 865 strangulated, 872 management of, after herniotomy, 882 protrusion of, in wounds of abdomen, 405 rupture of, 399 Omphalocele. See Hernia, umbilical. Onanism, 1083 operations for, 1084 Onychia, 549 syphilitic, 493, 550 Onyx, 725 Oophorectomy, 946, 1092 Oophorraphy, 947 Opacities of cornea, 727 crystalline lens. See Cataract. vitreous humor, 749 Opaline patch, 490 Open method of dressing stumps, 108 Opening an abscess, 423 Operations, 62 age influencing results of, 63 anaesthetics in, 72 et seq. assistants' duties in, 71 chilling in, 67 death, causes of, after, 66 et seq. diet after, 65 dressing wounds after, 72 of election, complaisance, or expedi- ency, 63 general health influencing results of, 63 general rules for, 71 hemorrhage after, 68 hygienic conditions influencing re- sults of, 64 inflammation after, 68 insanity after, 72 preliminary arrangements for, 70 preparation of patients for, 69 results of, circumstances which in- fluence, 63 scarlet fever after, 69 in scrofulous cases, 462 1128 INDEX. Operations— shock after, 66 state of internal organs influencing results of, 64 temperament and idiosyncrasy influ- encing results of, 64 treatment after, 65, 72 in tuberculous cases, 460 Ophthalmia, catarrhal, 715 chronic, 716 contagious, 719 croupous, 719 Egyptian, 719 gonorrhoeal. See Gonorrhoea, oph- thalmic. membranous, 719 neonatorum, 716 papular or pustular, 716 phlyctenular, 716, 724 purulent, 716, 717 rheumatic, 731, 733 scrofulous, 724 sympathetic, 733, 762 tarsi, 768 Ophthalmic surgery, anaesthetics in, 75 Ophthalmitis, 762 migratory, 763 Ophthalmoplegia externa and interna, 768 Ophthalmoscope, 747 diagnosis of cataract by, 739 cerebral concussion by, 329 morbid changes observed by, 749 et seq. Opisthotonos, 567 Opium in hospital gangrene, 436 inflammation, 61 injuries of head, 328 spontaneous gangrene, 432 strangulated hernia, 877, 878 Optic atrophy, 756 syphilitic, 494 nerve. See Nerve. neuritis, 755 syphilitic, 494 papilla, morbid changes in, 747, 755 Optico-ciliary neurotomy, 764 Orange-colored pus, 39 Orbit, diseases of, 776 erysipelas of, 447 extirpation of contents of, 764 hemorrhage into, in fractured skull, 334 injuries of, 360 Orchitis, 1069 gonorrhoeal. See Epididymitis. puncture of testis for, 471, 1069 strapping testis for, 471,1069 syphilitic, 41)5 Organic stricture. See Stricture. Orthopaedic surgery, 687 Orthoptic treatment of strabismus, 767 Os calcis. See Calcaneum. Oscheocele. See Hernia, scrotal. Osseous tumor, f21 Ossicula of ear, lesions of, 784, 790 Ossification of ciliary body, 732 crystalline lens, 738 Osteitis, 620 deformans, 620 scrofulous, 633 in stumps, 112 syphilitic, 496 of vertebrae. See Spine, antero-pos- terior curvature of. Osteocopic pain in syphilis, 496 Osteoid aneurism, 636 cancer, 537 Osteoma, 522, 631 Osteomalacia, 632 Osteo-myelitis, 621 in stumps, 112 treatment of, 623 Osteo-plastic resection of coccyx and. sa- crum, 921 olecranon, 302, 671 pelvis, 1054 upper jaw, 798 Osteoporosis, 620 Osteotomy, subcutaneous, 291, 655, 657, 695 et seq. for hallux valgus, 704 Osteotrite, 627 Otalgia, 792 Othaematoma, 777 Otitis media, 786 Otorrhoea, 780, 787 Otoscope, 788, 789 Outgrowths. See Tumors. Oval amputation, 104 Ovarian tumors, 939 suppuration in, 959 treatment of, 940 Ovaries, extirpation of. See Ovariotomy. both, with uterus, 947 gonorrhoeal inflammation of, 472 hernia of, 865 in strangulated hernia, 882 syphilitic affections of, 495 Ovariotomy, 942 clamp for, 945 disinfectant injections after, 946 double, 947 management of adhesions in, 944 pedicle in, 944 mortality after, 943 normal, 946 rectal, 946 vaginal, 946 Overlapping in fractures, 232 Over-distention of strictures, 1041 Ox, ligature from aorta of, 194 Oxalate-of-lime calculus, 961 Oxygen gas in .ipnoea, 375 Ozaena, 794 PACHYDERMATOCELE, 555 Pack-thread strictures, 1036 Paget's disease of nipple, 851 scrotum, 851, 1067 Pagliari, styptic for hemorrhage, 191 Pain, burning, in nerve injuries, 219 INDEX. 1129 Pain— in gunshot wounds, 171 inflammation, 44 spinal injuries, 347 Painful mammary tumors, 855 ulcer of anus. See Fissure. Palate, cancer of, 836 cleft, 832. See Staphylorraphy, and Uranoplasty. diseases of, 832 syphilitic, 489, 494 hard, acquired, perforation of, 835 fissure of, 832, 835 obturators for, 835 wounds of, 366 Palate-hook, 795 Palatine stertor, 76 Palmar abscess, 557 arch, hemorrhage from, 191, 197, 201 fascia, division of, 693 Panaris. See Paronychia. syphilitic, 496, 498 Pancreas, operations on, 404, 955 Pancreatectomy, 955 Pannus, 723 trachomatous, 720 Panophthalmitis, 762 Paper for dressing wounds, 66 splints, 238 Papilla, optic, diseases of, 755 Papillary tumor, or papilloma, 524 Papillitis, 755 Papillo-retinitis, 755 Papular ophthalmia, 716 Papule, moist. See Mucous patch. Paquelin's cautery, 87 for hemorrhoids, 934 in tracheotomy, 380 Paracentesis abdominis, 937 capitis, 706 corneae, 725, 762 pericardii, 397 thoracis, 394 Paraffin for fixed bandages, 85 epithelioma, 1067 Paralysis of bladder, 1013 of bowel, in strangulated hernia, 879 general, a cause of fracture, 228 nuclear, 768 of ocular muscles, 767 oesophagus, 840 reflex, 220 spinal, 345, 714 syphilitic, 495 of tympanic muscles, 791 Paralytic myosis and mydriasis, 768 strabismus, 764, 767 Paraphimosis, 1063 complicating chancroid, 481 Paraplegia, suspension for, 714 Parasites, vegetable, in auditory meatus, 780 Parenchymatous hemorrhage. See Hem- orrhage. iritis, 733 tissue, in inflammation, 36 Paronychia, 557 Parotid bubo, 814 duct, wound of, 365 gland, excision of, 815 inflammation of, 814 region, tumors of, 814 Passive motion in anchylosis, 654 fractures, 241 Pasteur, prophylaxis against hydropho- bia, 165 Patella, caries of, 560 dislocations of, 312 enlarged bursa of, 559 excision of, 684 fractures of, 278 necrosis of, 629 Pathfinder for urethral stricture, 1038 Pean, haemostatic forceps, 547 Pearl-tumor, 528 Pectoral muscle, abscess beneath, 387 Pedicle, management of, iu ovariotomy, 944 Pelvic organs, injuries of, 414 Pelvis, dislocation or diastasis of, 257, 294 distorted, in lithotomy, 988 fractures of, 257 obliquity of, in hip-disease, 646 rickets, 463 spinal curvature, 690 osteo-plastic resection of, 1054 Pemphigus of conjunctiva, 721 Penile fistula, 1052 Penis, amputation of, 1066 congenital adhesion of, to scrotum, 1060 contusion of, 417 diffuse inflammation of, 1064 dislocation of, 417 distortion of, in gonorrhoea. See Chordee. fistula in, 1052 gangrene of, 1064 herpetic and aphthous ulcers of, 1064 incurvation of, 1060 malignant disease of, 1066 strangulation of, 146, 417 structural affections of, 1064 thrombosis of, 1064 tumors of, 1066, 1067 venereal ulcers of. See Chancroid, and Syphilis. warts of, 1066 wounds of, 416 Peptonized blood, transfusion of, 91 Percussion for diagnosis of bone tumors, 634 ununited fracture, 250 Perforating ulcer, 321, 552 of tongue, 553 Perforation of mastoid process, 788 membrana tympani, 784 palate, 835 Periarthritis, 653, 692 Perioarditis from contusion of chest, 389 gonorrhoeal, 476 purulent, 397 1130 INDEX. Pericardium, incision of, 397 tapping the, 397 wounds of, 396 Perineal abscess, 470 band, 276 fistula, 1052 after lithotomy, 989 hernia, 902 lithotrity, 978, 994 section, 1045. See Urethrotomy, ex- ternal, without guide. Perinephric abscess, 958 Perineum, female, laceration of, 419 et seq. male, wounds of, 419 Periodic strabismus, 765 Periosteotome, 100 Periosteum, agency of, in repair of frac- tures, 235 flap of, in amputation of leg, 130 ununited fracture, 250 grafting, from animals, 671, 709 importance of preserving, in ex- cision, 664 Periostitis, 618 of mastoid process, 787 orbit, 776 in stumps, 112 syphilitic, 496 Periostosis, 632 Peripheral linear extraction of cataract, 743 Peri-phlebitis, 450 Peritomy, 720 Peritoneum, lesions of, in pyaemia, 453 rupture of, 399 Peritonitis, erysipelatous. See Erysipe- las. from gonorrhoea, 472 incision and drainage for, 402 septic, cathartics in, 402 in strangulated hernia, 874, 883 suppurative, 959 traumatic, 401 Perityphlitic abscess, 958 Permanent stricture. See Stricture. Permanganate of potassium, in hospital gangrene, 436 Permeable stricture, 1036, 1039. See Stricture. Pernio or chilblain, 321 Peroneal artery. See. Artery. Pessaries, medicated, in gonorrhoea, 473 Phagedaena, sloughing. See Gangrene, hospital. Phagedenic chancre, 485 chancroid, 477 Phalanges. See Fingers. Phantom stricture of rectum, 918 tumors, 525 Pharyngocele, 839 Pharyngotome, 838 Pharyngotomy. See GZsophngotomy. sub-hyoidean, 374, 3*3, 83!). 847 Pharynx, abscess behind, ^38 burns and scalds of, 370 Pharynx— diseases of, 838 syphilitic, 494 extirpation of, 839 foreign bodies in, 366, 383 Phimosis, 1061 complicating chancroid, 480 gangrene of penis from, 1064 predisposing to hernia, 862 Phlebectasis. See Varix. Phlebitis, 572 connection of, with pvaemia, 450 | Phlebolites, 184, 930 Phlebotomy. See Blood-letting. hepatic, 956 Phlegmasia dolens, 572 I Phlegmonous abscess. See Abscess. erysipelas. See Erysipelas. inflammation, 45 ulcer. See Ulcer. Phlyctenula pallida, 721 Phlyctenular conjunctivitis, 716 keratitis or ophthalmia, 724 Phosphatic calculus, 962 Phtheiriasis palpebrarum, 769 Phthisis, fistula in ano with, 924 Pigmentary sarcoma, 528 Piles. See Hemorrhoids. Pilocarpine in hydrophobia, 165 in tetanus, 571 after tracheotomy, 381 Pilo-nidal fistula, 512, 924 Pinguecula, 722 Pink-eye, 716 Pirogoff, amputation of foot, 126 Pityriasis of conjunctiva, 722 Plantar fascia, division of, 699, 703 Plaster, adhesive, 153 antiseptic, 153, 158 in fractured ribs, 255 isinglass, 153 Plaster-of-Paris bandage, 84 in spinal affections, 691, 713 Plastic lymph, 37 operations for burns, 318 on cornea, 728 eyelids, 769 et seq. lips. See Cheiloplasty, and Harelip. nose. See Rhinoplasty. palate. See Staphylorraphy, and Uranoplasty. perineum, 419 rectum, 922 for ulcers, 429 on urethra, 1052 et seq. vagina, 1055 et seq. Pleiade ganglionnaire, 488 Pleura, lesions of, in pyaemia, 453 wounds of. See Lung, wounds of. Pleurisy, gonorrhoeal, 476 from injury of chest, 389, 390 Pleurothotonos, 567 Plexiform neuroma, 562 Pliers, cutting. 100 for fixed bandages, 85 INDEX. 1131 Plugging the nostrils, 793, 794 Pneumatic aspiration and occlusion, 108 speculum for ear, 784 Pneumatocele or pneumocele, 390, 393 Pneumaturia, 1013 Pneumonia from injuries of chest, 389, 390 from wounds of throat, 367 Pneumothorax, 390, 393 Pneumo-uria, 1013 Pocketing the pedicle in ovariotomy, 945 Pointing of abscesses, 421 Poisoned wounds. See Wounds. Polypus, 515 of bladder, 1010 < ear, 781 frontal sinus, 803 larynx, 846 nasal, 796 naso-pharyngeal, 797 et seq. of rectum, 921 urethra, 1050 uterus, 1091, 1092 hard or fibrous, 1091 vagina, 1089 Polyscope, 1030 Popliteal artery. See Artery. Porro's operation, 947 Port-wine stain, 578 Porte-moxa, 86 Position in treatment of hemorrhage, 190 inflammation, 53 strangulated hernia, 878 Posterior catheterization, 1029 nasal syringe, 795 Posthitis, 4*72, 1064 Post-prostatic puncture of bladder, 1023 Pott, disease of spine, 709, 713 fracture of fibula, 283 Pouches, rectal, inflammation of, 936 Poultices, 57 vaginal, 473 Pregnancy, extra-uterine, 948 operations during, 64 Preparation of patients for operation, 69 Prepuce, division of, 1061 elongation of. See Phimosis. excision of, 1062 gangrene of, 481, 1064 herpetic ulceration of, 478 hypertrophy of, 1064 inflammation of. See Balanitis. Pre-rectal lithotomy, 993 Presbyopia, 760 Presse-artere, 201 Pressure in aneurism. See Aneurism, treatment of, by compression. in cancer, 541 carbuncle, 438 elastic, in irreducible hernia, 869 in reduction of dislocations, 289 hemorrhage, 191 inflammation, 59 ulcers, 430 Pressure-diverticulum of pharynx, 839 Preventive treatment of calculus, 964 cleft palate, 832 harelip, 809 Priapism in injuries of penis, 417 spine, 348 in vesical calculus, 967 Primary amputation, 114 bubo, 482, 488, 555 syphilis, 484 union of wounds. See Adhesion, and First intention. Probang for oesophagus, 384 Probe, chemical, 174 drainage, 224 drum, or reverberating, 174 electric, 174 flexible, 174, 626 jointed, 626 magnetic, 174 meerschaum, 174 Nelaton's, 173 uterine, 939 wire, 626 Probe-nippers, 174 Procidentia uteri, 1093 Profunda artery. See Artery, femoral, deep. Progression, cross-legged, 694 Progressive ossifying myositis, 557 Projectiles, momentum of, 168 Prolabium, restoration of, 806 Prolapsus ani. See Prolapsus of rectum. of laryngeal sac, 846 rectum, 934 operations for, 935 from vesical calculus, 967 tongue, 817 urethra, 1032 vagina, 1089 Proliferation of cells, 37 Proliferous cysts, 511, 512 of breast, 855 Prone position in affections of spine, 356, 713 and postural respiration, 376 Properitoneal hernia, 889, 898 Prostate, abscess of, 1016 atrophy of, 1024 bruising of, in lithotomy, 990 calculi of, 998, 1025 cancer of, 1024 cysts of, 1025 division of, in bilateral lithotomy, 992 lateral lithotomy, 985, 987, 988 hemorrhage from, 1012 hypertrophy of, 1017 complicating lithotomy, 987 lithotrity, 980 incontinence of urine from, 1014, 1015, 1019 retention of urine from, 1014, 1022 inflammation of. See Prostatitis. injuries of, 418 lesions of, in pyaemia, 453 1132 INDEX. Prostate— puncture of bladder through, 1022 tubercle of, 1025 tumors of, 1017 in lithotomy, 989 Prostatic calculi, 998, 1025 catheters, 1019 et seq. Prostatitis, 1016 Prostatorrhoea, 1016 Prostration with excitement, 141 Provisional callus, 236 tourniquet. See Tourniquet. Pruritus of anus, 937 Psammoma, 528 Pseudo-calculi, 963 Pseudo-glioma, 755 Pseudo-paralysis, syphilitic, 498 Psoas abscess, 712 Psoriasis of conjunctiva, 722 tongue, 816 Psychrophor, 1017 Pterygium, 722 Ptomaines in pyaemia, 449 tetanus, 568 Ptosis, 772 Pubis, dislocation or diastasis of, 257, 294 dislocation of femur on, 309 fracture of, 257 puncture of bladder above, 1024 resection of, 1011 Pudenda. See Genital organs, female. Pudendal hernia, 902 Pudic artery. See Artery. Pug-nose, 803 Pulleys, compound, in dislocations, 289, 310, 311 Pulpefaction of parts, 157 Pulpy degeneration of synovial mem- brane, 640 Pulsating bronchocele, 812 tumors, 525 in bone, 636 Pulsation of aneurism, 587 recurrent, 594 Pulse, venous, in chloroform anaesthesia, 76 Pulverization, continuous, 159 Puncta lacrymalia, eversion or oblitera- tion of, 774 Puncturation, 90, 446 Puncture of bladder. See Bladder. intestine, 401, 878, 883, 910 Punctured wounds. See Wounds. Pupil, artificial, operations for, 728, 737 et seq. in chloroform anaesthesia, 76 contraction and dilatation of, 735 in injuries of head, 327, 329 spine, 348 Pupillary membrane, persistent, 735 Purgatives in hernia, 870, 878 inflammation, 61 Purulent conjunctivitis or ophthalmia, 716, 717 diathesis. | Sge p ift infection. J J pericarditis, 397 Pus, 38 absorption of, in abscesses, 422 pyaemia, 450 characters of, in caries, 626 cold abscesses, 424 corpuscles, origin of, 39, 40 varieties of, 39 Pustular ophthalmia, 716 Pustule, malignant, 439 Putrid infection. See Pyaemia. Puzzle, Indian, for dislocations, 304 Pyaemia, 448 analogy of, with gonorrheal rheu- matism and urethral fever, 455, 475, 1038 with tubercle, 459 arterial, 451 causes of, 454 contagiousness of, 454 diagnosis of, 455 idiopathic or essential, 454 materies morbi of, 454 metastatic abscesses in, 451, 452 morbid anatomy of, 452 pathology of, 449 prognosis of, 456 symptoms of, 454 treatment of, 456 trephining as a prophylactic against, 339 Pyaemic patches, 452 Pyarthrosis, 619, 639 Pyocyanine, bacillus of, 39 Pylorus, dilatation of, 954 resection of, 953 Pyocyanine, 39 Pyogenic diathesis or fever. See Pyaemia. Pyonephrosis, 949, 950, 958 Pyrexia, paralytic, 349 Pyridine in gonorrhoea, 468 Pyrogallic acid in chancroid, 481 in epithelioma, 546 QUADRUPLE amputation, 107 ligature for naevus, 579 Quilled suture, 152 Quilt-suture, 151 Quiuia in shock, 67, 142 RABBIT, grafting periosteum from, 709 transplantation of eye from, 764 Rabid animals, bites of, 163 Racemose aneurism. See Aneurism by anastomosis. Rachilysis, 691 Rachitis. See Rickets. adultorum. See Osteomalacia. Rack for fractures of lower extremity, 283 Radial artery. See Artery. Radiating incisions in ulcers, 428 Radical cure of hernia, 866 cases favorable for, 868 femoral, 899 inguinal, 893 umbilical, 886 ventral, 885 INDEX. 1133 Radical cure of— hydrocele, 1073 varicocele, 1077 Radius, dislocations of, 300 excision of, 179, 673 fractures of, 269, 270 Railway spine, 350 Ramoneur, 384 tracheal, 381 Ranula, 818, 819 acute, 816, 819 Rapid breathing, analgesia from, 75 lithotrity with evacuation, 975 Rarefaction of bone, 620 Raspatory, 100 Rattlesnake poisoning, 162 Raynaud's disease, 440 Reaction from shock, 67, 141 et seq. Re-adjustment of tendons for strabismus, 767 Ready method, Marshall Hall's, 376 Reclination of cataract, 740 Rectal anaesthesia, 78 ovariotomy, 946 Rectangular flap amputation, 105 staff, 986, 994 Rectilinear ecraseur, 933 Rectocele, 1089 Recto-labial fistula, 923 Recto-urethral fistula, 922, 1054 Recto-vaginal fistula, 922 Recto-vesical fistula, 922, 1054 lithotomy, 995 Rectotomy, linear, 416, 919, 920 Rectum, abscess near, 924 bougies for, 918 cancer of, 919 encysted, 936 excision of, 919, 920, 921 exploration of, by hand, 918 fistulae of, 922 foreign bodies in, 416 hemorrhage from, 929 et seq. imperforate, 914 occlusion of, 914 operation for narrowing, 936 polypus of, 921 pouches of, inflamed, 936 prolapsus of, 934. See Prolapsus. puncture of bladder through, 1023 speculum for, 923 stricture of, 917 malignant, 919 phantom, 918 simple or fibrous, 917 warty, 919 syphilitic lesions of, 494 tapping through, 942 tumors of, 921 ulcers of, 927 wounds of, 416 in lithotomy, 990 Recurrent.bandage, 83 fibroid, 525 stricture. See Contractile stricture. tumors, 508, 525 Red corpuscles in inflammation, 35 Red-vision, 758 Redness in inflammation, 42 Reducible hernia. See Hernia. Reduction of dislocations, 287 spinal, 355 fractures, 238 compound, 244 impacted and partial, 247 hernia, 866 strangulated, 875, 876. See Taxis. in mass. 879 prolapsus of rectum, 935 Reef-knot, 101 Reflex paralysis, 220 Refraction, 758 Re-infusion of blood, 91 Relaxation of membrana tympani, 783 Relaxation-sutures, 154 Renal calculus, 963 nephrotomy for, 948 vessels, thrombosis of, in spinal in- juries, 344 Repair after excision, 664 of fractures, 235 wounds, 147 et seq. in arteries, 188 nerves, 218 tendons, 220, 698 veins, 182 Resection. See Excision. of bladder, 415 intestine, 413. See Enterectomy. osteo-plastic, of coccyx and sacrum, 921 olecranon, 302, 671 pelvis, 1054 upper jaw,798 of pubis, 1011 rectum, 908, 920, 921, 936 sciatic nerve, 516 spine. See Trephining. stomach, 953 tendo Achillis, 702 Resection-sound, 665 Residual abscess. See Abscess. Resolution, 52 Resorcin in chancroid, 479 epithelioma, 546 gonorrhoea, 468 keloid, 551 lupus, 554 venereal warts, 549 Respiration, artificial, 375 prone and postual, 376 Rest in concussion of brain, 328 inflammation, 53 joint affections, 222 et seq., 639, 643 spinal affections, 356, 713 Results of operations, circumstances which influence, 63 et seq. Retention cysts, 509 of urine, 1013. See Urine. in gonorrhoea, 470 after lithotrity, 978 in spinal injuries, 347 1131 INDEX. Retina, concussion of, 360, 361 diseases of, 752 tumors of, 755 Retinitis, 753 syphilitic, 491, 498, 753 Retraction of divided arteries, 188 muscles, after amputation, 110 nipple, in cancer, 531, 857 Retractor, 101 grooved, for excisions, 665 Retrograde dilatation of oesophagus, 84 Retrojections in gonorrhoea, 469 Retro-peritoneal suppuration, 402 Retro-pharyngeal abscess, 838 Reversed spiral bandage, 82 Revulsion, 85. See Counter-irritation. Rhagades, 490, 926 Rheumatic iritis, 733 ophthalmia, 731, 733 Rheumatism, gonorrhoeal. See Gom rhoeal. Rheumatoid arthritis. See Arthritis. Rhinenrynter for epistaxis, 793 Rhinolites. 799 Rhinoplasty, 800 Rhinorrhoea, 794 Rhinoscopy, 795 Ribbon,lead, 154 Ribs, changes in, in rickets, 463 dislocations of, 294 excision of, 395, 397, 669, 958, 959 fracture of, 255 necrosis of, 629 Rickets, 462 in bone, 632 predisposing to fracture, 228 Rigidity of membrana tympani, 783 Ring for fracture of patella, 279 strangulation by, 146, 1064 Ring-forceps for piles, 931, 933 Rinne's test of hearing, 791 Ripening cataract, 739 Risus sardonicus, 568 Rodent ulcer, 551 Rolando, sulcus of, 340 Roller bandages, 82 Rope windlass for dislocations, 289, 309 Rotation of vertebrae in lateral curvatui of spine, 689, 691 Rotatory displacement in fractures, 232 Round ligaments, shortening, 1094 Rubefacients, 85 Run-around. See Onychia. Rupia, syphilitic, 493 Rupture. See Hernia. of abdominal muscles, 399 aneurism, 591, 594, 595 arteries, 184, 400 bladder, 414, 1049 gall-bladder, 400 heart, 388, 569 intestine, 400, 880 kidneys, 347, 400 liver, 399 lungs, 387 muscles and tendons, 220, 569 ! Rupture of— nerves, 217 oesophagus, 383 perineum, 419 peritoneum, 399 sphincter ani, 927, 931, 932 vaginae, 1090 stomach, 400 stricture of urethra, 1041 ureter, 400 urethra, 417, 1049 [ uterus, 948 vena cava, 400 SAC of hernia. See Hernia. laryngeal, prolapsus of, 846 Sacciform disease of anus, 936 Sacculated aneurism, 583 bladder, 1009 oesophagus, 840 pharynx, 839 Sacro-iliac disease, 650 junction, division of, 1006 Sacrum, fracture of, 258 osteo-plastic resection of, 921 Saemisch's ulcer, 726 Sal alembroth, 158 Salicylic acid in boils, 437 Saline enemata in hemorrhage, 92 solutions, intra-peritoneal use of, 92 Salivary fistula, 365, 804 Salivation, mercurial, 504 Salpingectomy, 947 Salts of blood in inflammation, 36 Salufer, 158 Sand-bags for fractured thigh, 275 Sanguineous cysts, 510 Sanious pus, 39 Saponaceous matter in calculi, 963 Sapraemia, 448 Sarcocele, 1078 cystic, 1079, 1080 malignant, 1080 simple, 1078 syphilitic, 495, 1079 tuberculous, 1079 Sarcoma, 525 et seq. of bone, 635 breast, 856 bursae, 561 nostrils, 799 sero-cystic, 511, 854, 855 of testis, 1079, 1080 tonsil, 837 Sarsaparilla in inflammation, 62 Saw, amputating, 99 Butcher's, 127, 130, 665 chain, 665, 666 Hey's, 338 Sayre, hip-disease, 647 et seq. spinal affections, 691, 692, 713, 714 Scabbing, healing by, 149 Scalds. See Burns. Scalp, aneurism by anastomosis of, 576 contusions of, 323 erysipelas of, 447 INDEX. 1135 Scalp— naevus of, 579, 580 tumors of, 704 sebaceous, 513 wounds of, 323 Scalpel, 99 Scaphoid bone, dislocation of, 314 Scapula, dislocation of, 295 excision of, 667, 668 fracture of, 262 Scarification, 89 Scarlet fever after operations, 69 Scarpa, shoe for club-foot, 699 Schneiderian membrane, inflammation and thickening of, 794 Sciatic artery. See Artery. hernia, 903 nerve, resection of, in elephantiasis, 516 pain in cancer, 542 Scirrhous cancer. See Scirrhus. Scirrhus, 530 acute, 534, 856 atrophic, 542, 856 of breast, 856 cachexia in, 532 capsulated, 857 cuirass-like, 534, 856 infiltration of, 530 lardaceous, 531, S56 microscopic appearances of, 533 morbid anatomy of, 533 natural history of, 530 treatment of. See Cancer, treatment of. ulceration of, 531 Scissors, canula, 746 for cutting uvula, 836 Sclera, diseases of, 731 Sclerema. See Scleroderma. Scleritis, 731 Scleroderma, 516, 555 Sclero-keratitis, 731 Sclerosis of bone, 620, 621 Sclerotic catarrh of tympanum, 788 staphyloma of, 729 tumors of, 732 Sclerotitis, 731 Sclerotomy, 762 subconjunctival, 755 Scoop, lithotomy, 983, 986 Scoop-syringe, 744 Scotoma, 757 Screw extractor, 174 Scrofula or scrofulosis, 460 in bone, 461, 633 joints, 461 lymphatic glands, 461 mucous membranes, 461 operations in, 462 in skin, 460 treatment of, 461 Scrofulous diathesis, 460 ophthalmia, 724 osteitis, 633 sarcocele. See Sarcocele, tuberculous. Scrofulous— synovitis, 640 temperament, 460 ulcer, 460, 462 Scrotal fistula, 1052 hernia, 864, 888, 889 diagnosis of, 893 Scrotum, contusions of, 418 diffuse inflammation of, 1064 epithelioma of, 1067 erysipelas of, 447 excision of, 1065 for varicocele, 1077 a fissure or cleft of, 1060 gangrene of, 431 hypertrophy or elephantiasis of, 1065 Paget's disease of, 851, 1067 , wounds of, 418 Scultetus, bandage of, 83, 84 Sealing gunshot wounds of chest, 391 Searcher for lithotomy, 983 Sebaceous tumor, 513 Second intention, union by, 149 Secondary abscesses. See Pyaemia. adhesion, 149 amputation, 114 aneurism, 594 cataract, 746 deposits of encephaloid, 535 epithelioma, 543 scirrhus, 531 fever, 51 hemorrhage. See Hemorrhage. t syphilis, 488. See Syphilis. Secretion in inflammation, 34, 45 Section of bone in amputation, 103 excision, 665, 666 Caesarean, 941 of nerves for tetanus, .572 perineal, 1045. See Urethrotomy, external. of tendons. See Tenotomy. veins for phlebitis, 574 varicocele, 1077, 1078 varix, 576 Sedatives in inflammation, 60 Sediments from urine, 960 Semilunar bone, dislocation of, 303 cartilages, dislocation of, 313 excision of, 313 Semi-malignant tumors, 508, 525 Seminal cysts, 511, 1074 emissions, 1083 vesicle, hydrocele of, 1075 inflammation of, 1070 Senile gangrene, 431 amputation for, 94 Sensory paralysis in spinal injuries, 347 Separation, line of, 49 of epiphysis, deformity after, 230 Septhaemia and septicaemia. See Pyaemia. Septic peritonitis, cathartics in, 402 Septum of nose, diseases of, 799 displacements of, 252 Sequestra, classification of, 174 s. extraction of, 630 1136 INDEX. Sequestra— in fractures, compound, 245 gunshot, 174 in necrosis, 628 syphilitic, 497 Sero-cystic sarcoma, 511, 854, 855 Sero-pus, 39 Serous cyclitis, 733 cysts, 509 exudation in tympanum, 790 iritis, 733 membranes, erysipelas of, 443 in pyaemia, 453 Serpiginous chancroid, 478 Serre-fines, 154 for urinary vaginal fistulae, 1055 Serum, artificial, 944 effusion of, in lung wounds, 390, 394 of hernial sao, 864, 872 Seton, 86 in cold abscess, 425 fistulae, 426 of breast, 853 perineal, 1052 oakum. .8'ee Oakum. in staphyloma, 730 ununited fracture, 250 Setting fractures, 238 Sex, mode of determining, in cleft scro- tum, 1060 Shadow-test for refraction, 759 Shell-wounds, 169 Shock, 139 amputation during, 143 in burns, 316 causes of, 140 death from, 66, 141 effect of anaesthetics on, 143 in gunshot wounds, 171 injuries of abdomen, 400 lung wounds, 390 reaction from, 141 secondary or insidious, 67, 144 temperature in, 141, l43 treatment of, 67, 142 in wounds of testis, 140 Short-cut ligatures, 101, 108 Short sight. See Myopia. Shortening in fracture, 232 of thigh, 273, 276 consecutive, 278 Shot, round, wounds by, 169 small, wounds by, 168 Shoulder, amputation above, 123 at, 121 anchylosis of, 658 contraction of, 692 diseases and injuries of. See under Joints. dislocations of, 295 et seq. excision of, 176, 669 Shoulder-girdle, 261 Sigmoid catheter, 946 Signe de Dance, 906 Silica in calculi, 963 Silicate-of-potassium bandage, 85 Silver-fork deformity in fraotured radius, 270, 271 Silvester, artificial respiration, 375 Sinuses, 426 of brain, wounds of, 342 frontal, affections of, 777, 803 Siphon, aspirator, 92 trocar, 941 Sirop Gibert, 505 Skey, tourniquet, 98 Skin, diseases of, 548 malignant, 554 syphilitic, 489, 492, 497 in pyaemia, 453 scrofula in, 460 Skin-grafting. See Transplantation. Skull, contusions of, 332 extravasation within, 326, 330, 337 fracture of, 333 at base, 333 hernia cerebri in, 336 trephining for, 337 et seq. fungus of, 704 inflammation within, 331 necrosis of, 629 in rickets, 463 suppuration within, 331, 339 syphilitic diseases of, 497 trephining the, 337 et seq. tumors of, 704 Sliding tubes for stricture, 1041 Sling for fractures of upper extremity, 272 Slough, 40, 48 separation of, 49 Sloughing of aneurisms, 590 et seq. of bursa patellae, 560 cancer, 531, 535 hernial sac, 873, 883 phagedaena. Nee Gangrene, hospital. in spinal injuries, 349 ulcer, 427 Snake-bites, 162 Snare for aural polypi, 781 laryngeal growths, 846 Snellen's clamp, 770 Snow-blindness, 758 Soft cancer. See Encephaloid. chancre. See Chancroid. fibroma, 515 Softening of bone. See Osteomalacia. brain in head injuries, 327, 331 in inflammation, 45 of spinal cord, 345 Solar plexus, concussion of, 399 Soluble glass, 85 Solution of cataract, 745 Solvent treatment of calculus, 964, 971 Sonde a dard, 996 Soot cancer, 1067 Sound, Bellocq's, 793, 794 for bladder, 967, 968, 970 resection, 665 urethral, 1026 uterine, 939 INDEX. 1137 Sounding for calculus, 967 in women, 970 Spanish windlass, 98 Spasm of bladder, 1015 intestine, 904 muscles after amputation, 110 in dislocation, 288 fracture, 233, 239 spinal injuries, 346 tetanus, 568 of oesophagus, 839 sphincter ani, 926 • vaginae, 1090 urethra, 1033 Spasmodic retention of urine, 1014 stricture. See Spasm. Speculum, aural, 779, 784 nasal, 795 rectal, 923 vaginal, 1054 et seq., 1088, 1089 Spermatic cord. See Cord. Spermatocele, 1074 Spermatorrhoea, 1083 Sphacelus, 48. See Gangrene, Mortifica- tion, and Sloughing. Sphincter ani, rupture of, 927, 931, 932 spasm of, 926 vaginae, spasm of, 1090 Spica bandage, 83 Spider-bite, 163 Spina bifida, 707 false, 709 ventosa, 635 Spinal abscess, 710 et seq. canal and s. column. See Vertebral. cord, compression of, 344, 357 concussion of, 343 from indirect causes, 350 state of, after amputation, 110 in hydrophobia, 165 inflammation of, 345 injuries of, 343 laceration of, 345 progressive disorganization of, 345 syphilitic affections of, 495 tumors of, 715 wounds of, 345 membranes, inflammation and lacer- ation of, 345 meningocele, 707 myosis, 757 paralysis, 714 Spindle-celled sarcoma, 525 Spine, anchylosis of, 715 caries of. See Antero-posterior cur- vature. concussion of. See Spinal Cord. curvature of, antero-posterior, 709 lateral, 689. See Lateral curva- ture. in rickets, 463 diseases of, 707 dislocations and fractures of, 351. See Vertebrae. injuries of, 343 72 Spine, injuries of— cerebral complications of, 349 color of blood in, 181 trephining for, 357 et seq. necrosis of, 715 Pott's disease of. See Antero-poste- rior curvature. railway, 350 sprains of, 351 trephining the, 357 et seq. Spiral bandage, 82 spring for extension, 643 Splay-foot. See Talipes valgus. Spleen, abscess in, 958 acupuncture of, 953 excision of, 404, 951 lesions of, in pyaemia, 453 rupture of, 399 Splenectomy. See Spleen, excision of. Splicing nerves, 219 tendo Achillis, 702 Splints, 238 Bond's, 270, 271 bracketed, 278, 682, 684 Carr's, 271 Coover's, 271 Dupuytren's, 283 for excision of knee, 681, 682 Gordon's, 271 interdental, 254 suspension, 277, 278, 282 for vesico-vaginal fistula, 1057 Splinters. See Sequestra. Splitting vesical calculi, 988 Sponge, artificial, 66 Sponge-grafting, 149, 426 Spongy iritis, 734 Spontaneous cure of aneurism, 590 dislocation, 285, 291 gangrene, 431 haematocele, 1075 hemorrhage, 187 rupture of spleen, 399 stomach, 400 Spoons for cataract, 743, 744 sharp, 425 Spoon-saw, 1091 Sprains, 222 of muscles, 220 vertebral column, 351 Sprain-fracture, 222 Spring catarrh, 721 Spurious cataract, 738 Squint. See Strabismus. Staff for lithotomy, 982 et seq. in female, 1000 hollow, 986 rectangular, 986, 994 straight, 986 Syme's, for division of strictures, 1043, 1044 Stammering with urinary organs, 1014 Stapes, anchylosis of, to fenestra ovalis, 789 Staphyloma, 729 ciliary, 729, 731 1138 INDEX. Staphyloma— of cornea, 729 of iris, 729 posterior, 729 of sclerotic, 729 Staphyloplasty, 835 Staphylorraphy, 832 Starched bandage, 84 Steam, death from inhaling, 317 Steaming in inflammation, 57 Steatoma. See Tumor, fatty. Stercoraceous abscess, 958 vomiting in intestinal obstruction, 904 et seq. strangulated hernia, 874 Sterility in male, 1084 from undescended testes, 1068 Sterno-cleido-mastoid muscle, congenital tumor of, 220, 496, 816 division of, 688 Sternum, dislocation or diastasis of, 256, 294 excision of, 668, 669 fracture of, 256 trephining the, 257, 389 Stertorous breathing from anaesthetics, 76 in compression of brain, 329 Stethoscope in diagnosis of fracture, 233 Stillicidium lacrymarum, 774 Stimulants in inflammation, 54, 58 Stings of insects, Ki2 Stirrup, adhesive-plaster, for extension, 275 Stomach, dilatation of orifices of, 954 foreign bodies in, 413 hernia of, 865 opening the. See Gastrostomy and Gastrotomy. resection of, 953 rupture.of, 400 suture Of, 404, 406 washing out, in intestinal obstruc- tion, 907 wounds of, 406 Stomach tube, introduction of, 844 Stomatitis, gangrenous, 432 syphilitic, 498 Stone in bladder or kidney. See Calculus. fit of, 963. Storing electricity, 87 Strabismometer, 765 Strabismus, 764, 767 Strangulated hernia, 871. See Hernia. Strangulation, 146 of aneurism, 602 epithelioma, 546 hemorrhoids, 930, 932 internal, 904 diagnosis of, 906 statistics of, 905, 909 in strangulated hernia, 880 treatment of, 908 of naevus, 579 penis, 146, 1063, 1064 prolapsus of rectum, 935 by ring, 146, 1064 Strangulation— of staphyloma, 731 by tight bandaging, 239, 240 Strangury,1007 in gonorrhoea, 470 Strapping the breast, 852, 853 testis, 1069 for epididymitis, 471 ulcers, 428, 429 Streptococcus erysipelatosus, 441 Strieker, theory of inflammation, 37, 38, 40 Stricture fever, 1038 of intestine, 905, 906 oesophagus, 367, 840 rectum, 917 et seq. seat of, in strangulated hernia, 871 of trachea, 367, 848 urethra, 1034 catheterization in, 1048 classification of forms of, 1036 Cock's operation for, 1047 congestive, 1034 contractile, 1036, 1040, 1042 diagnosis of, 1038 dilatation of, 1039 et seq. external urethrotomy for, 1043, 1045, 1049 extirpation of, 1048 false passages in, 1040 in female, 1050 forced catheterization for, 1044, 1049 impermeable, 1036, 1044 internal urethrotomy for, 1042 irritable, 1036, 1037, 1040, 1042 lancetted catheter for, 1044 locality of, 1035 morbid anatomy of, 1035 permanent or organic, 1034 permeable, 1036, 1039 puncture of bladder for, 1049 recurrent. See Contractile. retention of urine from, 1037, 1048 rupture for, 1041 of bladder or urethra in, 1049 spasmodic. See Urethra, spasm of. Syme's operation for, 1043 symptoms of, 1037 syphilitic, 494 tapping urethra for, 1047, 1049 traumatic, 1034 et seq. treatment of, 1038 et seq. urethral fever following, 1037 urethrotomy for, external, with guide, 1043 without guide, 1045, 1049 internal, 1042 Struma, 458 Strumous synovitis, 640 Stumps, affections of, 110 dressing of, 108 antiseptic, 109 INDEX. 1139 Stumps— fractures in, 242 secondary hemorrhage from, 205 structure of, 109 Stye. See Hordeolum. Stylet-pince, 174 Styptic colloid, 153 cotton, 781 Styptics in hemorrhage, 191 Sub-astragaloid amputation, 126 Subclavian artery. See Artery. Subclavicular dislocation, 297 Sub-conjunctival operation for strabis- mus, 766 sclerotomy, 755 Subcoracoid dislocation, 297 Subcrustaceous cicatrization, 149 Subcutaneous division of urethral stric- ture, 1044 injection. See Hypodermic. nerve-stretching, 220 osteotomy, 291, 655, 657, 695 et seq. wounds, 146 Subglenoid dislocation, 295 Subglossitis, 816 Sub-hyoidean laryngotomy or pharyn- gotomy, 374, 383, 839, 847 Subluxation of knee, 313 lower jaw, 294 Submammary inflammation, 851 Submaxillary gland, tumors of, 815 Subperiosteal abscess, 619 hemorrhage, 463 Sub-retinal effusion, 754 Subscapular friction, 654 Sub-spinous dislocation, 297 Suction operation for cataract, 746 trocar, 92, 394 Sugar-loaf stump, 110 Sulcus of Rolando, 340 Super-laryngeal encysted tumor, 816 Supernumerary nipples or mammae, 849 Supination in fractures of forearm, 269, 271 Suppositories, vaginal, in gonorrhoea, 473 Suppuration. See Abscess, Inflamma- tion, and Pus. in aneurismal sac, 590, 594 bacilli of, 40 blue, 39 in bone, 622, 624 diffused, 426 in stumps, 111 in hemorrhoids, 928 intra-cranial, 331, 339 in joints. See Pyarthrosis. orange-colored, 39 retro-peritoneal, 402 subperiosteal, diffuse, 619 Suppurative fever. See Pyaemia. peritonitis, 959 stage of inflammation, 38, 46 Supra-mammary inflammation, 851 Supra-pubic cystotomy for enlarged tate, 1024 lithotomy, 996, 1000 Surgeon, demeanor of, in operations, 71 qualifications necessary for, 62 Surgeon's knot, 101 Surgery, 33. military. See Gunshot wounds. minor, 81 orthopaedic, 687 plastic. See Plastic operations. Surgical fever and s. typhus. See Pyaemia. kidney, 1037 Suspension for fractures, 282 in spinal affections, 691, 713, 715 Susurrus in pulsating tumors of bone, 636 Suture, 72, 101, 151 et seq. in amputation, 101 Appolito's, 406 of bladder, 415 in bone, 250, 251, 660, 681 buried, 420 button, 1057, 1058 in cataract operations, 742 continued or glover's, 151, 152 of diaphragm, 398 gall-bladder, 411 Gely's, 406 harelip, 151, 152 India rubber, 151, 152 interrupted, 151 lace, 1052 Lembert's, 406 materials used for, 72 quilled, 152 quilt, 151 for radical cure of hernia, 867 et seq. relaxation, 154 in strabismus, 766 tongue-and-groove, 802 twisted, 151, 152 in wounds of chest, gunshot, 391 heart, 397 intestine, 404, 406, 413 lacerated, 156 of neck, penetrating, 367 nerves, 219, 563 scalp, 323 scrotum, 418 stomach, 404, 406 tendon,221 Swelling in inflammation, 36, 43 white. See Arthritis. Symblepharon, 773 Syme, amputation at ankle, 127 cheiloplasty, 807 radical cure of hernia, 894 rhinoplasty, 803 stricture of urethra, 1036 et seq. Symmetrical gangrene, 440 Sympathetic nerve, lesions of, in tetanus, 570 ophthalmia, s. irritation, and s. neu- rosis, 762,763 Symphysis pubis, diastasis at, 257 puncture of bladder through, 1024 resection of, 1011 j Synchisis, 750 1140 INDEX. Synchronous amputation, 106 Syndectoiny, 720, 726 Synechia, anterior, 729 posterior, 733, 737, 738 Synostosis, 654 Synovial cysts, 510 Synovitis, 637 scrofulous or strumous. See Art! tis, gelatinous. Syphilides, 489 Syphilis, 482 alopecia in, 491, 493 of areolar tissue, 495 of arteries, 495 from bites, 162 of bone and periosteum, 496, 634 bubo in, 487, 500, 502 causes of, 482 chancre in, 484 etseq. chorea from, 495 confrontation in, 499 congenital, 497 contagion in, 482, 483 course, or natural history of, 484 dementia from, 495 diagnosis of, 498 of ear, 492 eye, 491, 494, 498, 724 et seq. gummy tumors in, 496 of hands and feet, 493, 496, 498, 5 hereditary, 497, 505 history of, 482 incubation of, 4^4, 48S inheritance of, 482 inoculation in, 499 iodide of potassium for, 504, 505 of intestines, 494 lips, 490, 5oo lymphatic enlargement in, 490 mercury for, 501 et seq. morbid anatomy of, 484 of mucous membranes, 490, 493 mucous patches in, 489, 504 origin of, from chancres, 487 of muscular and fibroid tissues, 496 nervous system, 492, 495, 500 nodes in, 496 onychia in, 493, 550 osteocopic pain in, 496 panaris in, 496, 498 primary, 484 prognosis of, 500 pseudo-paralysis in, 498 rhagades in, 490 secondary, 488 of skin, 489, 492, 497 solid viscus, 494 stages of, 4^4 stricture from, 494, 1039 tertiary, 492 of testis, 495, 1079 throat, 4-9 et seq. tongue, 490, 493, 500 treatment of, 501 et seq. urethral, vaginal, and uterine dis- charges in, 467, 490 Syphilodermata, 489 Syphilization, 506 Syringe, ear, 365 lithotomy, 983 penis, 467 posterior nasal, 795 prostatic, 1017 n- j Syringo-myelocele, 707 Syringotome, 925 T-BANDAGES, 83 Tait, removal of uterine appendages, 947 Taliacotius, rhinoplasty, 801 Talipes, 698 arcuatus, 699 calcaneo-valgus, 702 calcaneo-varus, 792 calcaneus, 702 equino-valgus, 703 equino-varus, 700 equinus, 699 treatment of, without cutting ten- dons, 703 valgus, 702 varus, 700 Tampon, tracheal, 829 Tanjore pill, 163 Tapping. See Paracentesis. ' hydrocele, 1072 ovarian cysts, 941 Tar cancer, 543 Tarsal cartilage, grooving the, 770 ligaments, section of, 701 tumor. See Chalazion. Tarso-cheiloplasty, 770 Tarsotomy for club-foot, 702 Tarsus, amputations through, 125 et seq. dislocations of, 314 excisions of, 685 for varus, 701 fractures of, 284 Tattooing the cornea, 728 syphilis transmitted by, 483, 4-4 Tauber, amputation of foot, 126 Taxis, 876 abdominal, 907 adjuvants to, 877 for femoral hernia, 900 incarcerated hernia, 870 inguinal hernia, 897 strangulated hernia, 876 Teale, amputation, 105, 108, 133 cheiloplastic operations, 319 suction operation for cataract, 746 Teeth in hereditary syphilis, 498 Telescopic speculum, 108> Temperament, influence of, on result of operations, 64 scrofulous, 460 Temperature of abscesses, 422 in epilepsy from cranial injury, 339 extreme, recovery from, 321, 349 in inflammation, 43 inflammatory fever. 50 pyaemia, 455 INDEX. 1141 Temperature in— shock, 141, 143 spinal injuries, 349 tetanus, 568 Temporal artery. See Artery. Temporary lengthening in fractures, 276 Tenaculum, 100. Tendinous tumor, 518 Tendo Achillis, division of, 699 resection and splicing of, 702 rupture of, 220 suture of, 221 Tendons, contraction of. See Orthopaedic surgery. after amputation, 112 diseases of, 556 division of. See Tenotomy. fatty tumors of, 559 injuries of, 220 luxation of, 221 repair in, 220, 698 Tenosynovitis, 557 tuberculous, 557 Tenotome, 688 Tenotomy for club-foot, 699 et seq. club-hand, 693 contracted joints, 692 et seq. dislocation of astragalus, 314 congenital, 291 old, 291 hip-disease, 649 knock-knee, 695 lateral curvature of spine, 692 repair after, 220, 698 for strabismus, 765 et seq. wry-neck, 688 Tensor tympani, tenotomy of, 784 Tertiary syphilis, 492 Testis, abscess of, 1069 absence of, 1068 cancer of, 1080 dentigerous cyst of, 513 disappearance of, 1068 excision of, 1068, 1081, 1082. See Castration. hernia of, 1069, 1070 hydatid, 1079, 1080 inflammation of, 1069. See Orchitis. inversion of, 1068 lesions of, in pyaemia, 453 lymphadenoma of, 1080 malformations and malpositions of, 1068 neuralgia of, 1070 position of, in hydrocele, 1072, 1074 in inguinal hernia, 890 puncture of, 471, 1069 ' sarcocele of. See Sarcocele. sarcoma of, 1079, 1080 strapping the, 471, 1069 swelled. See Epididymitis. syphilitic affections of, 495 transplantation of, 1068 tumors of, 1078 et seq. undescended, 1068 wounds of, 418 Testis, wounds of— shock in, 140 Tetanus, 566 amputation for, 96, 571 bacillus of, 568 contagion of, 568 diagnosis of, 570 hydrophobicus, 570 nascentium, 567 after operation for piles, 933 pathology of, 568 prognosis of, 570 ptomaines of, 568 in spinal injuries, 349 symptoms of, 567 treatment of, 570 Thecae, inflammation of. See Tenosyno- vitis. Thermal hammer, 86 Thigh, amputation of, 132 Thigh-bone. See Femur. Third intention, union by, 149 Thoracic viscera,, ruptures of, 387 Thorax. See Chest. Thrill in aneurism, 587 Throat, diseases of, 816 syphilitic, 489, 494, 504 injuries of. See Air-passages, Larynx, Neck, and Trachea. Thrombosis, 184 arterial, 453 connection of, with pyaemia, 451 of penis, 1064 Thrombus, 144, 146 Thudichum's douche for ozaena, 795 foreign bodies in nose and ear, 364, 365 Thumb, amputation of, 118 dislocations of, 304 excision and fracture of. See Fingers. Thyroid artery. See Artery. foramen, dislocation into, 308 gland. See Gland. Thyroideal laryngotomy, 847 Thyroidectomy, cretinoid condition fol- lowing, 814 Thyrotomy, 378 Tibia, anterior curvature of, 698 congenital absence of, 698 dislocations of, 313 epiphyseal separations of, 281 excision of, 179, 684 fractures of, 280, 283 section of, in amputation, 130 Tibial artery. See Artery. Tic douloureux, 564 Tinea tarsi, 768 Tinnitus aurium, 784, 792 Tip-tilted nose, 803 Tip-toe exercise in flat-foot, 703 knock-knee, 695 Tirefond, 174 Tobacco enemata, 878, 908 ulceration of tongue from, 817 Toe-nail, avulsion of, 550 hypertrophy of, 550 72* 1142 INDEX. Toe-nail— ingrowing, 550 ulcer, 549 Toes, amputation of, 124 contraction of, 703 dislocations of, 315 dorsal disease of, 553 excision of, 686 fractures of, 284 Tongue, abscess of, 817 aneurism by anastomosis of, 576 atrophy of, 817 cancer of, 820 chancre of, 500 corns on, 549 cysts of, 818 diseases of, 816 syphilitic, 490, 493, 500 epithelioma of, 820 excision of, 820 foreign bodies in, 366 hypertrophy or prolapsus of, 817 ichthyosis of, 524, 818 malignant tumor of, 820 naevus of, 580 neuralgia of, 818 operations on, 818 et seq. papilloma of, 524 removal of, 820 tumors of, 818 ulcers of, 817 perforating, 553 wounds of, 366 Tongue-and-groove suture, 802 Tongue-tie, 818 Tonics in inflammation, 62 Tonsillitis, 836 Tonsillotome or tonsil guillotine, 837 Tonsils, diseases of, 836 syphilitic, 489, 494 evulsion of, 837 excision of, 837, 838 foreign bodies in, 383 hypertrophy of, 837 lingual, 820 Tooth-wounds. .See Wounds. Torsion, 192 compared with acupressure and liga- tion, 202 for hemorrhoids, 933 Torticollis. See Wry-neck. Tour de maitre, 1028 Tourniquet, 93, 96 et seq. abdominal, 136 for dislocations, 289, 310 Esmarch's, 96 provisional, 175 Trachea, diseases of, 845 syphilitic, 494 fracture or rupture of, 370 tumors of, 848 Tracheal canula or tube, 380 tampons, 829 Tracheocele, 846 Tracheotomy, 378 compared with laryngotomy, 382 Tracheotomy— in excision of upper jaw, 829 for foreign bodies in air-passages, 373 glossitis, 816 hemorrhage in, 380 for injuries of larynx and trachea, '369 malignant nasal tumor, 799 oedema of glottis, 370 statistics of, 845 for stricture of larynx or trachea, 368 of oesophagus, 842 in tetanus, 571 Trachoma, 719 Traction operation for cataract, 743 Transfusion of blood, 91, 190, 457 Transplantation of bone, 250, 671 cuticle, 429, 541 eye-lashes, 769 hairs, 429 muscles, 557 periosteum from animals, 671, 709 rabbit's eye, 764 nerve, 565 testis, 1068 Transportation of patients with fractures, 237 Transverse fracture, 229 obliteration of vagina, 1059 Traumatic aneurism, t. arthritis, etc. See Aneurism, Arthritis, etc. fever. See Fever, inflammatory. typhus. See Gangrene, hospital. Trephine, 341, 342 for bone-disease, 625 Trephining for abscess of bone, 625 cornea, 762 in epilepsy, 339 ilium for psoas abscess, 714 in injuries of head, 337 mastoid process, 788 for osteo-myelitis, 623 spine, 357, 715 sternum, 257, 389 trochanter femoris, 651 Trichiasis, 769 Trigger-finger, 694 Tripier's amputation, 129 Tripoli for fixed bandages, 84 Trismus, 567 Trocar for hydrocele, 1072 ovariotomy, 944 siphon, 941 suction, 92, 394 Trochanter, amputation through, 133 caries of, 648 trephining, for hip-disease, 651 Tromatopnea, 390, 393, 397 Truss for hernia, 865 femoral, 899 inguinal, 893 irreducible, 869 umbilical, 886 prolapsus of rectum, 936 varicocele, 1077 IND EX. 1143 Tube, enterotomy, 911 Eustachian. See Eustachian. Fallopian. See Fallopian. perineal, 983, 987, 990, 1044 rectal, 907 stomach, introduction of, 844 tracheal, 380 Tubercle or tuberculosis, 459 analogy of, to pyaemia, 459 of bladder, 1011 bone, 633 choroid, 752 mucous. See Syphilis, mucous patch. painful subcutaneous, 524, 525, 563 of breast, 855 of prostate, 1025 syphilitic, 492 of testis, 1079 tongue, 817 urethra, 1050 Tubercular disease of foot, 553 syphilitic sarcocele, 495 Tuberculous cases, operations in, 460 sarcocele, 1079 tenosynovitis, 557 ulcer of anus, 927 conjunctiva, 721 tongue, S17 Tubes of Galli, 219 Tubular aneurism, 583 needle, 834 Tumors, 506 adenoid, 522 amputation for, 95 bony, 521 cartilaginous, 519 causes of, 507 classification of, 507 chondroid, 518 cystic. See Cysts. desmoid, 518 erectile, 524, 576 excision of, 546 fatty, 513 fibro-calcareous, 517 fibro-cartilaginous, 519 fibro cellular, 515 fibro-cystic, 517, 518 fibro-fatty, 514 fibro-muscular, 517, 518 fibro-nucleated, 526, 528 fibro-plastic, 526, 528 fibrous or fibroid, 517 malignant, 519, 539 recurrent, 525 floating, 525 glandular, 522 lymphoid, 523 malignant, 508, 530. See Cancer Epithelioma. mixed, 519 mucous, 517 muscular, 518 myeloid, 526 neuralgic, 524 non-malignant, 508 Tumors— osseous, 521 painful subcutaneous, 524, 525, 563 papillary, 524 phantom, 525 pulsating, 525 recurrent, 508, 525 sebaceous. See Cysts. semi-malignant, 508, 525 tendinous, 518 vascular, 524, 576 villous. See Papillary. Tumors of antrum, 824, 826 auditory meatus, 782 auricle, 778 bladder, 1010 bone, 634 brain, 705 breast, 854. See Breast. bursae, 561 cheeks, 804 choroid, 752 cicatrices, 551 conjunctiva, 723 epiglottis, 820 eyelids, 773 gums, 822 intestine, 906 iris, 735 jaw, lower, 830 upper, 825 labia majora, 1088 larynx, 846 superlaryngeal encysted, 816 lips, 805 malar bone, 826 mouth, 818 muscle, 557 neck, 815 nerves. See Neuroma. nostrils, 796, 799 optic nerve, 756 orbit, 776 ovary, 939. See Ovarian tumors. palate, 836 parotid region, 814 penis, 1066, 1067 pharynx, 838 prostate, 989, 1017 rectum, 921 retina, 755 scalp, 704 sclerotic, 732 scrotum, 1065,1067 skin, 548 et seq. skull, 704 spermatic cord, 1080 spinal cord, 715 sterno-mastoid, congenital, 220, 496, 816 submaxillary gland, 815 tendons, 559 testis. See Sarcocele and Testis. thyroid gland, 812 tongue, 818 trachea, 848 1144 INDEX. Tumors of— umbilicus, 937 urethra, 1050 uterus, 1090. See Uterus. vagina, 108«> Tunica albuginea, puncture of, 471, 1069 vaginalis, excision of, 1074 haematocele of, 1075 4 hydrocele of. See Hydrocele. Tuning-fork in aural surgery, 790 Tunnelling the prostate, 1022 Turbinated bones, removal of, for nasal polypus, 797 Turned-up nose, 803 Turpentine, Chian, in cancer, 541 oil of, in hemorrhage, 191 hospital gangrene, 435 syphilitic iritis, 5.05 Twisted suture, 151, 152 Twisting of vertebrae in lateral curvature of spine, 689, 691 Tympanum, diseases of cavity of, 786 inflamed mucous membrane of, 786, 788 inflation of, 785 et seq. malignant growths of, 782 membrane of. See Membrani tym- pani. syphilitic inflammation of, 492 membranous bands in, 788 mucus in, 790 paralysis of muscles of, 791 sclerosis of mucous lining of, 788 serous exudation in, 790 Typhus, surgical. See Pyaemia. traumatic. See Gangrene, hospital. TTLCERATION, 40, 46 L arrest of, 47 of bone. See Caries. cartilage, 641 phagedaenic, in chancre, 485, 502 in chancroid, 477, 481 serpiginous, in chancroid, 478, 481 Ulcers, 426 amputation for, 430 of anus, painful, 926 atheromatous, 582 cancerous, 531 of cheeks, 804 cicatrization of, 47, 48 classification of, 426 of cornea, 726, 728 duodenum, in burns, 316 eczematous, 429 epitheliomatous, 544 of foot, perforating, 552 granulation of, 47 of gums, 822 hemorrhagic, 430 indolent or callous, 428 transplantation of cuticle for, inflamed or phlegmonous, 427 irritable, 428 of lips, 805 lupous, 553 Ulcers— mechanical, of stumps, 110 of mucous membranes, 431 neuralgic, 428 of nose, 799 penis, 1064 perforating, 321, 552 of rectum, 926, 927 repair of, 47 rodent, 551 of vulva, 1088 scrofulous, 460 et srq. simple or healthy, 427 venereal. See Chancroid. I sloughing, 427 syphilitic, 485, 492, 496, 505 toe-nail, 549 of tongue, 817 perforating, 553 treatment of, after cicatrization, 430 tuberculous, 721, 817, 927 of vagina, painful, 1089 varicose, 430 venereal. See Chancroid, and Syph- ilis. warty, of cicatrices, 551 weak or cedematous, 427 Ulcus serpens, 726 Ulna, dislocations of, 300 et seq. excision of, 179, 673 fractures of, 268, 269, 271 Ulnar artery. See Artery. Umbilical hernia, 886 tumors and fistulae, 937 Umbilicus, gonorrhoea of, 465, 475 Uncipressure, 201 Union by adhesion, 148 by first intention, 148 of fractures, 235 delayed, 248 by granulation, 149 immediate, 148 of nerves, 218 by second intention, 149 of tendons, 220 by third intention, 149 Upper jaw. See Jaw, upper. Urachal calculus, 1000 fistula, 1054 I Urachus, cyst of, 960 Uranoplasty, 835 Urates in calculi, 961 I Ureter, catheterization of, 963, 1000 congenital fistula of, 1002 dilatation of, 963, 1037 impaction of calculus in, 963 inversion of, 1006 occlusion of, in operation for vesico- vaginal fistula, 1058 removal of calculus from, 964 rupture of, 400 Uretero-vaginal fistula, 1058 Urethan in tetanus, 571 Urethra, abscess of, 470 bougies for, 1026 [ calculus in, 977, 998 INDEX. 1145 Urethra— cancer of, 1050 catheters for, 1025 et seq. changes in, in enlarged prostate, 1018 deficiency in floor of. See Hypospa- dia. in roof of. See Epispadia. diseases of, 1025 electric illumination of, 1030 endoscope for, 1029 exploration of, 1025 false passages in, 1040 female, dilatation of, 999, 1009, 1051 fissure of, 1050, 1051 fistulae of. See Fistula. foreign bodies in, 417 hemorrhage from, 1012 in catheterization, 1040 gonorrhoea, 470 inflammation of, 1032. See also Gon- orrhoea. inflation of, 1028 laceration of, 417, 1040 malformations of, 1030 obliteration of, 1036 occlusion of, 1030 prolapsus of, 1032 rupture of, 417, 1049 sounds for, 1026 spasm of, 1033 stricture of, 1034. See Stricture. complicating lithotrity, 980 congestive, 1034 tapping the, 1047 tubercle of, 1050 tumors of, 1050 vermicular movement of, 1048 wounds of, 417 Urethral calculus, 998 discharge in syphilis, 467, 490 fever, 1037 analogy of, to pyaemia and gon- orrhoeal rheumatism, 455, 475 complicating lithotrity, 981 fistula, 1051 lithotomy, 999 Urethritis, 1032. See also Gonorrhoea. Urethrocele, 1032 Urethroplasty, 1053 Urethro-rectal fistula, 922, 1054 Urethrotomes, 1042 Urethrotomy, external, with guide, 1043 without guide, 1045 for retention of urine, 1049 internal, 1042 Urethro-vaginal fistula, 1054 Uric-acid calculus, 960 Urinary calculus. See Calculus. deposits, 960 diathesis, 960 fistula. See Fistula. organs, condition of, influencing re- sult of operations, 64 effect of calculus on, 970 enlarged prostate on, 1018 stricture of urethra on, 1037 Urine, albuminous, in calculus, 981 bloody. See Haematuria. changes in, after spinal, injuries, 348 extravasation of, 403, 417, 1049 flow of, stopped by calculus, 967 incontinence of, in adults, 1015 in children, 1014 after lithotomy, 989 from enlarged prostate, 1014, 1015, 1019 in spinal injuries, 347 infiltration of, after lithotomy, 990 retention of, 1013 from abscess of prostate, 1016 in cystitis, 1007 gonorrhoea, 470 hysterical, 1014 after lithotrity, 978 with overflow, 1013 from paralysis of bladder, 1013 prostatic enlargement, 1018 prostatitis, 1016 spasm of urethra, 1033 in spinal injuries, 347 from stricture of urethra, 1037, 1048 congestive, 1034 secretion of, in intestinal obstruction, 906 suppression of, from renal calculus, 963 in spinal injuries, 347 Uriseptic suppuration, 1037 Urostealith in calculi, 963 Uterine appendages, removal of, 947 discharge in syphilis, 490 fibroids, 1090 probe or sound, 939 Uterus, absence of, 1086, 1087 amputation of neck of, 1094 cancer of, 1093 epithelioma of, 1093 excision of, 1092 with both ovaries, 947 injuries of, 418 laceration of neck of, 1094 polypi of, 1091, 1092 procidentia of, 1093 prolapsus of, 1089, 1093 rupture of, 948 tumors of, 1090 diagnosis of, from ovarian tu- mors, 939 fibro-cellular. See Polypi. fibro-cystic, 1092 fibrous or fibro-muscular, 1090 malignant, 1093 myeloid and recurrent fibroid, 1093 Uvula, bifid, 832 elongation of, 836 scissors for, 836 VACCINATION, 88 V transmission of syphilis by, 483 Vagina, absence of, 1086 1146 INDEX. di>eases of, 1088 double, lo87 fistulae of. See Fistulae. foreign bodies in, 419 gonorrhoea of, 472 hemorrhage from wounds of, 419 imperforate, 1 (186 injuries of, 419 obliteration of, 1087 transverse, 1059 painful ulcer or fissure of, 1089 polypi of, 1089 prolapsus of, 1089 spasm of, 1090 tapping abdomen through, 942 tumors of, 1089 Vaginal discharge in syphilis, 490 hernia, 903 lithotomy, 1000 ovariotomy, 946 poultices. 473 speculum, l(t54, 1055, 1088, 1089 Vaginismus, 1090 Vagino-cerviplasty, 1093 Vagino-rectal fistula, 922 Valgus. >W< Talipes. Valvular stricture of urethra, 1036 Varicocele, 1076 diagnosis of, from hernia, 893 operations for, 1077 et seq. Varicose aneurism, 208 lymphatics, 556 ulcer, 430 veins, 574 of spermatic cord. See Varicocele. Varix. See Varicose veins. aneurismal, 208 non-traumatic, 602 in stumps, 111 arterial, 576 Varus. See Talipes. Varus-shoe, 700, 701 Vas deferens, rupture of, 418 Vascular tumors, 524, 576 of penis, 1066 Vegetations. See Warts. adenoid, 796 Vein or veins, air in, 182 condition of, in pyaemia, 453 diseases of, 572 hemorrhage from, 181 inflammation of, 572. See Phlebitis. injuries of, 181 remote consequences of, 184 internal jugular, wounds of, 181 ligation of, 181, 457 pressure of aneurism on, 587, 595 repair in wounds of, 182 rupture of, 181 in reducing dislocations, 290, 291 saphena, dilated, diagnosis of from femoral hernia, 899 spermatic, valves in, 1076 superficial, enlarged in cancer of breast, 857 Veins— varicose, 574 wounds of, 181 communicating with arteries, 208 Vein-brooch, 576 Vein-stones, 184, 930 Vena cava, rupture of, 400 wounds, 397 Venereal diseases, 465. See Chancroid, Gonorrhoea, and Syphilis. warts. See Warts. Venesection, 90. See Bloodletting. in shock, 142 Venous aneurism, 181 naevi, 578 pulse in chloroform anaesthesia, 76 Ventilation, influence of, on result of operations, 64, 65 Ventral hernia. See Hernia. Veratrum viride in aneurism, 591 inflammation, 60 Vermicular movement of urethra, 1048 Verrucae. See Warts. Vertebrae, caries of. See Spine, antero- posterior curvature of. necrosis of, 715 rotation of, in lateral curvature of spine, 689, 691 Vertebral artery. See Artery. canal, hemorrhage into, 344 column, dislocations of, 351, 355 fractures of, 351 et seq. trephining for, 357 sprains of, 351 Vertebrated catheter, 1020, 1021 Vesical calculus. See Calculus. catarrh, 1008 irritation in gonorrhoea, 466 Vesicants, 86. See also Blisters. Vesication in fracture, 239 Vesicle, seminal, hydrocele of, 1075 inflammation of, 1070 Vesico-rectal fistula, 922, 1054 Vesico-uterine fistula, 1054, 1058, 1059 Vesico-utero-vaginal fistula, 1054, 1058 Vesico-vaginal fistula, 1054 et seq. Vesicular granulations, 719 Vezien's suture, 406 Villate, liqueur de, 112, 627 Villous cancer, 538 epithelioma, 543 tumors, 524 of bladder, 1010 Virchow, pathology of inflammation, 36 et seq. Viscera, abdominal, diseases of, 937 et seq. injuries of, 399 et seq. statistics of, 404 pelvic, injuries of, 414 et seq. thoracic, injuries of,' 387 et seq. Visceral syphilis, 494 Vision, field of, in amaurosis, 757 Vitreous humor, diseases of, 749 Voice, impairment of, in throat wounds, 367 INDEX. 1147 Volkmann's sharp spoon, 425 Volvulus, 904 etst y. Vomiting of blood in fractured skull, 334 from displacement of ensiform carti- lage, 757 in injuries of head, 326, 331 spine, 347 intestinal obstruction, 905 shock, 141 strangulated hernia, 873 Vulva, adhesion of, 1085 diseases of, 1087 imperforate, 1085 inflammation of, 1088 gonorrhoeal, 472 injuries of, 419 ulcer of, rodent, 1088 venereal. See Chancroid, and Syphilis. warts of, 108S WANDERING cens> 3? H Ward carriage, 65, 66 Warm bath in retention of urine, 470, 1022,1048 strangulated hernia, 878 Warmth in inflammation, 56 Warts, 548 of cheeks, 804 larynx, 846 penis, 1066 skin-grafting with, 429 venereal, 477, 480, 549 of vulva, 10S8 Warty tumors and ulcers of cicatrices, 551 Washing out stomach in intestinal ob- struction, 907 Water-dressing in gunshot wounds, 175 warm, in inflammation, 56 Wax in ear, 779 Weak ankles, 703 sight, 760 ulcer, 427 Webbed fingers, 694 Weber, test of hearing, 791 Wecker, operation for cataract, 745 Weight for bubo, 502 extension in anchylosis, 655 arthritis, 643 fractured femur, 275, 276, 277 hip-disease, 649 for hemorrhage, 191 Wens. See Tumors, fibro-cellular. Whale, ligature from sinew of, 194 White corpuscles in inflammation, 35 in pyaemia, 453 gangrene, 440 swelling. See Arthritis. Whitehead, excision of internal piles, 932 Whitlow. See. Panaris, and Paronychia. Wind of ball, 169 Windlass, .rope, for dislocations, 289, 309 Spanish, 98 Windpipe. See Larynx and Trachea. Wire coil in aneurism, 602 for drainage, 224, 424 seton for hydrocele, 1074 snare for laryngeal growths, 846 splint for excision of ankle, 684 knee, 682 suture for radical cure of hernia, 867 Wood, epispadia, 1031 extroversion of bladder, 1004 hypospadia, 1031 radical cure of hernia, 868, 886, 895, 899 rhinoplasty, 803 truss for hernia, 866, 886, 893 Woollv choroid, 752 Wounds, 146 antiseptic treatment of, 157 arrow, 161 arterio venous, 208 bayonet, 161 condition of, in erysipelas, 442 hospital gangrene, 434 pyaemia, 453 tetanus, 567 contused. See Wounds, lacerated, dissection, 167 gunshot, 168 amputation and excision in, 175 characters of, 168 contusion of bone in, 180 debridement in, 175 direction of ball in, 171 dressing of, 173 entrance and exit wounds in, 170 hemorrhage from, 172, 173 momentum of projectile in, 168 nature of, 169 pain of, 171 remote consequences of, 180 removal of foreign bodies from, 173 shock in, 171 sloughing in, 169 symptoms of, 171 treatment of, 172 hernia following, 861 incised, 146 dressing of, 150 gaping of, 147 glazing of, 150 healing of, 147 hemorrhage from, 147 pain of, 146 treatment of, 149 lacerated, 154 amputation for, 95, 157 gangrene following, 155 treatment of, 156 open, 146 of particular tissues and organs. See the parts themselves. poisoned, 162 punctured, 160 treatment of, 162 repair of, 147 subcutaneous, 146 1148 INDEX. Wounds— tooth, 162 Wrist, amputation at, 120 diseases and injuries of. Set under Joints. dislocations of, 303 excision of, 176, 673 fractures involving, 270 Wry-neck, 687 with painful spasm, 689 Wutzer, radical cure of hernia, 894 XANTIIIC oxide or Xanthine calculus, 962 Xerosis of conjunctiva, 728 Y-LIGAMENT, 305 Yellow spot. See Maculea lutea. VINC plate for ulcers, 430 11 Zone, genital, 419 Zonular cataract, 739 Zygoma, fracture of, 252 THE END. cd cp i- LEA BROTHERS S CO.'S CLASSIFIED CATALOGUE OF ■ MEDICAL AND SURGICAL flJublkattonB. 3^ In asking the attention of the profession to the works advertised in the following pages, ^ the publishers would state that no pains are spared to secure a continuance of the confi- • dence earned for the publications of the house by their careful selection and accuracy and ^ finish of execution* The large number of inquiries received from the profession for a finer class of bindings than is -j usually placed on medical books has induced us to put certain of our standard 'publications in ^ half Russia; and, that the growing taste may be encouraged, the prices have been fixed at so small an advance over the cost of sheep as to place it within the means of all to possess a library that shall have attractions as well for the eye as for the mind of the reading practitioner. gj The printed prices are those at which books can generally be supplied by booksellers Q throughout the United States, who can readily procure for their customers any works not 'C kePt in stock. 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Or JOURNAL, >i NEWS, VISITING LIST and YEAR-BOOK, $8.50, in advance. Practical Medical Periodicals. j- "T"T7"ITH 1889, The Journal enters upon its sixty-ninth and The g VV News upon its forty-seventh year. Anticipating the require- ments of the times, The News changed from a monthly journal to a vastly larger weekly newspaper in 1882, and The Journal changed from a quarterly to a monthly in 1888, increasing its contents and simultaneously reducing its price. Jointly these two periodicals combine all that is possible and desirable in medical journalism, the promptness of the newspaper and the elaboration of the magazine. {Continued on next page.) 2 Lea Brothers & Co.'s Periodicals—Am. Journal, Medical NewH. The American Journal and Tjje IJedical fleWg. Continued from First Page. Great care is exercised to make them thoroughly practical and of the utmost possible assistance in the every-day work of the physician, surgeon and obstetrician. 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The illustrations are very numerous and unusu- ally clear, and each part seems to have received its due share of attention. We can conceive such a work to be useful, not only to students, but to practitioners as well. It reflects credit upon the industry and energy of its able editor.—Boston Medical and Surgical Journal, Sept. 3.1874. We can say with the strictest truth that it is the best work of the kind with which we are ac- quainted. It embodies in a condensed form all recent contributions to practical medicine, and ia therefore useful to every Dusy practitioner through- out our country, besides being admirably adapted to the use of students of medicine. The book is faithfully and ably executed.—Charleston Medical Journal, April, 1875. NEILL, JOHN, M. D., and SMITH, F. G., M. I)., Late Surgeon to the Penna. Hospital. Prof, of the Institutes of Med. in the Univ. of Penna. An Analytical Compendium of the Various Branches of Medical Science for the use and examination of Students. 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A., Etc A MEDICAL DICTIONABY, including English, French, German, Italian and Latin Technical terms Used in Medicine and the Collateral Sciences. By John S. Billings, A. M., M. D., LL. D. WITH THE COLLABORATION OF FRANK BAKER, M. D., WASHINGTON MATTHEWS, M.D., JAMES M. FLINT, M.D., H. C. YARROW, M. D., R. LOR INI, M.D., W. T. COUNCILMAN, M.D., S. M. BURNETT, M. D., WILLIAM LEE, M.D., J. H. KIDDER, M.D., C. S. MINOT, M.D. In press. DUNGLISON, ROBLEY, M.D., Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal, Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, and the French and other Synonymes, so as to constitute a French as well as an English Medical Lexicon. Edited by Richard J. Dunglison, M. D. In one very large and handsome royal octavo volume 01 1139 pages. Cloth, $6.50; leather, raised bands, $7.50; very handsome half Russia, raised bands, $8. About the first book purchased by the medical ■tudent is the Medical Dictionary.' The lexicon •xplanatory of technical terms is simply a sine qua non. In a science so extensive and with such col- laterals as medicine, it is as much a necessity also to the practising physician. To meet the wants of students and most physicians the dictionary must be condensed while comprehensive, and practical while perspicacious. It was because Dunglison's met these indications that it became at once the dictionary of general use wherever medicine was studied in the English language. In no former revision have the alterations and additions been ■o great. The chief terms have been set in black letter, while the derivatives follow in small caps; an arrangement which greatly facilitates reference. —Cincinnati Lancet and Clinic, Jan. 10,1874. A book of which every American ought to be proud. When the learned author of the work passed away, probably all of us feared lest the book should not maintain its place in the advancing science whose terms it defines. Fortunately, Dr. Richard J. Dunglison, having assisted his father in the revision of several editions of the work, and having been, therefore, trained in the methods and imbued with the spirit of the book, has been able to edit it as a work of the kind should be edited—to carry it on steadily, without jar or inter- ruption, along the grooves of thought it has trav- elled during its lifetime. To show the magnitude of the task which Dr. Dunglison has assumed and carried through, it is only necessary to state that more than six thousand new subjects have been added in the present edition.—Philadelphia Medical Times, Jan. 3,1874. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references.—London Medical Qazette. HOBLYN, RICHARD D., M. D. A Dictionary of the Terms Used in Medicine and the Collateral Sciences. Revised, with numerous additions, by Isaac Hays, M. D., late editor of The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 double-columned pages. Cloth, $1.50; leather, $2.00. It is the best book of definitions we have, and ought always to be upon the student's table.—Southern Medical and Surgical Journal. STUDENTS9 SERIES OF MANUALS. A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, written by eminent Teachers or Examiners, and issued in pocket-size 12mo. volumes of 300-540 pages, richly illustrated and at a low price. The following vol- umes are now ready: Treves HtWhual of Surgery, by various writers, in three volumes, each, $2; Bell's Comparative Physiology and Anatomy, $2; Gould's Surgical Diagno- sis, $2; Robertson's Physiological Physics, $2; Bruce's Materia Medica and Therapeu- tics (4th edition), $1.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's Dissectors' Manual, $1.50; Ralfe's Clinical Chemistry, $1.50; Treves' Surgical Applied Anatomy, $2; Pepper's Surgical Pathology, $2; and Klein's Elements of Histology (3d edition), $1.50. The following is in press: Pepper's Forensic Medicine. For separate notices see index on last page. SERIES OF CLINICAL MANUALS. In arranging for this Series it has been the design of the publishers to provide the profession with a collection of authoritative monographs on important clinical subjects m a cheap and portable form. The volumes will contain about 550 pages and will be freely illustrated by chromo-lithographs and woodcuts. The following volumes are now ready: Carter & Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, $2.25; Ball on the Rectum and Anus, $2.25; Marsh on the Joints, $2; Owen on Surgical Diseases of Children, $2; Morris on Surgical Diseases of the Kidney, $2.25; Pick on Fractures and Dislocations, $2; Butlin on the Tongue, $3.50; Treves on Intestinal Obstruction, $2; and Savage on Insanity and Allied Neuroses, $2. The following are in active preparation: Broadbent on the Pulse, and Lucas on Diseases of the Urethra. For separate notices see index on last page. Lea Brothers & Co.'s Publications—Anatomy. 5 GRAY, HENRY, F. R. S., Lecturer on Anatomy at St. George's Hospital, London. a ■r\nt#rom3r> Descriptive and Surgical. The Drawings by H. V. Carter, M. D., and Dr. Westmacott. The dissections jointly by the Author and Dr. Carter. With an Introduction on General Anatomy and Development by T. Holmes, M.A., Surgeon to bt. Lreorge s Hospital. Edited by T. Pickering Pick, F. R. C. S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Royal College of burgeons of England. A new American from the eleventh enlarged and improved London edition, thoroughly revised and re-edited by William W. Keen, M. D., Professor of Anatomy in the Pennsylvania Academy of the Fine Arts, etc. To which is added the Becond American from the latest English edition of Landmarks, Medical and Surgi- cal, by Luther Holden, F. R. C. S. In one imperial octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Price of edition in black: Cloth, $6; leather, $7; half Russia, $7.50. Price of edition in colors (see below): Cloth, $7.25; leather, $8.25; half Russia, $8.75. This work covers a more extended range of subjects than is customary in the ordinary text-books, giving not only the details necessary for the student, but also the application to those details to the practice of medicine and surgery. It thus forms both a guide for the learner and an admirable work of reference for the active practitioner. The engravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference with descriptions at the foot. In this edition a new departure has been taken by the issue of the work with the arteries, veins and nerves distinguished by different colors. The engravings thus form a complete and splendid series, which will greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recall- ing the details of the dissecting-room. Combining, as it does, a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of great service to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. For the convenience of those who prefer not to pay the slight increase in cost necessi- tated by the use of colors, the volume is published also in black alone, and maintained in this style at the price of former editions, notwithstanding the largely increased size of the work. Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, has been appended to the present edition as it was to the previous one. This work gives in a clear, condensed and systematic way all the information by which the practitioner can determine from the external surface of the body the position of internal parts. Thus complete, the work will furnish all the assistance that can be rendered by type and illustration in anatomical studv. The most popular work on anatomy ever written. It is sufficient to say of it that this edition, thanks to its American editor, surpasses all other edi- tions.—Jour, of the Amer. Met. Ass'n, Dec. 31,1887. A work which for more than twenty years has had the lead of all other text-books on anatomy throughout the civilized world comes to hand in such beauty of execution and accuracy of text and illustration as more than to make good the large promise of the prospectus. It would be in- deed difficult to name a feature wherein the pres- ent American edition of Gray could be mended or bettered, and it needs no prophet to see that the royal work is destined for many years to come to hold the first place among anatomical text- books. The work is published with black and colored plates. It is a marvel of book-making.— American Practitiontr and News, Jan. 21,1888. Gray's Anatomy is the most magnificent work upon anatomy which has ever been published in the English or any other language.—Cincinnati Medical News, Nov. 1887. As the book now goes to the purchaser he is re- ceiving the best work on anatomy that is published in any language.— Virginia Med. Monthly, Dec. 1887. Gray's standard Anatomy has been and will be for years ths text-book for students. The book needs only to be examined to be perfectly under; stood.—Medical Press of Western New York, Jan. 1888. Also for sale separate— HOLDEN, LUTHER, F. R. C. S., Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Landmarks, Medical and Surgical. Second American from the latest revised English edition, with additions by W. W. Keen, M. D, Professor of Artistic Anatomy in the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, $1.00. This little book is all that can be desired within its scope, and its contents will be found simply in valuable to the young surgeon or physician, since thev bring before him such data as he requires at every examination of a patient. It is written in laneuase so clear and concise that one ought almost to learn it by heart. It teachesi diagnosis by external examination, ocular and palpable, of the hodv with such anatomical and physiological facts m directly bear on the subject. It is eminently the student's and young practitioner's book.—Phy- sician and Surgeon, Nov. 1881. The study of these Landmarks by both physi- cians and surgeons is much to be encouraged. It inevitably leads to a progressive education of both the eye and the touch, by which the recognition of disease or the localization of injuries is vastly as- sisted. One thoroughly familiar with the facts here taught is capable of a degree of accuracy and a confidence of certainty which is otherwise unat- tainable. We cordially recommend the Landmarks to the attention of every physician who has not yet provided himself with a copy of this useful, practical guide to the correct jlacing of all the anatomical parts and organs.—Canada Medical and Surgical Journal, Dec. 1881. 6 Lea Brothers & Co.'s Publications—Anatomy. ALLEN, HARRISON, M. D., Professor of Physiology in the University of Pennsylvania. A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. With an Intro- ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 illustrations on 109 full page lithographic plates, many of which are in colors, and 241 engravings in the text. In six Sections, each in a portfolio. Section I. Histology. Section II. Bones and Joints. Section III. Muscles and Fasclb. Section IV. Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. Organs of Sense, or Digestion and Genito-Urinary Organs, Embryology, Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, and General and Clinical Indexes. Price per Section, $3.50; also bound in one volume, cloth, $23.00; very handsome half Russia, raised bands and open back, $25.00. For sale by subscription only. Apply to the Publishers. It is to be considered a study of applied anatomy In its widest sense—a systematic presentation of ■uch anatomical facts as can be applied to the practice of medicine as well as of surgery. Our author is concise, accurate and practical in his statements, and succeeds admirably in infusing an interest into the study of what is generally con- sidered a dry subject. The department of Histol- ogy is treated in a masterly manner, and the ground is travelled over by one thoroughly famil- iar with it. The illustrations are made with great care, and are simply superb. There is as much of practical application of anatomical points to the every-day wants of the medical clinician as to those of the operating surgeon. In fact, few general practitioners will read the work without a Feeling of surprised gratification that so many points, concerning which they may never have thought before are so well presented for their con- sideration. It is a work which is destined to be the best of its kind in any language.—Medical Record, Nov. 25,1882. CLARKE,W. B.,F.R.C.S. & LOCKWOOD,C.B.,F.R.C.S. Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. Limp cloth, red edges, $1.50. See Student^ Series of Manuals, page 4. Messrs.Clarke and Lockwood have written abook I intimate association with students could have that can hardly be rivalled as a practical aid to the given. With such a guide as this, accompanied dissector. Their purpose, which is "how to de- by so attractive a commentary as Treves' Surgical scribe the best way to display the anatomical Applied Anatomy (same series), no student could structure," has been fully attained. They excel in fail to be deeply and absorbingly interested in the a lucidity of demonstration and graphic terseness I study of anatomy.—New Orleans Medical and Sur- of expression, which only a long training and | gieal Journal, April, 1884. TREVES, FREDERICK, F. R. C. S., Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital, Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 4. He has produced a work which will command a larger circle of readers than the class for which it was written. This union of a thorough, practical acquaintance with these fundamental branches, quickened by daily use as a teacher and practi- tioner, has enabled our author to prepare a work which it would be a most difficult task to excel.— The American Practitioner, Feb. 1884. This number of the "Manuals for Students" is most excellent, giving just such practical knowl- edge as will be required tor application in relieving the injuries to which the living body is liable. The book is intended mainly for students, but it will also be of great use to practitioners. The illus- trations are well executed and fully elucidate the text.—Southern Practitioner, Feb., 1884. BELLAMY, EDWARD, F. R. C. S., Senior Assistant-Surgeon to the Charing-Cross Hospital, London. The Student's Guide to Surgical Anatomy: Being a Description of the most Important Surgical Regions of the Human Body, and intended as an Introduction to operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. WILSON, ERASMUS, F. R. S. A System of Human Anatomy, General and Special. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. Cloth, $4.00; leather, $5.00.________________________ CLELAND, JOHN, M. D., F. R. S., Professor of Anatomy and Physiology in Queen's College, Oalway. A Directory for the Dissection of the Human Body. In one 12mo. volume of 178 pages. Cloth, $1.25. HARTSHORNE'S HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second edition, revised. In one royal 12mo. volume of 310 pages, with 220 woodcuts. Cloth, $1.75., HORNER'S SPECIAL ANATOMY AND HISTOL- OGY. Eighth edition, extensively revised and modified. In two octavo volumes of 1007 pages, with 320 woodcuts. Cloth, $6-00. Lea Brothers & Co.'s Publications—Physics, Physiol., Anat. 7 DRAPER, JOHN C, M. D., LL. D., Professor of Chemistry in the University of the City of New York. Medical Physics. A Text-book for Students and Practitioners of Medicine. In one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. FROM THE PREFACE. The fact that a knowledge of Physics is indispensable to a thorough understanding of Medicine has not been as fully realized in this country as in Europe, where the admirable works of Desplats and Gariel, of Robertson and of numerous German writers constitute a branch of educational literature to which we can show no parallel. A full appreciation of this the author trusts will be sufficient justification for placing in book form the sub- stance of his lectures on this department or science, delivered during many years at the University of the City of New York. Broadly speaking, this work aims to impart a knowledge of the relations existing between Physics and Medicine in their* latest state of development, and to embody in the pursuit of this object whatever experience the author has gained during a long period of teaching this special branch of applied science. This elegant and useful work bears aniple testi mony to the learning and good judgment of the author. He has fitted his work admirably to the exigencies of the situation by presenting the reader with brief, clear and simple statements of such propositions as he is by necessity required to master. The subject matter is well arranged, liberally illustrated and carefully indexed. That it will take rank at once among the text-books is certain, and it is to be hoped that it will find a place upon the shelf of the practical physician. where, as a book of reference, it will be found useful and agreeabl*.—Louisville Medical News, September 26,1885. Certainly we have no text-book as full as the ex- cellent one he has prepared. It begins with a statement of the properties of matter and energy. After these the special departments of physics are explained, acoustics, optics, heat, electricity and magnetism, closing with a section on electro- biology. The applications of all these to physiology and medicine are kept constantly in view. The text is amply illustrated and the many difficult points of the subject are brought forward with re- markable clearness and ability.—Medical and Surg- ical Reporter, July 18,1885. That this work will greatly facilitate the study of medical physics is apparent upon even a mere cursory examination. It is marked by that scien- tific accuracy which always characterizes Dr. Draper's writings. Its peculiar value lies in the fact that it is written from the standpoint of the medical man. Hence much is omitted that ap- pears in a mere treatise on physical science, while much is inserted of peculiar value to the physi- cian.—Medical Record, August 22,1885. ROBERTSON, J. McGREGOR, M. A., M. B., Muirhead Demonstrator of Physiology, University of Glasgow. Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- tions. Limp cloth, $2.00. See Students' Series of Manuals, page 4. ments. It will be found of great value to the The title of this work sufficiently explains the nature of its contents. It is designed as a man- ual for the student of medicine, an auxiliary to his text-book in physiology, and it would be particu- larly useful as a guide to his laboratory experi- practitioner. It is a carefully prepared book of reference, concise and accurate, and as such we heartily recommend it.—Journal of the American Medical Association, Dec. 6,1884. DALTON, JOHN C, M. D., Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York. Doctrines of the Circulation of the Blood. A History of Physiological Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 12mo. volume of 293 pages. Cloth, $2. Dr. Dal ton's work is the fruit of the deep research of a cultured mind, and to the busy practitioner it cannot fail to be a source of instruction. It will inspire him with a feeling of gratitude and admir- ation for those plodding workers of olden times, who laid the foundation of the magnificent temple of medical science as it now stands.—New Orleans Medical and Surgical Journal, Aug. 1885. In the progress of physiological study no fact was of greater moment, none more completely revolutionized the theories of teachers, than the discovery of the circulation of the blood. This explains the extraordinary interest it has to all medical historians. The volume before us is one of three or four which have been written within a few years by American physicians. It is in several respects the most complete. The volume, though small in size, is one of the most creditable con- tributions from an American pen to medical history that has appeared.—Med. to speak, can, if he chooses, ui>ilvt< Imii-i' i . .. i;ir with any branch of chem- istry wiiii-h > ■• i u- ,i..-r,7l Pnlnre-ed In two large and handsome octavo volumes, containing 1936 pages. S^llSiofSSer, $12*00; vSy handsome half Russia, raised bands, $13.00. GRIFFITH, ROBERT EGLESFIELD, M. D. A Universal Formulary, containing the Methods of Preparing and Adminis- tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- ists "Third edition, thoroughly revised, with numerous additions, by John M. Maisch, Phar D Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. In one octavo volume of 775 psees. with 38 illustrations. Cloth, $4.50; leather, $5.50. 12 Lea Brothers & Co.'s Publications—Mat. Med., Therap. STILLE, A., M. D.. LL. D., & MAISCH, J. M., Phar. D., Professor Emeritus of the Theory and Prac- Prof, of Mat. Med. and Botany in Phila. tice of Medicine and of Clinical Medicine College of Pharmacol, Sec'y to the Ameri- in the University of Pennsylvania. can Pharmaceutical Association. The National Dispensatory. CONTAINING THE NATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS AND USES OF MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPEIAS OF THE UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS REFERENCES TO THE FRENCH CODEX. Fourth edition revised, and covering the new British Pharmacopoeia. In one mag- nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings. Price in cloth, $7.25 ; leather, raised bands, $8.00; very handsome half Russia, raised bands and open back, $9.00. *** This work will be furnished with Patent Beady Reference Thumb- letter Index for $1.00 in addition to the price in any style of binding. In this new edition of The National Dispensatory, all important changes in the recent British Pharmacopoeia have been incorporated throughout the volume, while in the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical novelties which have been established in professional favor since the publication of the third edition two years ago. Since its first publication, The National Dispensatory has been the most accurate work of its kind, and in this edition, as always before, it may be said to be the representative of the most recent state of American, English, German and French Pharmacology, Therapeutics and Materia Medica. It is with much pleasure that the fourth edition I discovery have received due attention.—Kansas of this magnificent work is received. The authors \ City Medical Index, Nov. 1887. and publishers have reason to feel proud of this, the most comprehensive, elaborate and accurate work of the kind ever printed in this country. It is no wonder that it has become the standard au- thority for both the medical and pharmaceutical profession, and that four editions have been re- quired to supply the constant and increasing demand since its first appearance in 1879. The entire field has been gone over and the various articles revised in accordance with the latest developments regarding the attributes and thera- peutical action of drugs. The remedies of recent % ■ We think it a matter for congratulation that the profession of medicine and that of pharmacy have shown such appreciation of this great work as to call for four editions within the comparatively briel period of eight years. The matters with which it deals are of so practical a nature that neither the physician nor the pharmacist can do without the latest text-books on them, especially those that are so accurate and comprehensive as this one. The book is in every way creditable both to the authors and to the publishers.—New York Medical Journal, May 21,1887. IARQUHARSON, ROBERT, M. D., F. R. C. P., LL. D., Lecturer on Materia Medica at St. Mary's Hospital Medical School, London. A Guide to Therapeutics and Materia Medica. New (fourth) American, from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia. By Frank Woodbury, M. D., Professor of Materia Medica and Therapeutics and Clinical Medicine in the Medico-Chirurgical College of Philadelphia. In one handsome 12mo. volume of 581 pages. Cloth, $2.50. Just ready. FROM THE AMERICAN EDITOR'S PREFACE TO THE FOURTH EDITION. Although the fourth English edition of this work was practically rewritten and con- siderably enlarged, so rapid has been the advance in therapeutics and so great the additions to our materia medica that the American editor has found it necessary to make very many additions so as to make the body of the work include all remedies and preparations of the last revision of the U. S. Pharmacopoeia; a number of non-officinal but important new drugs are also considered, thus making the work as complete in the department of materia medica as it is in therapeutics. In view of the recent publication of the Formulary of the Ameri- can Pharmaceutical Association, containing many valuable formulae that physicians should be familiar with, it has been deemed advisable to add this, although it has increased the size of the book by nearly sixty pages. New prescriptions have also been added. In its present form it is believed that it will continue to serve a useful purpose as a handy ref- erence book on therapeutics and materia medica for the busy practitioner as well as for the medical student. EDES, ROBERT T., M. D., Jackson Professor of Clinical Medicine in Harvard University, Medical Department. A Text-Book of Therapeutics and Materia Medica. Intended for the Use of Students and Practitioners. Octavo, 544 pages. Cloth, $3.50; leather, $4.50. The treatise will be found to be concise and practical, bringing the subject down to the latest developments cf therapeutics and pharmacology. The student and practitioner will find the book a valuable one for reference and study, the former being facilitated by a full and excellent index.— St. Louis Medical and Surgical Journal, Jan. 1888. The present work seems destined to take a prom- inent place as a text-book on the subjects of which it treats. It possesses all the essentials which we cine. Such they can find in the present author. All the newest drugs of promise are treated of. The clinical index at the end will be found very useful. We heartily commend the book and con- gratulate the author on having produced .-o good a one.— N. Y. Medical Joui nal, Feb. 18,1888. Dr. Edes' book represents better than any older book the practical therapeutics of the present day. The book is a thoroughly practical one. The classification of remedies ha* reference to their expect in a book of its kind, such as conciseness, ' therapeutic action, and such a classification will clearness, a judicious classification, and a reason- always meet the approval of the student. The reli- able degree of dogmatism. The style deserves tive importance of different remedies is indicated the highest commendation for its dignity and ] by the space devoted to each, and by the use of purity of diction. The student and young practi- , larger type in the titles of the more important tioner need a safe guide in this branch of medi- | articles.—Pharmaceutical Era, Jan. 1888. Lea Brothers & Co.'s Publications—Pathol., Histol. 13 PAYNE, JOSEPH F., M. D., F. R. C. P., Member of the Pathological Society, Senior Assistant Physician and Lecturer on Pathological Anat- omy, St. Thomas' Hospital, London. A Manual of General Pathology. Designed as an Introduction to the Prac- tice of Medicine. Octavo of 524 pages, with 152 illus. and a colored plate. Cloth, $3.50. Knowing, as a teacher and examiner, the exact needs of medical students, the author has in the work before us prepared for their especial use what we do not hesitate to say is the best introduc- tion to general pathology that we have yet ex- amined. A departure which our author has taken is the greater attention paid to the causa- tion of disease, and more especially to the etiologi- cal factors in those diseases now with reasonable certainty ascribed to pathogenetic microbes. In this department he has been very full and explicit, not only in a descriptive manner, but in the tech- nique of investigation. The Appendix, giving methods of research, is alone worth tne price of the book, several times over, to every student of pathology.—St. Louis Med. and Surg. Jour., Jan.'89.J SENN, NICHOLAS, M.D., Ph.D., Professor of Principles of Surgery and Surgical Pathology in Rush Medical College, Chicago. Surgical Bacteriology. In one handsome octavo of 259 pages, with 13 plates, of which 9 are colored. Cloth, $1.75. Just ready. The immense advances made by surgery during recent years are chiefly due to the new science of Bacteriology. In this volume is collected for the first time, and in avail- able form, the light which this new science sheds upon surgery. It is a work for all who deal with wounds of any nature—for the.general practitioner and obstetrician as well as for the surgeon. COATS, JOSEPH, M. D., F. F. P. S., Pathologist to the Glasgow Western Infirmary. A Treatise on Pathology. In one very handsome octavo volume of 829 pages, with 339 beautiful illustrations. Cloth, $5.50; leather, $6.50. The work before us treats the subject of Path- ology more extensively than it is usually treated in similar works. Medical students as well as physicians, who desire a work for study or refer- ence, that treats the subjects in the various de- partments in a very thorough manner, but without prolixity, will certainly give this one the prefer- ence to any with which we are acquainted. It sets forth the most recent discoveries, exhibits, in an interesting manner, the changes from a normal condition effected in structures by disease, and points out the characteristics of various morbid agencies, so that they can be easily recognized. But, not limited to morbid anatomy.it explains fully how the functions of organs are disturbed by abnormal conditions.—Cincinnati Medical News, Oct. 1883. GREEN, T. HENRY, M. D., Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School, London. Pathology and Morbid Anatomy. New (sixth) American from the seventh revised English edition. In one octavo vol. of 500 pp., with 150 engravings. In Press. WOODHEAD, G. SIMS, M. D., F. R. C. P. E., Demonstrator of Pathology in the University of Edinburgh. Practical Pathology. A Manual for Students and Practitioners. In one beau- tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. It forms a real guide for the student and practi- themselves with this manual. The numerous tioner who is thoroughly in earnest in his en- drawings are not fancied pictures, or merely deavor to see for himself and do for himself. To schematic diagrams, but they represent faithfully the laboratory student it will be a helpful com- the actual images seen under the microscope. panion, and all those who may wish to familiarize The author merits all praise for having produced themselves with modern methods of examining a valuable work.—Medical Record, May 31,1884. morbid tissues are strongly urged to provide SCHAFER, EDWARD A., F. R. S., Assistant Professor of Physiology in University College, London. The Essentials of Histology. In one octavo volume of 246 pages, with 281 illustrations. Cloth, $2.25. This admirable work was greatly needed. It has been written with the object of supplying the student with directions for the microscopical examination of the tissues, which are given m a clear and understandable way. Although espe- cially adapted for laboratory work, at the same time it is intended to serve as an elementary text-book of histology, comprising all the essen- tial facts of the science. The author has recom- mended only those methods upon which long ex- perience has proved that full dependence can be placed.—The Physician and Surgeon, July, 1887. KLEIN. E., M. D., F. R. S., Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hoep., London. Elements of Histology. Fourth edition. In one 12mo. volume of 376 pages, with 194 illus. Limp cloth, $1.75. Just ready. See Students' Series of Manuals, page 4. Considered with regard to its contents, it can only be looked on as a large and comprehensive volume. New and original illustrations have been added with the help of which the structure of each tissue becomes clear to the reader. A copious index affords a ready reference to the histology of every tissue and organ, and presents, at the same time, a complete glossary of the scientific terms.— Provincial Medical Journal, May 1,1889. PEPPER, A. J., M. B., M. S., F. R. C. S., Surgeon and Lecturer at St. Mary's Hospital, London. Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 4. Its form k> practical, its language is clear, and I in it nothing that is unnecessary. The list ot the information set forth is well-arranged, well- subjects covers the whole range of surgery, indexed and well-illustrated. The student will find | York Medical Journal, May 31,1884. New 14 Lea Brothers & Co.'s Publications—Practice of Med. FLINT, AUSTIN, M. D., LL. D. Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellewe Hospital Medical College, N. Y. A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly re- vised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome octavo volume of 1160 pages, with illustrations. Cloth, $5.50; leather, $6.50; very handsome half Eussia, raised bands, $7.00. general approval by medical students and practi- tioners as the work of Professor Flint. In all the medical colleges of the United States it is the fa- vorite work upon Practice; and, as we have stated before in alluding to it, there is no other medical work that can be so generally found in the libra- ries of physicians. In every state and territory of thiavast country the book that will be most likely to be found in the office of a medical man, whether in city, town, village, or at some cross-roads, is Flint's Practice. We make this statement to a considerable extent from personal observation, and it is the testimony also of others. An examina- tion shows that very considerable changes have been made in the sixth edition. The work may un- doubtedly be regarded as fairly representing the present state of the science of medicine, and as reflecting the views of those who exemplify in their practice the present stage of progress of med- ical art.—Cincinnati Medical News, Oct. 1886. A new edition of a work of such established rep- utation as Flint's Medicine needs but few words to commend it to notice. It may in truth be said to embody the fruit of his labors in clinical medicine, ripened by the experience of a long life devoted to its pursuit America may well be proud of having produced a man whose indefatigable industry and gifts of genius have done so much to advance med- icine; and all English-reading students must be grateful for the work which he has left behind him. It has few equals, either in point of literary excel- lence, or of scientific learning, and no one can study its pages without being struck by the lu- cidity and accuracy which characterize them. It is qualities such as these which render it so valu- able for its purpose, and give it a foremost place among the text-books ^f this generation.—The London Lancet, March 12,1887. No text-book on the principles and practice of medicine has ever met in this country with such HARTSHORNE, HENRY, M. D., LL. D., Lately Professor of Hygiene in the University of Pennsylvania. Essentials of the Principles and Practice of Medicine. A Handbook for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75; half bound, $3.00. Within the compass of 600 pages it treats of the I this one; and probably not one writer in our day — ral | had a better opportunity than Dr. Hartshorne for g | condensing all the views of eminent practitioners into a 12mo. The numerous illustrations will be very useful to students especially. These essen- tials, as the name suggests, are not intended to supersede the text-books of Flint and Bartholow, but they are the most valuable in affording the means to see at a glance the whole literature of any laryngoscope, ophthalmoscope, etc.), general ther apeutics, nosology, and special pathology and prac tice. There is a wonderful amount of Information contained in this work, and it is one of the best of its kind that we have seen.—Glasgow Medical Journal, Nov. 1882. An indispensable book. No work ever exhibited a better average of actual practical treatment than disease, and the most valuable treatment—Chicago Medical Journal and Examiner, April, 1882. BRISTOWE, JOHN SYER, M. D., F. R. C. P., Physician and Joint Lecturer on Medicine at St. Thomas' Hospital, London. A Treatise on the Practice of Medicine. Second American edition, revised by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. Cloth, $5.00; leather, $6.00. The book is a model of conciseness, and com- I and practice, as skin diseases, syphilis and insan- bines, as successfully as one could conceive it to ity, but they will not be objected to by readers, as be possible, an encyclopaedic character with the I he has studied them conscientiously, and drawn smallest dimensions. It differs from other admi- from the life.—Medical and Surgical Reporter, De- rable text-books in the completeness with which it covers the whole field of medicine.—Michigan Medical News, May 10,1880. His accuracy in the portraiture of disease, his care in stating subtle points of diagnosis, and the faithfully given pathology of abnormal processes have seldom been surpassed. He embraces many diseases not usually considered to belong to theory cember 20,1879. The reader will find every conceivable subject connected with the practice of medicine ably pre- sented, in a style at once clear, interesting and concise. The additions made by Dr. Hutchinson are appropriate and practical, and greatly add to its usefulness to American readers.—Buffalo Med- ical and Surgical Journal, March, 1880. WATSON, SIR THOMAS, M. D., Late Physician in Ordinary to the Queen. Lectures on the Principles and Practice of Physic. A new American from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In two large octavo volumes of 1840 pages. Cloth, $9.00; leather, $11.00. LECTURES ON THE STUDY OF FEVER. By A. Hudson, M. D., M. R. I. A In one octavo volume of 308 pages. Cloth, $2.50. A TREATISE ON FEVER. By Robert D. Lyons, K. C C In one 8vo. vol. of 354 pp. Cloth, $2.26. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological and Therapeutical Relations. In two large and hand- some octavo volumes of 1468 pp. Cloth, $7.00. A CENTURY OF AMERICAN MEDICINE, 1776—1876. By Drs. E. H. Clabke, H. J. Bisxlow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one 12mo. volume of 370 pages. Lea Brothers & Co.'s Publications—System of Med. 15 For Sale by Subscription Only. A System of Practical Medicine. BY AMERICAN AUTHORS. Edited by WILLIAM PEPPER, M. D., LL. D., PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the Hospital of the University of Pennsylvania. The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. Price per volume, cloth, $5; leather, $6; half Russia, raised bands and open back, $7. In this great work American medicine is for the first time reflected by its worthiest teachers, and presented in the full development of the practical utility which is its pre- eminent characteristic. The most able men—from the East and the West, from the North and the South, from all the prominent centres of education, and from all the hospitals which afford special opportunities for study and practice—have united in generous rivalry to bring together this vast aggregate of specialized experience. The distinguished editor has so apportioned the work that to each author has been assigned the subject which he is peculiarly fitted to discuss, and in which his views will be accepted as the latest expression of scientific and practical knowledge. The practitioner will therefore find these volumes a complete, authoritative and unfailing work of reference, to which he may at all times turn with full certainty of finding what he needs in its most recent aspect, whether he seeks information on the general principles of medi- cine, or minute guidance in the treatment of special disease. So wide is the scope of the work that, with the exception of midwifery and matters strictly surgical, it embraces the whole domain of medicine, including the departments for which the physician is accustomed to rely on special treatises, such as diseases of women and children, of the genito-urinary organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology and otology. Moreover, authors have inserted the formulas which they have found most efficient in the treatment of the various affections. It may thus be truly regarded as a Complete Library of Practical Medicine, and the general practitioner possessing it may feel secure that he will require little else in the daily round of professional duties. In spite of every effort to condense the vast amount of practical information fur- nished, it has been impossible to present it in less than 5 large octavo volumes, containing about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary octavos. Illustrations are introduced wherever requisite to elucidate the text. A detailed prospectus will be sent to any address on application to the publishers. These two volumes bring this admirable work to a close, and fully sustain the high standard reached by the earlier volumes; we have only therefore to echo the eulogium pronounced upon them. We would warmly congratulate the editor and his collaborators at the conclusion of their laborious task on the admirable manner in which. from first to last, they have performed their several duties. They have succeeded in producing a work which will long remain a standard work of reference, to which practitioners will look for guidance, and authors will resort for facts. From a literary point of view, the work is without any serious blemish, and in respect of production, it has the beautiful finish that Americans always give their works.—Edinburgh Medical Journal, Jan. 1887. • * The greatest distinctively American work on the practice of medicine, and, indeed, the super- lative adjective would not be inappropriate were even all other productions placed in comparison. An examination of the five volumes is sufficient to convince one of the magnitude of the enter- prise, and of the success which has attended its fulfilment.— The Medical Age, July 26,1886. This huge volume forms a fitting close to the great system of medicine which in so short a time as won so high a place in medical literature, and has done such credit to the profession in this country. Among the twenty-three contributors are the names of the leading neurologists in America, and most of the work in the volume is of the highest order.—Boston Medical and Surgical Journal, July 21,1887. , J , We consider it one of the grandest works on Practical Medicine in the English language. It is a work of which the profession of this country can feel proud. Written exclusively by American physicians who are acquainted with all the varie- ties of climate in the United States, the character of the soil, the manners and customs of the peo- ple, etc., it is peculiarly adapted to the wants of American practitioners of medicine, and it seems to us that every one of them would desire to have it. It has been truly called a "Complete Library of Practical Medicine," and the general practitioner will require little else in his round of professional duties.—Cincinnati Medical News, March, 1886. Each of the volumes is provided with a most copious index, and the work altogether promises to be one which will add much to the medical literature of the present century, and reflect great credit upon the scholarship and practical acumen of its authors.—The London Lancet, Oct. 3,1885. The feeling of proud satisfaction with which the American profession sees this, its representative system of practical medicine issued to the medi cal world, is fully justified by the character of the work. The entire caste of the system is in keep- ing with the best thoughts of the leaders and fol- lowers of our home school of medicine, and the combination of the scientific study of disease and the practical application of exact and experimen- tal knowledge to the treatment of human mal- adies, makes every one of us share in the pride that has welcomed Dr. Pepper's labors. Sheared of the prolixity that wearies the readers of the German school, the articles glean these same fields for all that is valuable. It is the outcome of American brains, and is marked throughout by much of the sturdy independence of thought and originality that is a national characteristic. Yet nowhere is there lack of study of the moat advanced views of the day.—North Carolina Medv- cal Journal, Sept. 1886. 16 Lea Brothers & Co.'s Publications—Clinical Med., etc. FOTHERGILL, J. M., M. D., Edin., M. R. C. P., Lond., Physician to the City of London Hospital for Diseases of the Chest. The Practitioner's Handbook of Treatment; Or, The Principles of Thera- peutics. New (third) edition. In one 8vo. vol. of 661 pages. Cloth, $3.75; leather, $4.76. To have a description of the normal physiologi- cal processes of an organ and of the methods of treatment of its morbid conditions brought together in a single chapter, and the relations between the two clearly stated, cannot fail to prove a great convenience to many thoughtful but busy physicians. The practical value of the volume is greatly increased by the introduction of many prescriptions. That the profession appreciates that the author has undertaken an important work and has accomplished it is shown by the demand for this third edition.—N. Y. Med. Jour., June 11,'87. This is a wonderful book. If there be such a thing as "medicine made easy," this is the work to accomplish this result.— Va. Med. Month., June,'87. It is an excellent, practical work on therapeutics, well arranged and clearly expressed, useful to the student and young practitioner, perhaps even to the old.—Dublin Journal of Medical Science, March. 1888. We do not know a more readable, practical and useful work on the treatment of disease than the one we have now before us.—Pacific Medical and Surgical Journal, October, 1887. VAUGHAN, VICTOR C, Ph. D., M.D., Prof, of Phyt. and Path. Chem. and Assoc. Prof, of Therap. and Mat. Med. in the Univ. of Mich. and NOVY, FREDERICK G., M. D. Instructor in Hygiene and Phys. Chem. in the Univ. of Mich. Ptomaines and Leucomaines, or Putrefactive and Physiological Alkaloids. In one handsome 12mo. volume of 311 pages. Just ready. Cloth, $1.75. This book is what has been wanted for some years by the medical profession. The subject of ptomaines and leucomaines, so far as their disease- producing relations are concerned, has been under special study scarcely more than a decade, but within that period facts have been discovered observers and experimenters on micro-organisms. and to trace the relationship of cause and effect of the putrefacative alkaloids. We congratulate the authors upon the successful presentation of the current views on the subject in such manner as to make them easily comprehensible, while to upon which theories of permanent standing have ] the practitioner, after he has carefully read the been built, until now the practitioner is far be- book, it will serve, also, as a frequent reference hind the times if he does not appreciate the importance of ptomaines. This is the first attempt made to collect into book form the results of work, because of the technical information it gives. Va. Medical Monthly, Sept. 1888. REYNOLDS, J. RUSSELL, M. D., Professor of the Principles and Practice of Medicine in University College, London. A System of Medicine. With notes and additions by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- tions. Price per volume, cloth, $5.00; sheep, $6.00; very handsome half Russia, raised bands, $6.50. Per set, cloth, $15; leather, $18; half Russia, $19.50. Sold only by subscription. STILLE, ALFRED, M. D., LL. D., Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. FINLAYSON, JAMES, M. D., Editor, Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc Clinical Manual for the Study of Medical Cases. With Chapters by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of the Female Organs; Dr. Robertson on Insanity; Dr. Gemmell on Physical Diagnosis; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- taking, Family History and Symptoms of Disorder in the Various Systems. New edition. In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. This manual is one of the most complete and and a study of means to the end which cannot perfect of its kind. It goes thoroughly into the fail in laying an excellent foundation for the Question of diagnosis from every possible point, student for future success as an able diagnostician. t must lead to a thoroughness of observation, an —Medical Record, August 13,1887. examination in detail of every scientific appliance, FENWICK, SAMUEL, M. D., Assistant Physician to the London Hospital. The Student's Guide to Medical Diagnosis. From the third revised and enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 87 illustrations on wood. Cloth, $2.25. . HABERSHON, S. O., M. D., Senior Physician to and late Lect. on Principles and Practice of Med. at Guy's Hospital, London. On the Diseases of the Abdomen; Comprising those of the Stomach, and other parts of the Alimentary CanaL OZsophagus, Caecum, Intestines and Peritoneum. Second American from third enlarged and revised English edition. In one handsome octavo volume of 554 pages, with illustrations. Cloth, $3.50. TANNER, THOMAS HAWKES, M. D. A Manual of Clinical Medicine and Physical Diagnosis. Third American from the second London edition. Revised and enlarged by Tilbury Fox, M. D. In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. Lea Brothers & Co.'s Publications—Hygiene, Electr., Pract. 17 BARTHOLOW, ROBERTS, A, M., M. D., LL. D., Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. Medical Electricity. A Practical Treatise on the Applications of Electricity to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 308 pages, with 110 illustrations. Cloth, $2.50. should read it, especially when it is recalled what possibilities lie in the path of the further study of the therapeutics of electricity. Dr. Bartholow has here presented the profession with a concise work that, beginning with elementary descriptions and principles, gradually grows, page by page, into a magnificently practical treatise, describing opera- tions in detail, and giving records of successes that prove electricity to be marvellous as a curative agent in many forms of disease. The doctor can- not now do better than to possess himself of Dr. Bartholow's treatise, just as it is.— Virginia Medi- cal Monthly, June, 1887. The fact that this work has reached its third edi- tion in six years, and that it has been kept fully abreast with the increasing use and knowledge of electricity.demonstrates its claim to be considered a practical treatise of tried value to the profession. The matter added to the present edition embraces the most recent advances in electrical treatment. The illustrations are abundant and clear, and the work constitutes a full, clear and concise manual well adapted to the needs of both student and practitioner.— The Medical News, May 14,1887. This "practical treatise on the applications of electricity to medicine and surgery" has grown to be so important a work that every practitioner RICHARDSON, B. W., M.D., LL. D., F.R.S., Fellow of the Royal College of Physicians, London. Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, $5; very handsome half Russia, raised bands, $5.50. Dr. Richardson has succeeded in producing a work which is elevated in conception, comprehen- sive in scope, scientific in character, systematic in arrangement, and which is written in a clear, con- cise and pleasant manner. He evinces the happy faculty of extracting the pith of what is known on the subject, and of presenting it in a most simple, intelligent and practical form. There is perhaps no similar work written for the general public thatcontains such acomplete,reliable and instruc- tive collection of data upon the diseases common to the race, their origins, causes, and the measures for their prevention. The descriptions of diseases are clear, chaste and scholarly; the discussion of the question of disease is comprehensive, masterly and fully abreast with the latest and best knowl- edge on the subject, and the preventive measures advised are accurate, explicit and reliable.—The American Journal of the Medical Sciences, April, 1884. Thi»is a book that will surely find a place on the table of every progressive physician. To the medi- cal profession, whose duty is quite as much to prevent as to cure disease, the book will be a boon. —Boston Medical and Surgical Journal, March 6, '84. The treatise contains a vast amount of solid, val- uable hygienic information.—Medical and Surgical Reporter, Feb. 23,1884. THE YEAR-BOOK OF TREATMENT FOR 1889. A Comprehensive and Critical Review for Practitioners of Medi- cine. In one 12mo. volume of 349 pages, bound in limp cloth, $1.25. Just ready. #*# For special commutations with periodicals see page 2. THE YEAR-BOOK OF TREATMENT FOR 1887. Similar to above. 12mo., 341 pages. Limp cloth, $1.25. This is one of the most valuable books for its price which is published in this or any coun- try. It contains a summary of the changes in medical practice, the new remedies introduced, and the experience with them and with others which have been longer in use, during the year 1887, made up from the reading and observation of a number of very capable men. The classifica- tion is according to diseases, so that one who con- sults these pages can obtain in a few minutes an excellent idea of the present status of therapeu- tics in regard to any given ailment. The book also has a good index, by means of which the reader may ascertain the different diseases for which any particular drug has been used during the year past.—Medical and Surgical Reporter, April 14,1888. THE YEAR-BOOK OF TREATMENT FOR 1886. Similar to that of 1887 above. 12mo., 320 pages. Limp cloth, $1.25. SCHREIBER, DR. JOSEPH. A Manual of Treatment by Massage and Methodical Muscle Ex- ercise Translated by Walter Mendelson, M. D., of New York. In one handsome octavo volume of 274 pages, with 117 fine engravings. Just ready. Cloth, $2.75. This is a work abounding in common sense, a book that sweeps away a great deal of nonsense by which a simple matter has been made obscure, a volume that ought to be read by every one inter- ested in modern therapeutics. The work gives admirable directions for the employment of mas- sage, and capital descriptions of methodical exer- cise, after which there is a detailed account of the results of treatment of different diseases by these methods. A full bibliography adds to the value of the volume, which can be recommended as one of the best on the subjects with which it deals.— Edinburgh Medical Journal, April, 1888. 8TURGES' INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the Investigation of Disease. In one handsome l2mo. volume of 127 pages. Cloth, 81.25. DAVIS' CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES By N. S. Davis M. D. Edited by Frank H. Davis, M. D. Second edition. 12mo. 287 pages. Cloth, $1.75. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one octavo volume of S20 pages. Cloth, $2.50. PAVY'S TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment From the second London edition. In one octavo volume of 238 pages. Cloth, 82.00. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With additions by D. F. Condk, M. D. 1 vol. 8vo.,m>. 603. Cloth, $2.50. CHAMBERS' MANUAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one hand- some octavo volume of 302 pp. Cloth, $2.75. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 18 Lea Brothers & Co.'s Publications—Throat, Lungs, Heart. FLINT, AUSTIN, M. D., LL. D., Professor of the Principles and Practice of Medicine in BeUevue Hospital Medical College, N. Y. A Manual of Auscultation and Percussion; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fourth edition. In one handsome royal 12mo. volume of 278 pages, with 14 illustrations. Cloth, $1.75. The original work done by Dr. Flint in the devel- | passed through four editions attests its popularity opmentof the art of physical diagnosis will always make this manual an authority on this subject. Among all the works issued on this topic during the last few years, none exceeds this one in sim- plicity and completeness. The fact that it has There is a tendency among physical diagnosti- cians to make altogether too many varieties of morbid chest sounds, and especially of rales. The conciseness of Dr. Flint's Manual is one of its chief advantages —Medical Record, June 16,1888. BY THE SAME AUTHOR. A Practical Treatise on the Physical Exploration of the Chest and the Diagnosis of Diseases Affecting the Respiratory Organs. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and Complications, Fatality and Prognosis, Treatment and Physical Diag- nosis ; In a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50. A Practical Treatise on the Diagnosis, Pathology and Treatment of Diseases of the Heart. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate. Cloth, $4. Essays on Conservative Medicine and Kindred Topics. In one very hand- some royal 12mo. volume of 210 pages. Cloth, $1.38. BROWNE, LENNOX, F. R. C. S., E., Senior Physician to the Central London Throat and Ear Hospital. A Practical Guide to Diseases of the Throat and Nose, including Associated Affections of the Ear. With 120 illustrations in color, and 200 en- gravings on wood designed and executed by the Author. New (second) and enlarged edition. In one imperial octavo volume of 628 pages. Cloth, $6. Mr. Browne's book can be recommended to students and still more to practitioners as a clear. sound and practical guide to the diagnosis ana treatment of diseases of the throat. His experi- ence is not only large, but ripe, and he gives his readers the full benefit of it. A particularly praise- worthy feature is that from beginning to end Mr. Browne, whilst giving due prominence to local measures, never Tails to insist on the necessity of supplementing these by proper constitutional treatment.—London Medical Recorder, May, 1888. SEILER, CARL, M. D., Lecturer on Laryngoscopy in the University of Pennsylvania. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. New (third) edition. In one handsome royal 12mo. volume of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25. Just ready. Practical points, to which the book is limited, I will be found throughout the volume. Two care- have been considered as concisely as possible, fully-executed colored plates will be found of making the work an excellent one for ready refer- assistance to the student and practitioner.—South- ence on the subjects treated. Numerous additions | ern Practitioner, April, 1889. GROSS, S. D., M.D., LL.D., D.C.L. Oxon., LL.D. Cantab. A Practical Treatise on Foreign Bodies in the Air-passages. In one octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. COHEN, J. SOLIS, M. D., Lecturer on Laryngoscopy and Diseases of the Throat and^Chest in the Jefferson Medical College. Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third edition, thoroughly revised and rewritten, with a large number of new illustrations. In one very handsome octavo volume. Preparing. BROADBENT, W. H., M. D., I.*R. C. P., Physician to and Lecturer on Medicine at St. Mary's Hospital. The Pulse. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 4. PULLER ON DISEASES OF THE LUNGS AND I valence in various Countries. Second and revised AIR-PASSAGES. Their Pathology, Physical Di- edition. In one 12mo. vol., pp. 158. Cloth $1 25 agnosia, Symptoms and Treatment. From the SMITH ON CONSUMPTION; Its Early and Kernel second and revised English edition. In one ' octavo volume of 476 pages. Cloth, $3.50. WAL8HE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Third American edi- tion. In 1 vol. 8vo.. 416 pp. Cloth, $3.00. BLADE ON DIPHTHERIA; its Nature and Treat- ment, with an account of the History of its Pre- diable Stages. 1 vol. 8vo., pp. 253. Cloth. $2 26 LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 pages. Cloth,$3.00. WILLIAMS ON PULMONARY CONSUMPTION; its Nature, Varieties and Treatment. With an analysis of one thousand cases to exemplify its duration. In one 8vo. vol. of 303 pp. Cloth, $2.60 Lea Brothers & Co.'s Publications—Nerv. and Ment. Dis., etc. 19 ROSS, JAMES, M.D., F.R.C.P., LL.D., Senior Assistant Physician to the Manchester Royal Infirmary. A Handbook on Diseases of the Nervous System. In volume of 725 pages, with 184 illustrations. Cloth, $4.50; leather, $5.50 This admirable work is intended for students of medicine and for such medical men as have no time for lengthy treatises. In the present instance the duty of arranging the vast store of material at the disposal of the author, and of abridging the de- scription of the different aspects of nervous dis- eases, has been performed with singular skill, and the result is a concise and philosophical guide to one octavo the department of medicine of which it treats. Dr. Ross holds such a high scientific position that any writings which bear his name are naturally expected to have the impress of a powerful intel- lect. In every part this handbook merits the highest praise, and will no doubt be found of the greatest value to the student as well as to the prac- titioner.— Edinburgh Medical Journal, Jan. 1887. MITCHELL, S. WEIR, M. D., Physician to Orthopaedic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc. Lectures on Diseases of the Nervous System; Especially in Women. Second edition. In one 12mo. volume of 288 pages. Cloth, $1.75. No work in our language develops or displays more features of that many-sided affection, hys- teria, or gives clearer directions for its differen- tiation, or sounder suggestions relative to its general management and treatment. The book Is particularly valuable in that it represents in the main the author's own clinical studies, which have been so extensive and fruitful as to give his teachings the stamp of authority all over the realm of medicine. The work, although written by a specialist, has no exclusive character, and the general practitioner above all others will find its perusal profitable, since it deals with diseases which he frequently encounters and must essay to treat.—American Practitioner, August, 1885. HAMILTON, ALLAN McLANE, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelPs Island, N. Y. Nervous Diseases; Their Description and Treatment. Second edition, thoroughly revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. When the first edition of this good book appeared we gave it our emphatic endorsement, and the E resent edition enhances our appreciation of the ook and its author as a safe guide to students of clinical. neurology. One of the best and most critical of English neurological journals, Brain, has characterized this book as the best of its kind in any language, which is a handsome endorsement from an exalted source. The improvements in the new edition, and the additions to it, will justify its purchase even by those who possess the old.— Alienist and Neurologist, April, 1882. TUKE, DANIEL HACK, M. D., Joint Author of The Manual of Psychological Medicine, etc. Illustrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. New edition. Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, $3. It is impossible to peruse these interesting chap ters without being convinced of the author's per- fect sincerity, impartiality, and thorough mental grasp. Dr. Tuke has exhibited the requisite amount of scientific address on all occasions, and the more intricate the phenomena the more firmly has he adhered to a physiological and rational method of interpretation. Guided by an enlight- ened deduction, the author has reclaimed for science a most interesting domain in psychology, previously abandoned to charlatans and empirics. This book, well conceived and well written, must commend itself to every thoughtful understand- ing.—New York Medical Journal, September 6,1884. the general practitioner in guiding him to a diag- nosis and indicating the treatment, especially in many obscure and doubtful cases of mental dis- ease. To the American reader Dr. Folsom's Ap- pendix adds greatly to the value of the work, and will m lie it a desirable addition to every library. —American Psychological Journal, July, 1884. CLOUSTON, THOMAS S., M. D., F. R. C. P., L. R. C. S., Lecturer on Mental Diseases in the University of Edinburgh. Clinical Lectures on Mental Diseases. With an Appendix, containing an Abstract of the Statutes of the United States and of the Several States and Territories re- lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume oi 541 pages, with eight lithographic plates, four of which are beautifully colored. Cloth, " The practitioner as well as the student will ac- A' cept the plain, practical teaching of the author as a forward step in the literature of insanity. It is refreshing to find a physician of Dr. Clouston s experience and high reputation gi~in? the red side notes upon which his experience nas been founded and his mature judgment estaDiisned. Such clinical observations cannot but be useful to 8^*Dr. Folsom's Abstract may also be obtained separately in one octavo volume of 108 pages. Cloth, $1.50. SAVAGE, GEORGE H., M. D., Lecturer on Mental Diseases at Guy's Hospital, London. Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, page 4. PLAYFAIR, W. S., M. D., F. R. C. P. The Systematic Treatment of Nerve Prostration and Hysteria. In one handsome small 12mo. volume of 97 pages. Cloth, $1.00. Blandford on Insanity and its Treatment: Lectures on the Treatment, Medical and Legal, of Insane Patients. In one very handsome octavo volume. Jones' Clinical Observations on Functional Nervous Disorders. Second American Edition. In one handsome octavo volume of 340 pages. Cloth, $3.25. 20 Lea Brothers & Co.'s Publications—Surgery. ASHHURST, JOHN, Jr., M. D., Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. The Principles and Practice of Surgery. New (fourth) edition, enlarged and revised. In one large and handsome octavo volume of 1114 pages, with 597 illustra- tions. Cloth, $6; leather, $7 ; half Russia, $7.50. As with Erichsen so with Ashhurst, its position in professional favor is established, and one has now but to notice the changes, if any, in theory and practice, that are apparent in the present as compared with the preceding edition, published three years ago. The work has been brought well up to date, and is larger and better illustrated than before, and its author may rest assured that it will certainly have a " continuance of the favor with which it has heretofore been received."—The American Journal of the Medical Sciences, Jan. 1886. Every advance in surgery worth notice, chroni- cled in recent literature, has been suitably recog- nized and noted in its proper place. Suffice it to say, we regard Ashhurst's Surgery, as now pre- sented in the fourth edition, as the best single volume on surgery published in the English lan- guage, valuable alike to the student and the prac- titioner, to the one as a text-book, to the other as a manual of practical surgery. With pleasure we give this volume our endorsement in full.—Nev> Orleans Medical and Surgical Journal, Jan., 1886. GROSS, S. D., M. D., LL. D., D. C. L. Oxon., LL. D. Cantab., Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. Strongly bound in leather, raised bands, $15; half Russia, raised bands, $16. Dr. Gross' System of Surgery has long been the standard work on that subject for students and practitioners.—London Lancet, May 10,1884. The work as a whole needs no commendation. Many years ago it earned for itself the enviable reputation of the leading American work on sur- gery, and it is still capable of maintaining that standard. A considerable amount of new material has been introduced, and altogether the distin- fuished author has reason to be satisfied that he as placed the work fully abreast of the state of our knowledge.—Med. Record, Nov. 18,1882. His System of Surgery, which, since its first edi- tion in 1869, has been a standard work in this country as well as in America, in "the whole domain of surgery," tells how earnest and labori- ous and wise a surgeon he was. how thoroughly he appreciated the work done by men in other countries, and how much he contributed to pro- mote the science and practice of surgery in his own. There has been no man to whom America is so much indebted in this respect as the Nestor of surgery.—British Medical Journal, May 10,1884. DRUITT, ROBERT, M. R. C. S., etc. Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- ley Boyd, M. B., B. S., F. R. C. S. In one 8vo. volume of 965 pages, with 373 illustra- tions. Cloth, $4; leather, $5. It is essentially a new book, rewritten from be- ginning to end. The editor has brought his work up to the latest date, and nearly every subject on which the student and practitioner would desire to consult a surgical volume, has found its place here. The volume closes with about twenty pages of formulae covering a broad range of practical therapeutics. The student will find that the new Druitt is to this generation what the old one was to the former, and no higher praise need be accorded to any volume.—North Carolina Medical Journal, October, 1887. Druitt's Surgery has been an exceedingly popu- lar work in the profession. It is stated that 50,000 copies have been sold in England, while in the United States, ever since its first issue, it has been used as a text-book to a very large extent. Dur- ing the late war in this country it was so highly appreciated that a copy was issued by the Govern- ment to each surgeon. The present edition, while it has the same features peculiar to the work at first, embodies all recent discoveries in surgery, and is fully up to the times. Cincinnati Medical News, September, 1887. BALL, CHARLES B., M. Ch., Dub., F. R. C. S. E., Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. Diseases of the Rectum and Anus. In one 12mo. volume of 417 pages, with 54 engravings and 4 colored plates. Cloth, $2.25. Just ready. See Series of Clinical Manuals, page 4. has done for intestinal obstruction, and both works are alike creditable.—N. Y. Medical Journal, Jan. 28,1888. A capital book in a capital series of clinical manuals. Thoroughly practical, it is both compre- hensive and condensed and the possessor of it will find but little use for any more extended work on the subject. Mr. Ball is a most sound surgeon.— The Medical News, Feb. 4,1888. It is a pleasure to read an exhaustive and well- arranged book, such as the one before us. It covers all the ground, and yet is written in a terse and concise style that makes it exceedingly good reading. The work is far in advance of the ordi- nary text-book on this specialty. It is very com- plete, and the matter is all of practical importance and well arranged. The writer has done for rectal surgery what Treves in the companion volume GIBNEY, V. P., M. D., Surgeon to the Orthopaedic Hospital, New York, etc. Orthopaedic Surgery. For the use of Practitioners and Students. some octavo volume, profusely illustrated. Preparing. In one hand- ROBERTS, J. B., M. D., and MORTON, T. S. K., M. D., Professor of Anatomy and Surgery xn the Adjunct Professor of Operative Surgery in the Philadelphia'.Polyclimc. Philadelphia Polyclinic. The Principles and Practice of Modern Surgery. For the use of Students and Practitioners of Medicine and Surgery. In one very handsome octavo volume of abont 500 pages, with many illustrations. Preparing. Lea Brothers & Co.'s Publications—Surgery. 21 ERICHSEN, JOHN E., F. R. S., F. R. C. S., Professor of Surgery in University College, London, etc. The Science and Art of Surgery; Being a Treatise on Surgical Injuries, Dis- eases and Operations. From the eighth and enlarged English edition. In two large and beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood. Cloth, $9; leather, raised bands, $11; half Russia, raised bands, $12. We have always regarded "The Science and Art of Surgery" as one of the best surgical text- books in the English language, and this eighth edition only confirms our previous opinion. We take great pleasure in cordially commending it to our readers.— The Medical News, April 11,1885. For many years this classic work has been made by preference of teachers the principal text-book on surgery for medical students, while through translations into the leading continental languages it may be said to guide the surgical teachings of the civilized world. No excellence of the former edition has been dropped and no discovery, device or improvement which has marked the progress of surgery during the last decade has been omitted. The illustrations are many and executed in the highest style of art. —Louisville Medical News, Feb. 14,1885. We cannot speak too highly of this excellent work. It represents the most advanced and settled views in regard to the science of surgery, and will ever be found a faithful guide and counsellor in practice.—Canada Lancet, May, 1885. It appears simultaneously in England, America, Spain and Italy, and is too well known as a safe guide and familiar friend to need further com- ment.—New York Medical Journal, March 28,1885. BRYANT, THOMAS, F. R. C. S., Surgeon and Lecturer on Surgery at Guy's Hospital, London. The Practice of Surgery. Fourth American from the fourth and revised Eng- lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 727 illustrations. Cloth, $6.50; leather, $7.50; half Russia, $8.00. The fourth edition of this work is fully abreast of the times. The author handles his subjects with that degree of judgment and skill which is attained by years of patient toil and varied ex- perience. The present edition is a thorough re- vision of those which preceded it, with much new matter added. His diction is so graceful and logical, and his explanations are so lucid, as to place the work among the highest order of text- books for the medical student. Almost every topic in surgery is presented in such a form as to enable the busy practitioner to review any subject in every-day practice in a short time. No time is lost with useless theories or superfluous verbiage. In short, the work is eminently clear, logical and practical.—Chicago Medical Journal and Examiner, April, 1886. This book is essentially what it purports to be, viz.: a manual for the practice of surgery. It is peculiarly well fitted for the student or busy general practitioner.—The Medical News, August 15,1886. TREVES, FREDERICK, F. R. C. S., Hunterian Professor at the Royal College of Surgeons of England. A Manual of Surgery. In Treatises by Various Authors. In three 12mo. volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See Students' Series of Manuals, page 4. We have here the opinions of thirty-three authors, in an encyclopaedic form for easy and ready reference. The three volumes embrace every variety of surgical affections likely to be met with, the paragraphs are short and pithy, and the salient points and the beginnings of new sub- jects are always printed in extra-heavy type, so that a person may find whatever information he may be in need of at a moment's glance.—Cin- cinnati Lancet-Clinic, August 21,1886. The hand of Mr. Treves is evident throughout in the choice, arrangement and logical sequence of the subjects. Every topic, as far as observed, is treated with a fulness of essential detail, which is somewhat surprising. Another characteristic of the work is the well-nigh universal acceptance of mod- ern and progressive views of pathology and treat- ment. The entire work is conceived and executed in a scientific spirit. It contains the bone and mar- row of modern surgery.—Annals of Surgery, Oct. 1886. BUTLIN, HENRY T., F. R. C. S., Assistant Surgeon to St. Bartholomew's Hospital, London. Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 4. The language of the text is clear and concise The author has aimed to state facts rather than to express opinions, and has compressed within the compass of this small volume the pathology, etiol- ogy, etc., of diseases of the tongue that are incon- veniently scattered through general works on sur- gery andthe practice of medicine. The physician and surgeon will appreciate its value as an aid and guide.—Physician and Surgeon, Sept. 1886. TREVES, FREDERICK, F.R. C.S., Surgeon to and Lecturer on Surgery at the London Hospital. Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 illustrations. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 4. A standard work on a subject that has not been I justice to the author in a few paragraphs. Intee- A stanaara wor*uu »=u , contemporary tinal Obstruction is a work that will prove of so comprehensively treated^by^any contempo y practitioner, the student, the English w^riter. Us corn^pleteness riders a mi q physician and ihe operating sur- [^Sa^^^l^S^^ ^^"^ 1 leon-British Medical Journal, Jan. 31,1885. GOULD, A. PEARCE, M. S., M. B., I. R. C. S„ Assistant Surgeon to Middlesex Hospital. # Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 pages. Cloth, $2.00. See Students' Series of Manuals, page 4. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D. In one 8vo. vol. of 784 pp. with 316 iHu^- CJotHj ^-JS. MILLER'S PRACTICE OF SURGERY Fourth "and revised American edition In °ne large 8vo, vol. of 682 pp., with 364 illustrations. Cloth, $8.75. SKEY'S OPERATIVE SURGERY. In one vol. 8vo. of 661 pages, with 81 woodcuts. Cloth, $3.25. MILLER'S PRINCIPLES OF SURGERY. Fourth American from the third Edinburgh edition. In one 8vo. vol. of 638 pages, with 340 illustrations. Cloth, $3.75. 22 Lea Brothers & Co.'s Publications—Surgery» Frac., Disloc. SMITH, STEPHEN, M. D., Professor of Clinical Surgery in the University of the City of New York. The Principles and Practice of Operative Surgery. New (second) and thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 1005 illustrations. Cloth, $4 00; leather, $5.00. This excellent and very valuable book is one of the most satisfactory works on modern operative surgery yet published. Its author and publisher have spared no pains to make it as far as possible an ideal, and their efforts have given it a position prominent among the recent works in this depart- ment of surgery. The book is a compendium for the modern surgeon. The present, the only revised edition since 1879, presents many changes from tic surgery, and the latest instruments known for operative work. It can be truly said thai as t% hand- book for the student, a com pan ion for the surgeon, and even as a book of reference for the physician not especially engaged in the practice or surgery, this volume will long hold a most conspicuous place, and seldom willits readers, no matter how unusual the subject, consult its pages in vain. Its compact form, excellent print, numerous illustra- the original manual. The volume is much en- tions, and especially its decidedly practical char- larged, and the text has been thoroughly revised, acter, all combine to commend it.—Boston Medical so as to give the most improved methods in asep- I and Surgical Journal, May 10,1888. HOLMES, TIMOTHY, M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. A Treatise on Surgery; Its Principles and Practice. New American from the fifth English edition, edited by T. Pickering Pick, F. R. C. S., Surgeon and Lecturer on Surgery at St. George's Hospital, London. In one octavo volume of 1000 pages, with 428 illustrations. Cloth, $6; leather, $7. Just ready. HOLMES, TIMOTH^Y^M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. A System of Surgery; Theoretical and Practical. IN TREATISES BY VARIOUS AUTHORS. American edition, thoroughly revised and re-edited by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. In three large imperial octavo volumes containing 3137 double-columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per Bet, cloth, $18.00; leather, $21.00; half Russia, $22.50. Sold only by subscription. STIMSON, LEWIS A., BTA^M. D., Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Surgery in the Medical Faculty of Univ. of City of N. Y., Corresponding Member of the Societe de Chirurgieof Paris. A Manual of Operative Surgery. New (second) edition. In one very hand- some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. There is always room for a good book, so that while many works on operative surgery must be considered superfluous, that of Dr. Stimson has held its own. The author knows the difficult art of condensation. Thus the manual serves as a work of reference, and at the same time as a handy guide. It teaches what it professes, the steps of operations. In this edition Dr. Stimson has sought to indicate the changes that have been effected in operative methods and procedures by the antiseptic system, and has added an account of many new operations and variations in the steps oi older operations. We do not desire to extol this manual above many excellent standard British publications of the same class, still we be- lieve that it contains much that is worthy of imi- tation.— British Medical Journal, Jan. 22,1887. By the same Author. A Treatise on Fractures and Dislocations. In two handsome octavo vol- umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Disloca- tions, 540 pages, with 163 illustrations. Complete work just ready, cloth, $5.50; leather, $7.50. Either volume separately, cloth, $3.00; leather, $4.00. The appearance of the second volume marks the I of Dislocations as it is taught and practised by the completion of the author's original plan of prepar- most eminent surgeons of the present time. Con- ing a work which should present in the fullest | taining the results of such extended researches it manner all that is known on the cognate subjects must for a long time be regarded as an authority of Fractures and Dislocations. The volume on Fractures assumed at once the position of authority on the subject, and its companion on Dislocations will no doubt be similarly received. The closing volume of Dr. Stimson's work exhibits the surgery — authority on all subjects pertaining to dislocations. Every practitioner of surgery will feel it incumbent on him to have it for constant reference.—Cincinnati Medical News, May, 1888. HAMILTON, FRANK H., M. D., LL. D.t Surgeon to Bellevue Hospital, New York. A Practical Treatise on Fractures and Dislocations. Seventh edition thoroughly revised and much improved. In one very handsome octavo volume of 998 pages, with 379 illustrations. Cloth, $5.50; leather, $6.50; half Russia, $7.00. This book is without a rival in any language. It fully given. The book is so well known that it does is essentially a practical treatise, and it gathers l not require any lengthened review. We can only within its covers almost everything valuable that say that it is still unapproached as a treatise — has been written about fractures and dislocations. The Dublin Journal of Medical Science, Feb 1886 The principles and methods of treatment are very | MARSH, HOWARD, F. R. C. S., Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 4. PICK, T. PICKERING, F. R. C. S., Surgeon to and Lecturer on Surgery at St. George's Hospital, London. Fractures and Dislocations. In one 12mo. volume of 530 pages, with 93 illustrations. Limp cloth, $2.00. See Series of Clinical Manuals, page 4. Lea Brothers & Co.'s Publications—Otol., Ophthal. 23 BURNETT, CHARLES H., A. M., M. D., Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society. The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. New (second) edition. In one handsome octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00; leather, $5.00. We note with pleasure the appearance of a second carried out, and much new matter added. Dr. edition of this valuable work. When it first came i Burnett's work must be regarded as a very valua- out it was accepted by the profession as one of i ble contribution to aural surgery, not only on the standard works on modern aural surgery in account of its comprehensiveness, but because it the English language; and in his second edition I contains the results of the careful personal observa- Dr. Burnett has fully maintained his reputation, j tion .and experience of this eminent aural surgeon. for the book is replete with valuable information | —London Lancet, Feb. 21,1885. and suggestions. The revision has been carefully | POLITZER, ADAM, Imperial-Royal Prof, of Aural Therap. in the Univ. of Vienna. A Text-Book of the Ear and its Diseases. Translated, at the Author's re- quest, by James Patterson Cassells, M. D., M. R. C. S. In one handsome octavo vol- ume of 800 pages, with 257 original illustrations. Cloth, $5.50. The whole work can be recommended as a reli-1 the practitioner in his treatment.—Boston Medical able guide to the student, and an efficient aid to | and Surgical Journal, June 7,1883. JULER, HENRY E., F. R. C. S., Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp.; late Clinical Ass't, Moorfieldt, London. A Handbook of Ophthalmic Science and Practice. In one handsome octavo volume of 460 pages, with 125 woodcuts, 27 colored plates, selections from the Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50; leather, $5.50. ......m ,_ It presents to the student concise descriptions j illustrations are nearly all original. We have ex- and typical illustrations of all important eye affec- amined this entire work with great care, and it J ' represents the commonly accepted views of ad- vanced ophthalmologists. We can most heartily commend this book to all medical students, prac- titioners and specialists.—Detroit Lancet, Jan. '85. tions placed in juxtaposition, so as to be grasped ! represents the commonly accepted views of ad- at a glance. Beyond a doubt it is the best illus- vanced ophthalmologists. We can most heartily - commend this book to all medical students, prac- trated handbook of ophthalmic science which has ever appeared. Then, what is still better, these NETTLESHIP, EDWARD, F. R. C. S., Ophthalmic Surg, and Led. on Ophth. Surg, at SL Thomas' Hospital, London. The Student's Guide to Diseases of the Eye. New (third) edition, thor- oughly revised. With a chapter on the Detection of Color-Blindness, by William Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. In one 12mo. volume of 479 pages, with 164 illust., test-types and formula?. Cloth, $2. Just ready. The extent of the sale of this now accepted I in the chapter devoted to operations. A very authority has conclusively shown that its claim for I important partof the work to general practitioners favor was not an imaginary one. The introductory is that embraced in the consideration of eye dis- chapter on optical outlines is a wonderfully clear statement of the principles involved. The writer's J" pro- decision of character has fully impressed his pi duction, and this is nowhere more apparent th eases in relation to general diseases and condi- tions. The arrangement of the remedies employed into a formulary is adopted, and it contains much an 1 useful knowledge.—South. Practitioner, Dec, 1887. NORRIS, WM. F., M. D., and OLIVER, CHAS. A., M. D. Clin. Prof, of Ophthalmology in Univ. of Pa. A Text-Book of Ophthalmology. In one octavo volume of about 500 pages, with illustrations. Preparing. CARTER, R. BRUDENELL, & FROST, W. ADAMS, F. R. C. S., F. R. C. S., Ophthalmic Surgeon to and Lecturer on Oph- Assistant Ophthalmic Surgeon to and Joint ffiLe Surged at St. George's Hospital, Lecturer ^^^J^gery at SL London. * rrr» • i r>i Ophthalmic Surgery. In one 12mo. volume of 559 pages, with 91 woodcuts, color blindness test, test-types and dots and appendix of formula;. Cloth, $2.25. See Series of Clinical Manuals, page 4._______________________ WELLS, J. SOELBERG, F. R. C. S., Professor of Ophthalmology in King's College Hospital, London, etc A Treatise on Diseases of the Eye. New (fifth) American from the third London edition. In one large octavo volume. Preparing. BROWNE, EDGAR A., Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skin Diseases. TTnw to Use the Ophthalmoscope. Being Elementary Instructions in Oph- thalrnoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116 pages, with 35 illustrations. Cloth, $1.00.________________ „ 1itdDvpp ANT) MOON'S HANDY BOOK OF | LAWSON ON INJURIES TO THE EYE, ORBIT HSSth at MIC SURGERY, foVthe use of Prac- AND EYELIDS: Their Immediate and Remote SSecondedition. ' In one octavo vol- Effects. 8 vo., 404 pp., 92 illus. Cloth, $3.50. Sme TmnSK. with 66 Wirt. Cloth, $2.75. I 24 Lea Brothers & Co.'s Publications—Urin. Di8., Dentistry, etc. ROBERTS, WILLIAM, M. D„ Lecturer on Medicine in the Manchester School of Medicine, etc A Practical Treatise on Urinary and Renal Diseases, including Uri- nary Deposits. Fourth American from the fourth London edition. In one hand- some octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. It may be said to be the best book in print on the guage in its account of the different affections.— " The " subject of which it treats.—The American Journal of the Medical Sciences, Jan. 1886. The peculiar value and finish of the book are in a measure derived from its resolute maintenance of a clinical and practical character. It is an un- rivalled exposition of everything which relates directly or indirectly to the diagnosis, prognosis and treatment of urinary diseases, and possesses a completeness not found elsewhere in our lan- Manehester Medical Chronicle, July, 1886. The value of this treatise as a guide book to the physician in daily practice can hardly be over- estimated. That it is fully up to the level of our present knowledge is a fact reflecting great credit upon Dr. Roberts, who has a wide reputation as a busy practitioner.— The Medical Record, July 31, 1886. PURDY, CHARLES W., M. D., Chicago. Bright's Disease and Allied Affections of the Kidneys. In one octavo volume of 288 pages, with illustrations. Cloth, $2. The object of this work is to " furnish a system- atic, practical and concise description of the pathology and treatment of the chief organic diseases of the kidney associated with albuminu- ria, which shall represent the most recent ad- vances in our knowledge on these subjects ;" and this definition of the object is a fair description of the book. The work is a useful one, giving in a short space the theories, facts and treatments, and going more fully into their later developments. On treatment the writer is particularly strong, steering clear of generalities, and seldom omit- ting, what text-books usually do, the unimportant items which are all important to the general prac- titioner.—The Manchester Medical Chronicle, Oct., 1886. MORRIS, HENRY, M. B., F. R. C. S., Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. ' Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 4. In this manual we have a distinct addition to surgical literature, which gives information not elsewhere to be met with in a single work. Such a book was distinctly required, and Mr. Morris has very diligently and ably performed the task he took in hand. It is a full and trustworthy book of reference, both for students and prac- titioners in search of guidance. The illustrations in the text and the chromo-lithographs are beau- tifully executed.— The London Lancet,Feb. 26,1886. See Series LUCAS, CLEMENT, M. B., B. S., F. R. C. S., Senior Assistant Surgeon to Guy's Hospital, London. Diseases of the Urethra. In one 12mo. volume. Preparing. of Clinical Manuals, page 4. THOMPSON, SIR HENRY^ Surgeon and Professor of Clinical Surgery to University College Hospital, London. Lectures on Diseases of the Urinary Organs. Second American from the third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. By the Same Author. On the Pathology and Treatment of Stricture of the Urethra and Urinary Fistula?. From the third English edition. In one octavo volume of 359 pages, with 47 cuts and 3 plates. Cloth, $3.50. THE AMERICAN SYSTEM OF DENTISTRY. In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- taining 3160 pages, with 1863 illustrations and 9 full page plates. Per volume, cloth, $6; leather, $7; half Morocco, gilt top, $8. The complete work is now ready. For sale by subscription only. doubtless it is), to mark an epoch in the history of dentistry. Dentists will be satisfied with it and proud of it—they must. It is sure to be precisely what the student needs to put him and keep him in the right track, while the profession at large will receive incalculable benefit from it.—Odonto- graphy Journal, Jan. 1887. As an encyclopaedia of Dentistry it has no su- fierior. It should form a part of every dentist's ibrary, as the information it contains is of the freatest value to all engaged in the practice of entistry.—American Jour. Dent. Sci., Sept., 1886. A grand system, big enough and good enough and handsome enough for a monument (which COLEMAN, A., L. R. C. P., F. R. C. S., Exam. L. D. S., Senior Dent. Surg, and Lect. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. A Manual of Dental Surgery and Pathology. Thoroughly revised and adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. It should be in the possession of every practi tioner in this country. The part devoted to first and second dentition and irregularities in the per- manent teeth is fully worth the price. In fact, price should not be considered in purchasing such a work. If the money put into some of our so- called standard text-books could be converted into such publications as this, much good would result —Southern Dental Journal, May, 1882. The author brings to his task a large experience acquired under the most favorable circumstances. There have been added to the volume a hundred pages by the American editor, embodying the views of the leading home teachers in dental sur- gery. The work, therefore, may be regarded as strictly abreast of the times, and as a very high authority on the subjects of which it treats.— American Practitioner, July, 1882. BASHAM ON RENAL DISEASES: A Clinical Guide to their Diagnosis and Treatment In one 12mo. vol. of 304 pages, with 21 illustrations. Cloth, $2.00. Lea Brothers & Co.'s Publications—Venereal, Impotence. 25 GROSS, SAMUEL W., A. M., M. D., LL. D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila. A Practical Treatise on Impotence, Sterility, and Allied Disorders Of the Male Sexual Organs. New (third) edition, thoroughly revised. In one very handsome octavo volume of 163 pages, with 16 illustrations. Cloth, $1.50. It must be gratifying to both author and pub- lishers that large first and second editions of this littlework were so soon exhausted, while the fact that it has been translated into Russian may indi- cate that it filled a void even in foreign literature. His is a careful and physiological study of the sexual act, so far as concerns the male, and all his conclusions are scientifically reached. The book has a place by itself in our literature, and furnishes a large fund of information concerning important matters that are too often passed over in silence.—The Medical Press, June, 1887. This now classical work on the subject of impo- tence and sterility in the male needs no extended review, for it is already well known to the pro- fession. Dr. Gross has by his tireless labor done more towards clearing up the diagnosis and treat- ment of these obscure cases than any other Ameri- can physician. The fact that this book has rapidly run through two large editions, and that the author is now forced to issue a third, is good and sufficient evidence of its excellence.—Atlanta Medical and Surgical Journal, April, 1888. TAYLOR, R. W., A. M., M. D., Surgeon to Charity Hospital, New York, Prof, of Venereal and Skin Diseases in the University of Vermont, Pres. of the Am. Dermatological Ass'n. The Pathology and Treatment of Venereal Diseases. Including the results of recent investigations upon the subject. Being the sixth edition of Bumstead and Taylor. Entirely rewritten by Dr. Taylor. Large and handsome 8vo. volume, about 900 pages, with about 150 engravings, as well as numerous chromo-lithographs. Preparing. A few notices of the previous edition are appended. It is a splendid record of honest labor, wide research, just comparison, careful scrutiny and original experience, which will always be held as a high credit to American medical literature. This is not only the best work in the English language upon the subjects of which it treats, but also one which has no equal in other tongues for its clear, comprehensive and practical handling of its themes.—Am. Jour, of the Med. Sciences, Jan, 1884. It is certainly the best single treatise on vene- real in our own, and probably the best in any lan- guage.—Boston Med. and Surg. Journal, April 3,1884. The character of this standard work is so well known that it would be superfluous here to pass in review its general or special points of excellence. The verdict of the profession has been passed; it has been accepted as the most thorough and com- plete exposition of the pathology and treatment of venereal diseases in the language. Admirable as a model of clear description, an exponent of sound pathological doctrine, and a guide for rational and successful treatment, it is an ornament to the medi- cal literature of this country. The additions made to the present edition are eminently judicious, from the standpoint of practical utility.—Journal of Cutaneous and Venereal Diseases, Jan. 1884. CORNIL, V.9 Professor to the Faculty of Medicine of Paris, and Physician to the Loureine Hospital. Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially revised by the Author, and translated with notes and additions by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. perusal without the feeling that his grasp of the wide and important subject on which it treats is The anatomy, the histology, the pathology and the clinical features of syphilis are represented in this work in their best, most practical and most instructive form, and no one will rise from its a stronger and surer one.—The London Practi- tioner, Jan. 1882. HUTCHINSON, JONATHAN, F. R. S., F. R. C. S., Consulting Surgeon to the London Hospital. Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. $2.25. See Series of Clinical Manuals, page 4. Cloth, Those who have seen most of the disease and those who have felt the real difficulties of diagno- sis and treatment will most highly appreciate the facts and suggestions which a.bound in these pages. It is a worthy and valuable record, not only of Mr. Hutchinson's very large experience and power of observation, but of his patience and assiduity in taking notes of his cases and keep- ing them in a form available for such excellent use as he has put them to in this volume.—London Medical Record, Nov. 12,1887. GROSS, S. D., M. D., LL. D., D. C. L., etc. A Practical Treatise on the Diseases, Injuries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third edition, thoroughly revised by Samuel W. Gross, M. D. In one octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50._____________ CULLERIER, A., & BUMSTEAD, F. J., M.D., LL.D., Suraeon to the Hopital du Midi. Late Professor of Venereal Diseases in the College of Physicians y and Surgeons, New York. An Atlas of Venereal Diseases. Translated and edited by Freeman J. Btjm- 8TEAD M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life. Strongly bound in cloth $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. TTTT.L ON SYPHILIS AND LOCAL CONTAGIOUS j FORMS OF LOCAL DISEASE AFFECTING TViSORDERS In one 8vo vol. of 479 p. Cloth,$3.25. PRINCIPALLY THE ORGANS OF GENERA- LEE'S LECTURES ON SYPHILIS AND SOME | TION. In one 8vo. vol. of 246 pages. Cloth. $2.26. 26 Lea Brothers & Go.'s Publications—Venereal, Skin. TA YLOR, ROBERT W., A. M., M. D., Surgeon tn Charity Hospital, New York, and to the Depar tinent of Venereal and Skin Diseases of the Xew York HospitaL A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis. Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and comprising 58 beautifully-colored plates with 192 figures, and 400 pages of text with 65 engravings. Price per part, $2.50. Parts I. and II. are just ready. For sale by subscrip- tion only. Specimen plates sent on receipt of 10 cents. A full prospectus is now ready for distribution on application. recognized as a standard authority on its subjects. The strong faith of its publishers in the merit and wide appreciation which they must feel assured awaits the Clinical Atlas at the hands of a discriminating medical public is evidenced by the very moderate figure at which it is supplied, a figure so much below that customarily charged for works of this class that only the widest dis- semination can possibly bring them a fair return for their evidently lavish outlay.—Southern Prac- titioner, Sept., 1888. Viewing this collection as a whole it may be said that it is difficult to overestimate its clinical value to the practitioner and diagnostician. A careful study of even the smallest of these portraits of disease will repay the student. Their practical value in teaching is exactly proportioned to their faithfulness to fact. In the important matters of etiology and treatment, the author is as lucid and practical as might be anticipated from one of his experience and previous contributions to derma- tological literature. Dr. Taylor's Atlas is to be warmly commended to the expert, the general practitioner, and the student, as an invaluable aid in acquiring a knowledge of the subjects illus- This magnificent Clinical Atlas, we do not hesi- tate to say, will he regarded as one of tlie most valuable and handsome contributions to the medi- cal literature of the age. As its name implies, the CHnical Atlas is intended as a working guide for any practitioner who chooses to deal with the wide- spread class of chronic diseases included in its title. For the adequate accomplishment of its fmrpose such a work must comprise pictures, life- ike in form and color, of a size as large as is com- patible with convenience, together with a descrip- tive, clinical and didactic text. The entire litera- ture of the subjects has been searched for its best illustrations, and selections made with proper permission of living authors. These have been complemented by numerous reproductions from a collection of original paintings from life, gathered by the author during many years of practice. The text has been designed to furnish the practitioner with clear and explicit directions for the proper management of his cases, and at the same time to stimulate the interest of those who may wish to devote their life-work to these subjects. A full statement of the clinical history, varying features, etiology, diagnosis, and prognosis has therefore been followed by definite and complete thera- peutical information. In their respective spheres the author and publishers have left nothing undone to make the Clinical Atlas a work which will be trated, combining in a high degree the advantages of a sound textbook, with the special assistance of colored illustrations.— The American Journal of the Medical Sciences, April, 1889. HYDE, J. NEVINS, A. M., M. D., Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. New (second) edition. In one handsome octavo volume of 676 pages, with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50; leather, $5.50. Just ready. We can heartily commend it, not only as an admirable text-book for teacher and student, but in its clear and comprehensive rules for diagnosis, its sound and independent doctrines in pathology, and its minute and judicious directions for the treatment of disease, as a most satisfactory and complete practical guide for the physician.—Ameri- can Journal of the Medical Science*. July, 1888. A useful glossary descriptive of terms is given. The descriptive portions of this work are plain and easily understood, and above all are very accurate. The therapeutical part is abundantly supplied with excellent recommendations. The picture part is well done. The value of the work to practitioners is great because of the excellence of the descriptions, the suggestiveness of the advice, and the correctness of the details and the principles of therapeutics impressed upon the reader.— Virginia Med. Monthly, May, 1888. The second edition of his treatise is like his clinical instruction, admirably arranged, attractive in diction, and strikingly practical throughout. The chapter on general symptomatology is a model in its way; no clearer description of the various primary and consecutive lesions of the skin is to be met with anywhere. Those on general diagno- sis and therapeutics are also worthy of careful study. Dr. Hyde has shown himself a compre- hensive reader of the latest literature, and has in- corporated into his book all the best of that which the past years have brought forth. The prescrip- tions and formulae are given in both common and metric systems. Text and illustrations are good. and colored plates of rare cases lend additional attractions. Altogether it is a work exactly fitted to the needs of a general practitioner, and no one will make a mistake in purchasing it—Medical Press of Western New York, June, 1888. FOX, T., M. D., F.R. C. P., and FOX, T. C, B.A., M.R. C.S., Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the University College Hospital, London. Westminster Hospital, London. An Epitome of Skin Diseases. "With Formulae. For Students and Prac- titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume of 238 pages. Cloth, $1.25. The third edition of this convenient handbook I manual to lie upon the table for Instant reference. calls for notice owing to the revision and expansion | Its alphabetical arrangement is suited to this use, which it has undergone. The arrangement of skin | for all one has to know is the name of the disease, diseases in alphabetical order, which is the method j and here are its description and the appropriate of classification adopted in this work, becomes a treatment at hand and ready for instant applica- positive advantage to the student The book is tion. The present edition has been very carefully one which we can strongly recommend, not only | revised and a number of new diseases are de- to students but also to practitioners who require a i scribed, while most of the recent additions to compendious summary of the present state of I dermal therapeutics find mention, and the formu- dermatology.—British Medical Journal, July 2,1883. lary at the end of the book has been considerably We cordially recommend Fox's Epitome to those augmented.—The Medical News, December, 1883. whose time is limited and who wish a handy | WILSON, ERASMUS, F\ILK~ The Student's Book of Cutaneous Medicine and Diseases of the Skin. In one handsome small octavo volume of 535 pages. Cloth, $3.50. HILLIER'S HANDBOOK OF SKIN DISEASES; for Students and Practitioners. Second Ameri- can edition. In one 12mo. volume of 363 pages. with plates. Cloth, f2.25. Lea Brothers & Co.'s Publications—Dis. of Women. 27 The American Systems of Gynecology and Obstetrics. A,,t5yste?iS of gynecology and Obstetrics, in Treatises by American ■a-utnors. gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics ana gynecology in the Medical Department of the University of Buffalo; and Obstet- rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the l^1V*eono Pennsylvania, Philadelphia. In four very handsome octavo volumes of ar>out you pages each, fully illustrated by wood engravings and colored plates. Volumes l. and 11. of the Gynecology, and Volume I. of the Obstetrics containing 2764 pages, »/l engravings and 8 colored plates, are now ready. Volume II. of the Obstetrics, completing the work, will be ready in May. Per volume: Cloth, $5.00; leather, $6.00; halt Kussia, $7.00. For sale by subscription only. Address the Publishers. Full descrip- tive circular free on application. LIST OF CONTRIBUTORS WILLIAM H. BAKER, M. D.. ROBERT BATTEY, M. D., SAMUEL C BUSEY, M. D., JAMES C. CAMERON, M. D.. HENRY C COE, A. M.. M. D. EDWARD P. DAVIS, M. D., G. E. De SCHWEINITZ, M. D., E. C DUDLEY, A. B., M. D., B. McE. EMMET, M. D., GEORGE J. ENGELMANN, M. D., HENRY J. GARRIGUES, A. M., M. D., WILLIAM GOODELL, A. M., M. D., EGBERT H. GRANDIN, A. M., M. D., SAMUEL W. GROSS, M. D., ROBERT P. HARRIS, M. D., GEORGE T. HARRISON, M. D., BARTON C. HIRST, M. D. STEPHEN Y. HOWELL, M. D., A. REEVES JACKSON, A. M., M. D., W. W. JAGGARD, M. D., EDWARD W. JENKS, M. D., LL. D., HOWARD A. KELLY, M. D., This is a very valuable contribution to the liter- ature of obstetrics. The editors, contributors and publishers are entitled to most hearty congratu- lations for the complete kind of work that has appeared.— The Obstetric Gazette, August, 1888. This, the companion work to the System of Gynecology by American Authors, equals it in the excellence of the subject-matter and the perfec- tion of the publishers' art. As a treatise for the use of the practitioner the work will be found to represent admirably the obstetric science of the day as exemplified in American practice.— The Medical News, August 25, 1888. There can be but little doubt that this work will find the same favor with the profession that has been accorded to the "System of Medicine by American Authors," and the "System of Gynecol- ogy byAmerican Authors." One is at a loss to know what to say of this volume, for fear that just and merited praise may be mistaken for flattery. The subjects of some of the papers are discussed in various works on obstetrics, though not to the full extent that is found in this volume. The papers of Drs. Engelmann, Martin, Hirst, Jaggard and Reeve are incomparably beyond anything that can be found in obstetrical works. Certainly the Edi- tor may be congratulated for having made such a wise selection of his contributors.—Journal of the American Medical Association, Sept. 8,1888. D., CHARLES CARROLL LEE, M. D., WILLIAM T. LUSK, M. D., LL. D., J. HENDRIE LLOYD, M. D, MATTHEW D. MANN, A. M., M. D., H. NEWELL MARTIN, F. R. S., M D. Sc, M. A., RICHARD B. MAURY, M. D., C. D. PALMER, M. D., ROSWELL PARK, M. D., THEOPHILUS PARVIN, M. D., LL. D., R. A. F. PENROSE, M. D., LL. D., THADDEUS A. REAMY, A. M., M. D., J. C. REEVE, M. D, A. D. ROCKWELL, A. M., M. D., ALEXANDER J. C. SKENE, M. D., J. LEWIS SMITH, M. D., STEPHEN SMITH, M. D., R. STANSBURY SUTTON, A. >!., M. D., LL. D., T. GAILLARD THOMAS, M. D., LL. D., ELY VAN DE WARKER, M. D., W. GILL WYLIE, M. D. In our notice of the "System of Practical Medi- cine by American Authors," we made the follow- ing statement:—"It is a work of which the pro- fession in this country can feel proud. Written exclusively by American physicians who are ac- quainted with all the varieties of climate in the United States, the character of the soil, the man- ners and customs of the people, etc., it is pecul- iarly adapted to the wants of American practition- ers of medicine, and it seems to us that every one of them would desire to have it." Every word thus expressed in regard to the "American Sys- tem of Practical Medicine" is applicable to the "System of Gynecology by American Authors," which we desire now to bring to the attention of our readers. It, like the other, has been written exclusively by American physicians who are acquainted with all the characteristics of American people, who are well informed in regard to the peculiarities of American women, their manners, customs, modes of living, etc. As every practis- ing physician is called upon to treat diseases of females, and as they constitute a class to which the familly physician must give attention, and cannot pass over to a specialist, we do not know of a work in any department of medicine that we should so strongly recommend medical men gen- erally purchasing.—Cincinnati Med. News, July,1887. THOMAS, T. GAILLARD, M. D., Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y. A Practical Treatise on the Diseases of "Women. Fifth edition, thoroughly revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $5.00; leather, $6.00; very handsome half Kussia, raised bands, $6.50. That the previous editions of the treatise of Dr. rician and gyneecologist as a safe guide to practi Thomas were thought worthy of translation into German, French, Italian and Spanish, is enough to give it the stamp of genuine merit. At home it has made its way into the library of every obstet- practice. No small number of~additions have been made to the present edition to make it correspond to re- cent improvements in treatment.—Pacific Medical and Surgical Journal, Jan. 1881. EDIS, ARTHUR W., M. D., Lond., F.R. C.P., M.R. C.S., Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. The Diseases Of Women. Including their Pathology, Causation, Symptoms, Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00; leather, $4.00. It is a pleasure to read a book so thoroughly good as this one. The special qualities which are conspicuous are thoroughness in covering the whole ground, clearness of description and con- ciseness of statement. Another marked feature of the book is the attention paid to the details of many minor surgical operations and procedures, as, for instance, the use of tents, application of leeches, and use of hot water injections. These are among the more common methods of treat- ment, and yet very little is said about them in many of the text-books. The book is one to be warmly recommended especially to students and general practitioners, who need a concise but com- plete rtsumi of the whole subject. Specialists, too, will find many useful hints in its pages.—Boston Med. and Surg. Journ., March 2,1882. 28 Lea Brothers & Co.'s Publications—Dis. of Women, Mi